Posterior assisted levitation for nucleus retrieval using Viscoat after posterior capsule rupture

Retrolental cohesive ophthalmic viscoelastic injection in severely subluxated cataracts: The "Viscolift technique"

INTRODUCTION

To describe a novel surgical approach in the management of subluxated cataracts.

METHODS

A 70-year-old Caucasian male with a subluxated cataract in the left eye was referred to our clinic at the Azienda Ospedaliero-Universitaria di Bologna- Ophthalmology Unit. The ophthalmic examination revealed a best-corrected visual acuity (BCVA) of 20/200 in the left eye with monocular diplopia and a severely subluxated NO6/NC6 cataract and the fundus examination did not reveal any vitreoretinal abnormalities. The right eye had 20/20 BCVA and was pseudophakic. After a 300° conjunctival peritomy, a single 25-gauge valved trocar 4 mm was inserted from the limbus in the inferotemporal quadrant, where the cataract was mainly dislocated and a corneal paracentesis to reduce the anterior chamber intraocular pressure was performed. Subsequently cohesive viscoelastic was progressively injected in the retrolental space through the trocar, to recenter and elevate the subluxated cataract. Thereafter, a complete centered capsulorhexis was performed, four capsular hooks were inserted to stabilize the bag, and complete phacoemulsification was performed with intact posterior capsular support. In the end, given the lack of capsular support elements such as the Cionni ring or Ahmed segment, a sutureless scleral fixated intraocular lens was implanted.

RESULTS

One week after surgery, the BCVA was 20/25, and the final BCVA at 6 months was 20/20, without any complications.

CONCLUSIONS

Retrolental cohesive ophthalmic viscoelastic injection could represent a novel effective surgical approach in recentering and elevating subluxated cataracts, facilitating the capsulorhexis, and reducing the risk of a pars plana approach.

Modified posterior-assisted levitation with intraocular lens scaffold and glued IOL for sinking nucleus in eyes with inadequate sulcus support

Posterior-assisted levitation is used to retrieve and levitate a sinking nucleus in cataract surgery associated with posterior capsule rupture. After the nucleus is levitated in the anterior chamber, the intraocular lens (IOL) scaffold procedure helps emulsify the nuclear remnants with the phacoemulsification probe and glue-assisted intrascleral haptic fixation (glued IOL) enables appropriate placement of an IOL in cases with insufficient capsule support. We describe a triumvirate procedure for a sinking nucleus in the absence of capsule support that combines modified posterior-assisted levitation, in which the nucleus is levitated from the existing sclerotomy sites of glued IOL surgery, with the IOL scaffold technique, enabling a closed-chamber approach when performed concurrently.

"Crack, Reduce, and Implant": A Safe Phaco Technique in a Case with Hard Brown Cataract

This report describes two maneuvers in different steps of phaco surgery in a case with hard cataract, which provide debulking of the central dense nucleus and prevents posterior capsule rupture (PCR). In the current case, clear corneal incisions were created, and anterior chamber was filled with ophthalmic viscosurgical device (OVD). Anterior capsule was punctured, and capsulorhexis was completed. Nucleus was cracked into two halves following vertical groove formation. Core nucleus was hollowed sideward bilaterally in the capsular bag. Nuclear halves were removed from capsular bag, and each one was pushed to one side on the iris plane. Capsular bag was inflated with OVD, and intraocular lens (IOL) was implanted. Nuclear halves were removed in confidence. The presented maneuvers initially reduce dense nucleus load in the safe zone and allow surgeon to use IOL as a barrier to protect floppy posterior capsule from early steps of the surgery.

Nitinol basket-assisted pars plana vitrectomy for retained lens material removal

PURPOSE

To evaluate the usefulness of different types of nitinol baskets to capture, lift and hold the lens material, dropped during a complicated phacoemulsification, as an adjunctive surgical tool in vitreoretinal surgery and to evaluate the outcomes and complication of this new surgical technique in a small series of patients.

METHODS

Patients who underwent pars plana vitrectomy (PPV) for retained lens fragments operated during December 2014 and March 2015 at the Academic Medical Center (AMC), Amsterdam, were included in this study. The PPV was performed using different settings and types of nitinol stone extractors (NSE). Three different stone extractors were used for the above-mentioned purpose. Preoperative (pre-op) and postoperative (post-op) data including best corrected visual acuity at 6 months follow-up visit, intra- and postoperative complications were recorded.

RESULTS

Seven eyes of seven patients with a follow-up of 6 months were included in this study. All the vitrectomies were performed the same day of the complicated cataract extraction. Mean pre-op Snellen visual acuity was 20/160; mean post-op visual acuity was 20/32. No complications were encountered due to the use of the NSE intraocularly. No retinal breaks were observed due to traction of the catheter at the site of insertion or due to his movement in and out the vitreous cavity.

CONCLUSION

The use of the nitinol lens cage seemed feasible and showed no complications in our small group of patients. It made easier the management of dropped nucleus without the need for a larger scleral opening also in case of very hard lens.

Influence of an intentionally induced posterior lens capsule rupture on the real-time intraocular pressure during phacoemulsification in canine ex vivo eyes

OBJECTIVE

To evaluate the changes in the intraocular pressure (IOP) following an intentionally induced posterior lens capsule rupture (PLCR) during phacoemulsification in enucleated canine eyes. Furthermore, to compare the IOPs between different stages of phacoemulsification for two different bottle heights (BH).

PROCEDURES

Coaxial phacoemulsification was performed using a venturi-based machine at a 60 or 90 cm BH. A pressure transducer, inserted into the anterior chamber through the peripheral cornea, monitored real-time IOP. For one half of the lens, the sculpt-segment removal (SS) was followed by irrigation/aspiration (IA). The PLCR was intentionally created, and the SS and IA were repeated on the residual lens fragments.

RESULTS

For the 60 cm BH, the mean IOP following the PLCR was significantly higher than before the PLCR during SS (28.30 ± 12.56 and 38.71 ± 9.43 mmHg before and after PLCR, respectively) and IA (42.76 ± 12.46 and 47.88 ± 7.10 mmHg before and after PLCR, respectively) stages (P < 0.001). For the 90 cm BH, the mean IOP following the PLCR was also significantly higher than before the PLCR during SS (33.39 ± 11.09 and 58.17 ± 6.89 mmHg before and after PLCR, respectively) and IA (62.39 ± 12.46 and 72.04 ± 8.59 mmHg before and after PLCR, respectively) stages (P < 0.001).

CONCLUSIONS

The occurrence of a PLCR led to an increase in IOP during both the SS and IA stages. The elevated IOP after the PLCR might be one of the most important factors for ocular tissue damage, as it reduces ocular perfusion. Additionally, the BH should be reduced following PLCR to prevent complications stemming from the raised IOP.

Clinical outcomes of pars plicata anterior vitrectomy: 2-year results

Purpose:

To demonstrate the safety and outcome of a surgical approach that uses pars plicata site for anterior vitrectomy during phacoemulsification procedure complicated by posterior capsule rupture and residual cortical matter.

Design:

Single center, retrospective, interventional, noncomparative study.

Materials and Methods:

Medical records of a consecutive series of 35 eyes of 35 patients who underwent pars plicata anterior vitrectomy (PPAV) were reviewed. The main outcome measures were corrected and uncorrected distance visual acuity (CDVA, UDVA), early and late postoperative complications and intraocular pressure (IOP). Ultrasound biomicroscopic (UBM) evaluation of sclerotomy site and spectral domain optical coherence tomography analysis for central macular thickness (CMT) was performed. The final visual outcome at 2 years was evaluated.

Results:

At 2 years follow-up, the mean postoperative UDVA (logarithm of the minimum angle of resolution [logMAR]) and CDVA (logMAR) was 0.49 ± 0.26 and 0.19 ± 0.14, respectively. There was no significant change in the IOP (P = 0.061) and the mean CMT at 2 years was 192.5 ± 5.54 μm. The postoperative UBM image of the sclerotomy site at 8 weeks demonstrated a clear wound without any vitreous adhesion or incarceration. Intraoperative hyphema was seen in 1 (2.8%) case and postoperative uveitis was seen in 2 (5.7%) cases, which resolved with medications. No case of an iatrogenic retinal break or retinal detachment was reported.

Conclusions:

PPAV enables a closed chamber approach, allows thorough cleanup of vitreous in the pupillary plane and anterior chamber and affords better access to the subincisional and retropupillary cortical remnant with a significant visual outcome and an acceptable complication rate.

Intraoperative management of posterior capsular rupture

PURPOSE OF REVIEW

Posterior capsular rupture (PCR) and vitreous loss are inevitable complications encountered in cataract surgery across all levels of surgical experience and in spite of technological advances to improve safety. Thus, cataract surgeons must always be prepared to practice safe and effective intraoperative management strategies for capsular rupture.

RECENT FINDINGS

Novel approaches for lens fragment removal, vitrectomy, and lens implantation have expanded the available options for cataract surgery in the setting of an open posterior capsule. Intraoperative PCR management strategies should prioritize safety and strive to minimize vitreous traction, stabilize anterior chamber volume, maintain capsular and zonular integrity, and protect the corneal endothelium and other anterior segment structures.

SUMMARY

With appropriate management of PCR and vitreous, surgeons may still deliver safe and satisfactory visual outcomes for modern cataract surgery.

2013 update on the management of posterior capsular rupture during cataract surgery

PURPOSE OF REVIEW

Posterior capsular rupture (PCR) is an infrequent complication of cataract surgery that can lead to significant ocular morbidity and permanent vision loss. In the setting of PCR, the primary objective is the safe and thorough evacuation of vitreous and lens fragments from the anterior segment. The secondary objective is the stable placement of an intraocular lens (IOL) selected for best refractive outcomes. Expedited referral to vitreoretinal specialists is recommended for management of posteriorly dislocated lens material and surveillance for retinal injury. It is the intention of this review to present current guidelines for the management of PCR.

RECENT FINDINGS

There are new techniques available to anterior and posterior segment surgeons in the setting of PCR. Endoillumination may facilitate visualization during anterior vitrectomy and the IOL may be used as a pupillary barrier to prevent loss of lens fragments. When secondary procedures are needed, early return to the operating room and small-gauge pars plana techniques may reduce patient morbidity.

SUMMARY

When approached carefully and systematically, patients may have good outcomes in the setting of PCR. Recent advancements in instrumentation and technique encourage further study and may lead to new standards of care.

Clinical outcomes of sleeveless phacotip assisted levitation of dropped nucleus

BACKGROUND/AIM

To demonstrate the feasibility of a sleeveless phacotip-assisted approach to levitate dropped nucleus.

METHODS

This single-centre, retrospective, interventional, non-comparative case series reviewed the medical records of 34 eyes of 34 patients. Corrected and uncorrected distance visual acuity (CDVA, UDVA), early and late postoperative complications and ultrasound biomicroscopic (UBM) evaluation of the sclerotomy site was analysed.

RESULTS

At 18 months follow-up, the mean postoperative UDVA and CDVA in Snellen's decimal equivalent was 0.42 ± 0.16 and 0.91 ± 0.2, respectively. There was a significant improvement in the UDVA (p=0.001) and CDVA (p=0.002). Nucleus drop occurred following intraoperative posterior capsular rupture in 25 eyes (73.5%), zonular weakness in 5 eyes (14.8%) and post-trauma in 4 eyes (11.7%). In the early postoperative period, corneal oedema was seen in 2 eyes, pigment dispersion in 3 eyes and vitritis in 2 eyes. There was loss of CDVA in 1 (2.9%) eye due to persistent cystoid macular oedema. UBM did not reveal any vitreous incarceration into the sclerotomy site.

CONCLUSION

Dropped nucleus was successfully levitated into anterior chamber with this technique, resulting in a significant visual outcome with a favourable complication rate.

Clinical outcomes of intraocular lens scaffold surgery: a one-year study

PURPOSE

To evaluate the safety and 1-year outcome of the intraocular lens (IOL) scaffold technique in eyes with soft to moderate nuclear remnants after intraoperative posterior capsule rupture (PCR).

DESIGN

Single-center, retrospective, interventional, noncomparative, consecutive case series.

PARTICIPANTS

A total of 20 eyes of 20 patients who had intraoperative PCR underwent IOL scaffold surgery in a tertiary clinic.

METHODS

A retrospective analysis of medical records of a consecutive series of patients who underwent IOL scaffold surgery from August 2011 to February 2013 was reviewed. All surgeries were performed by a single surgeon, and a 3-piece, 6.0-mm optic, acrylic, foldable IOL with a modified C-loop haptic configuration was implanted in all eyes.

MAIN OUTCOME MEASURES

The preoperative and postoperative parameters evaluated were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), specular microscopy, gonioscopy, ultrasound biomicroscopy, central macular thickness, intraocular pressure (IOP), and anterior and posterior segment inflammation. The final visual outcome at 1 year was evaluated.

RESULTS

At 1-year follow-up, the mean postoperative UDVA and CDVA in Snellen's decimal equivalent was 0.58 ± 0.15 and 0.90 ± 0.17, respectively. The IOL was placed in the sulcus for 14 eyes and in the capsular bag for 3 eyes, and glued intrascleral fixation of IOL was performed in 3 eyes. The mean postoperative refractive error at the final examination was -0.4 ± 0.05 diopter (standard error of mean). Postoperative CDVA of 20/20 and 20/30 was achieved in 75% (15 eyes) and 25% (5 eyes), respectively. There was no correlation between preoperative specular count and percentage loss of cells (P = 0.602; r(2)=0.015). The mean central macular thickness at 1 year was 182.5 ± 11.79 μm. Clinical macular edema was observed in 1 of 20 eyes (5%).

CONCLUSIONS

The IOL scaffold provided an effective, relatively noninvasive means of emulsifying moderate to soft nuclear remnants in eyes with intraoperative PCR, with a good visual outcome and a favorable complication rate.

Planned posterior assisted levitation in severe subluxated cataract: surgical technique and clinical results

We report the surgical technique and outcome of planned posterior assisted levitation (P-PAL) in four cases of subluxated cataract. P-PAL was planned as the preferred approach in all cases. A spatula was inserted via the pars plana, the whole lens was lifted to the anterior chamber and then removed through a scleral tunnel incision. Anterior chamber intraocular lenses were implanted in all cases. All four eyes had severe subluxation of the crystalline lenses with marked phacodonesis. Two eyes had history of blunt trauma, and the other two eyes had severe pseudoexfoliation with spontaneous lens subluxation. Follow-up ranged from 1 to 2 years in three cases. The postoperative visual acuity was 20/80 or better. No intraoperative complications were observed. In conclusion, the P-PAL technique was successfully performed during cataract surgery in four eyes with severe subluxated cataracts. There were no complications over the long-term follow-up.

Use of viscoelastic substance in ophthalmic surgery - focus on sodium hyaluronate

Among viscoelastic substances, sodium hyaluronate has become the most popular for intraocular surgeries since the introduction of Healon^® (sodium hyaluronate 1%, 4 × 10⁶ daltons) in 1979. This review focuses on the recent development of a new generation of sodium hyaluronate agents with new rheologic properties and the relevant new techniques used in cataract, glaucoma, corneal, and vitreoretinal surgeries. The introduction of sodium hyaluronate agents with different rheologic properties has improved the safety and reliability of intraocular surgeries. Although there have been numerous studies reporting the effectiveness of viscoelastic substances in intraocular surgeries, rigorous validation by multi-center randomized control trials is lacking in many cases. At present, no single viscoelastic agent is most suitable to all of the various intraocular surgical techniques. Therefore, ophthalmologic surgeons should keep up with recent developments of viscoelastic agents and relevant surgical techniques for better patient care.

Posterior-assisted levitation in cataract surgery

PURPOSE OF REVIEW

Posterior-assisted levitation (PAL) is a surgical maneuver for dealing with rupture of the posterior capsule or zonular dehiscence with threatened or actual subluxation of the nucleus or entire lens into the vitreous during phacoemulsification. PAL is often unknown or overlooked, especially by young or inexperienced surgeons.

RECENT FINDINGS

The advantages of PAL are, first, that it often enables completion of phacoemulsification and intraocular lens placement without conversion to an open eye with nuclear expression and second, it prevents luxation of nucleus, nuclear fragments, or the lens into the vitreous avoiding the necessity for trans pars plana vitrectomy (TPPV)-lensectomy. PAL has recently been criticized by vitreoretinal surgeons as dangerous and to be avoided. However, there is no large series or controlled study showing that the PAL maneuver is associated with an excessive complication rate as compared to cases of nuclear or lens subluxation in the vitreous managed by TPPV-lensectomy with or without previous PAL.

SUMMARY

PAL is a simple technique that can be extremely helpful. In cases in which the PAL maneuver is unsuccessful and in cases with complete luxation of nucleus or lens into the vitreous, the patient should be referred for TPPV-lensectomy.

Vitreous loss during cataract surgery: prevention and optimal management

Vitreous loss during cataract surgery is associated with a poor visual outcome. Experienced surgeons and those performing a high volume of cataract operations have lower rates of vitreous loss. Risk stratification systems, which allow prediction of intraoperative complications from preoperative criteria exist, so that less experienced surgeons can avoid higher risk cases. The management of vitreous loss includes counselling patients before surgery of the potential risks and complications. When vitreous loss occurs, it is important for the surgeon to avoid actions [corrected] which increase the chance of disaster for the eye. These include phacoemulsification in the presence of vitreous and attempts to recover dropped lens fragments from the posterior segment without vitrectomy. There are advantages in performing an anterior vitrectomy by the pars plana route rather than through the anterior chamber and this approach is facilitated by sutureless 23-gauge instruments. Dislocation of lens nuclear fragments into the vitreous is associated with a high incidence of retinal detachment as well as secondary glaucoma and cystoid macular oedema. Early involvement of a retinal surgeon in the management of these eyes is recommended.

Posterior-assisted levitation: Outcomes in the retrieval of nuclear fragments and subluxated intraocular lenses

PURPOSE

To report the outcomes of posterior-assisted levitation (PAL) to retrieve nuclear fragments and subluxated intraocular lenses (IOLs).

SETTING

Singapore National Eye Centre, Singapore, Singapore.

METHODS

In a retrospective series, the case notes of consecutive surgeries performed by a single surgeon between 1999 and 2006 were reviewed. Posterior-assisted levitation was performed for intraoperative posterior capsule rupture with nucleus-IOL dislocation or for late subluxation of posterior chamber intraocular lenses (PC IOLs). This was accomplished by the pars plana insertion of a needle followed by levitation of the subluxated object. Ophthalmic viscosurgical device injection was not used as an adjunct for levitation.

RESULTS

Fourteen patients with PAL were followed for a mean of 18.71 months (range 1 to 79 months). There were 3 cases of dropped nucleus/nuclear fragments, 1 case of intraoperative subluxated PC IOL, and 10 cases of late subluxated PC IOLs. Complications included 1 case of retinal detachment occurring 20 months after PAL and 1 case of cystoid macular edema in a patient with previous anterior uveitis. Best corrected visual acuity was 20/40 or better in all except 3 patients (1 retinal detachment, 1 corneal edema/scarring, 1 unspecified).

CONCLUSION

Posterior-assisted levitation provided an effective, relatively noninvasive means of levitating nuclear fragments and PC IOLs with few complications.

Posterior assisted levitation: Long-term follow-up data

PURPOSE

To report the long-term outcome of posterior assisted levitation (PAL) in cases of a sinking dropped nucleus.

SETTING

Department of Ophthalmology, Soroka University Medical Center, Beer-Sheva, Israel.

METHODS

The medical records of all the patients having cataract surgery at Soroka University Medical Center from January 1999 to December 2002 were retrospectively reviewed. The PAL technique was used in 7 eyes, 3 of which had mini-nuc cataract surgery and 4 of which had phacoemulsification. Posterior assisted levitation was done because of an intraoperative posterior capsule tear with vitreous loss and a sinking dropped nucleus. A spatula was inserted via the pars plana, and the nucleus was lifted to and removed from the anterior chamber.

RESULTS

The follow-up ranged from 16 to 28 months. The postoperative visual acuity was 20/40 or better in all but 2 eyes, which had 20/50 acuity because of age-related macular degeneration and diabetic macular edema, respectively. No postoperative complications were observed.

CONCLUSIONS

The PAL technique was successfully performed during cataract surgery in 7 eyes with a posterior capsule tear, vitreous loss, and a sinking dropped nucleus. There were no complications over the long-term follow-up.