Chronic cystoid macular edema in an eye with a capsule defect and posteriorly dislocated capsular tension ring

Using a Capsular Tension Ring (CTR) Inserter for CTR Explantation in Cases of Posteriorly Dislocated Intraocular Lens-CTR-Capsule Complex

PURPOSE

Explantation of a dislocated capsular tension ring (CTR) from the vitreous cavity can be challenging, typically requiring a bimanual hand-shake technique or cutting the CTR into segments. We present three cases of dislocated intraocular lens (IOL)-CTR-capsule complexes in which CTRs were explanted efficiently and safely by using a CTR inserter (CTR-I) through a clear corneal incision.

METHODS

Retrospective case series.

RESULTS

Capsular tension rings were successfully explanted by freeing the eyelet of the CTR from the capsule, engaging it with the CTR-I hook and retracting the CTR into the device's shaft while maintaining the entire IOL-CTR-capsule complex in a safe position behind the iris plane. No complications of the procedure were observed in all three cases. All patients had subsequent uneventful IOL exchange through sutureless scleral fixation during the same surgery.

CONCLUSION

The CTR inserter provides a simple and efficient approach to CTR removal from IOL-CTR-capsule complexes dislocated into the vitreous cavity. Greater awareness of this technique among providers is needed.

Refractory cystoid macular oedema due to intraocular lens haptic perforating the iris

Cystoid macular oedema is a well-known complication of cataract surgery associated with intraocular lens decentration or dislocation. A 55-year-old man, who had undergone a phacoemulsification and intraocular lens implantation surgery two months previously was referred because of reduced vision in the right eye. Ocular examination revealed that one of the haptics had perforated the iris at 6 o'clock. There was cystoid macular oedema of the right eye. A topical non-steroid anti-inflammatory drug, followed by intravitreal injections did not produce a significant regression. Finally, the haptic was repositioned surgically and the macular oedema dramatically resolved. Correct placement of the intraocular lens might avoid post-operative complications including cystoid macular oedema.

Surgical Repositioning of Dislocated Capsular Tension Rings

PURPOSE

To present techniques and results of surgical repositioning of subluxed and dislocated capsular tension rings (CTRs).

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Eleven patients with a previously implanted CTR in-the-bag for zonular weakness who presented with CTR-intraocular lens (IOL)-capsular bag decentration who underwent surgical repositioning.

METHODS

Data from 11 patients who underwent surgical repositioning were evaluated retrospectively for underlying diagnosis, interval between initial surgery and decentration, surgical technique, clinical results, and complications.

MAIN OUTCOME MEASURES

Capsular tension ring-IOL-capsular bag centration, final best-corrected visual acuity (BCVA), and surgical complications.

RESULTS

Of the 11 patients with CTR decentration, 3 had it early in the postoperative period, and 8 had it late. Mean (+/- standard deviation) durations from cataract extraction and CTR implantation to surgical repositioning were 6.1+/-7.9 months for those with decentration early and 49.6+/-15.3 months for late decentrations (overall range, 0.7-74.7). Of the 11 patients, 7 had pseudoexfoliation, and 4 of the 7 had associated glaucoma. Nine patients had subluxation of the CTR-IOL-capsular bag complex, which was managed by an anterior segment approach. A pars plana vitrectomy and levitation of the CTR was required in 2 patients due to complete dislocation of the CTR into the posterior vitreous. Surgical techniques for repositioning included single, double, or 3-point scleral suture loop fixation of the CTR through the capsular bag complex (8 eyes); use of the capsular tension segment (CTS) placed within the capsular bag for scleral suture fixation (2); or iris suture fixation of the IOL haptics (1). All patients achieved successful anatomical repositioning of the CTR-IOL-capsular bag complex. Mean preoperative BCVA improved from 20/100 to 20/40 postoperatively. After repositioning surgery, BCVA improved in 7 patients, was maintained in 2, and worsened in 2 (due to advanced glaucoma).

CONCLUSION

Postoperative CTR subluxation or dislocation is a risk for patients with severe or progressive zonulopathy. Decentrations may be effectively managed with scleral suture fixation of the CTR through the capsular bag or the use of the CTS.

Optimal timing of capsular tension ring implantation: Miyake-Apple video analysis

PURPOSE

To evaluate the appropriate timing for capsular tension ring implantation in cases of zonular weakness either prior to or after lens extraction using Miyake-Apple video analysis.

SETTING

John Moran Eye Center, Salt Lake City, Utah, USA.

METHODS

Four cadaver eyes were prepared using a standard Miyake-Apple protocol with image capture using digital video recording. After continuous curvilinear capsulorhexis and hydrodissection/viscodissection were performed, 2 eyes had early capsular tension ring implantation (CTR) and 2 eyes had CTR implantation after lens extraction. The 12.3 mm CTR was implanted in all eyes. Capsular bag torque and displacement, zonular elongation and stress, and ease of CTR placement were evaluated in each eye.

RESULTS

Early CTR implantation resulted in significantly increased capsular torque and displacement of up to 4.0 mm compared to insertion in an empty capsular bag. There was significant zonular elongation and tension during early placement.

CONCLUSION

In terms of minimizing further zonular stress and damage and capsular destabilization, the ideal timing for CTR placement is after lens extraction and decompression of the capsular bag.

Closed foldable capsular rings

A new foldable capsular tension and bending ring system with a sharp-edged design is described. The closed foldable capsular rings (CFCR) consist of 8 hydrophobic and 8 hydrophilic ring segments. The CFCRs have a 9.2 mm minimum overall diameter. The CFCRs were inserted using various cartridge systems or a two-folded technique with a forceps. The CFCRs were implanted after phacoemulsification through a small (1.6 to 3.2 mm) incision in 104 human adult eyes without intraoperative complications. No postoperative complications such as capsule folds or inward bending were observed over a 6-month follow-up. Posterior capsule opacification was minimal or absent in all eyes.

Extraction of endocapsular tension ring after phacoemulsification in eyes with pseudoexfoliation

PURPOSE

To describe an easy and effective surgical technique for removing the endocapsular tension ring (CTR) after phacoemulsification.

DESIGN

New surgical technique.

METHODS

One 10-0 polypropylene suture needle is passed through the hole at one end of the CTR. Then, the CTR is introduced into the capsular bag before phacoemulsification. If the posterior capsule ruptures, the CTR can be removed by pulling the suture toward the corneal incision and rotating the CTR to remove it.

RESULTS

We performed this technique in 23 cases with a risk of zonular damage and did not encounter complications at any point in the procedure.

CONCLUSIONS

We recommend this procedure in eyes with risk of zonular dialysis and posterior capsule rupture, especially in advanced pseudoexfoliative cataracts or if the surgeon has limited experience with these cases.