Histology of anterior capsule fibrosis following phacoemulsification

A Modified Femtosecond Laser Technique for Anterior Capsule Contraction Syndrome

Anterior capsule contraction syndrome (ACCS) is a rare, late complication of cataract surgery, associated with impairment of visual function. In this paper, we describe a new surgical technique to treat ACCS by femtosecond laser procedure. The femtosecond laser was used to perform an anterior capsulotomy with a customized size, in order to avoid IOL damage. After ophthalmic viscosurgical device injection in the anterior chamber, the anterior capsule flap was separated from the IOL surface by gentle hydrodissection. This manoeuvre enabled an easy and safe removal of the fibrotic material by vitreal microscissors. Our technique allowed a complete removal of the fibrotic material and opening of the capsule, with immediate complete visual acuity recovery without IOL damage. In conclusion, femtosecond laser appears to be safe and effective for treatment of ACCS with long-lasting efficacy.

[Differentiated method of surgical prophylaxis against anterior capsular contraction syndrome during phacoemulsification]

Prevention of the anterior capsular contraction syndrome (ACCS) in the late postoperative period in patients with lens subluxation is a current problem of phacoemulsification (PE).

PURPOSE

To develop and clinically evaluate a differentiated method of surgical prophylaxis against ACCS during PE in patients with lens subluxation.

MATERIAL AND METHODS

Phacoemulsification surgery with in-the-bag IOL implantation and postoperative follow-up were carried out in 192 patients (192 eyes) with cataract and lens subluxation. In all patients, complete anterior capsulorhexis at the beginning of the surgery was not possible. A differentiated approach was used for capsulorhexis extension at the final stage of the operation after in-the-bag IOL implantation. Three groups of patients were formed according to the three most common clinical situations.

RESULTS

There were no signs of ACCS development in as many as 189 (98.4%) cases. In 3 (1.6%) cases, slight narrowing of the anterior capsulorhexis opening was noted, however, with no effect to the IOL position and functional results of the operation.

CONCLUSION

The differentiated approach to anterior capsulorhexis in patients with lens subluxation allowed to perform phacoemulsification with in-the-bag IOL implantation and to avoid ACCS development in the late postoperative period.

Femtosecond laser assisted capsulotomy in the treatment of capsule contraction case report

Purpose

To present the surgical value of femtosecond laser capsulotomy in the treatment of capsular contraction.

Observations

The clinical case of a 63-year-old male patient with single eye who, two months after cataract surgery without complications, presented a significant dislocation of the secondary intraocular lens due to a capsule contraction and epithelial metaplasia that covered the lens optics and caused low vision.

Conclusions

The femtosecond laser-assisted capsulotomy proved to be effective and safe with minimal traction on the zonule and no IOL damage, in this patient with a follow-up of 29 months.

Circular YAG laser anterior capsulotomy for anterior capsule contraction syndrome

PURPOSE

To evaluate circular neodymium: YAG laser incision in cases of anterior capsular contraction syndrome (ACCS) by comparing it to radial Neodymium: YAG laser incision as for efficacy and safety.

SETTINGS

Ophthalmology Department, Benha University Hospitals.

METHODS

The study was done on 74 eyes of 66 patients with symptomatic ACCS. Eyes were randomly allocated to one of the two groups. Group I were treated by circular YAG laser anterior capsulotomy. Group II were treated by radial YAG laser anterior capsulotomy. All cases passed a full ophthalmic examination before laser capsulotomy, 1 week, 1 month, 6 months and 12 months after laser.

RESULTS

BCVA at the 1st week and the 1st month after the capsulotomy did not show any significant difference between the two groups; however at the 3rd and 6th months, the circular group showed better visual acuity than the radial group (p 0.001 and < 0.001, respectively). All post-YAG UCVA and BCVA were significantly higher than pre-YAG UCVA and BCVA in both groups. IOL decentration occurred in two cases in radial group. Circular group had significantly higher percentage of contraction relief (94.4%) than the radial group (66.7%) with p value 0.003.

CONCLUSION

Circular Nd:YAG anterior capsulotomy is more effective and safe than radial capsulotomy in 1-year follow-up.

[Capsule contraction syndrome in pseudophakia]

This is a review of the literature on capsule contraction syndrome (CCS) in pseudophakic patients that involves severe fibrosis along the margin of the anterior capsule's opening and progressive contraction of the capsular bag. Possible causes of CCS and principles of its prevention and treatment have been analyzed.

Sprouty is a negative regulator of transforming growth factor β-induced epithelial-to-mesenchymal transition and cataract

Fibrosis affects an extensive range of organs and is increasingly acknowledged as a major component of many chronic disorders. It is now well accepted that the elevated expression of certain inflammatory cell-derived cytokines, especially transforming growth factor β (TGFβ), is involved in the epithelial-to-mesenchymal transition (EMT) leading to the pathogenesis of a diverse range of fibrotic diseases. In lens, aberrant TGFβ signaling has been shown to induce EMT leading to cataract formation. Sproutys (Sprys) are negative feedback regulators of receptor tyrosine kinase (RTK)-signaling pathways in many vertebrate systems, and in this study we showed that they are important in the murine lens for promoting the lens epithelial cell phenotype. Conditional deletion of Spry1 and Spry2 specifically from the lens leads to an aberrant increase in RTK-mediated extracellular signal-regulated kinase 1/2 phosphorylation and, surprisingly, elevated TGFβ-related signaling in lens epithelial cells, leading to an EMT and subsequent cataract formation. Conversely, increased Spry overexpression in lens cells can suppress not only TGFβ-induced signaling, but also the accompanying EMT and cataract formation. On the basis of these findings, we propose that a better understanding of the relationship between Spry and TGFβ signaling will not only elucidate the etiology of lens pathology, but will also lead to the development of treatments for other fibrotic-related diseases associated with TGFβ-induced EMT.

Tissue reaction to hydrophilic intraocular lenses

The implant of intraocular lenses (IOLs) following cataract surgery induces a foreign body reaction to the IOL and a lens epithelial cell reaction. The host response to the IOL is mainly influenced by biomaterial properties. With the increasing use of phacoemulsification and small incision cataract surgery, there is growing interest in the use of foldable IOLs made of different materials. Hydrophilic acrylic IOLs include a wide group of foldable biomaterials different in terms of water content. These lenses have been reported to show a good biocompatibility after implantation. Nevertheless, tissue reaction to the implant of hydrophilic lenses is variable and not directly related to the hydrophilicity of their surface. A different adsorption of proteins on the IOL optic surface might be responsible for the different cellular reaction and lens epithelial cell response. Other properties besides hydrophilicity should be taken into account to classify IOL biomaterials.

Capsular peeling in anterior capsule contraction syndrome: surgical approach and histopathological aspects

We present 4 cases of anterior capsule contraction syndrome in which progressive shrinkage of the anterior capsulorhexis developed after uneventful phacoemulsification. Three eyes were pseudophakic, and 1 eye remained aphakic. The newly formed membrane was surgically peeled from the anterior capsule, restoring the capsular bag.

Lens epithelial cell reaction after implantation of different intraocular lens materials

PURPOSE

To determine the influence of intraocular lens (IOL) material on anterior capsular opacification and membrane growth over the anterior IOL surface in patients who have undergone standardized small-incision cataract surgery and foldable IOL implantation in the capsular bag.

DESIGN

Randomized controlled trial.

PARTICIPANTS

Eighty-eight cataract patients (88 eyes).

METHODS

Patients were randomly assigned to receive one of four different foldable IOLs after phacoemulsification: Storz Hydroview H60M, Corneal ACR6D, AMO SI40NB, and Alcon AcrySof MA60BM. Examinations on days 7, 30, 90, 180, 360, and 720 after surgery included ophthalmologic examination, slit-lamp biomicroscopy, and photography using red reflex and focal illumination of the anterior IOL surface.

MAIN OUTCOME MEASURES

Best-corrected visual acuity was measured at each examination. In addition, the anterior capsule opacification and the membrane growth on the anterior IOL surface were graded according to a subjective method by the same researcher.

RESULTS

The fibrosis of the anterior capsule was more frequently observed in the group using Corneal ACR6D and AMO SI40NB. The Hydroview and ACR6D groups showed a higher percentage of cases with membrane growth from the rhexis edge on the anterior IOL surface. AcrySof showed the lowest presence of fibrosis of the anterior capsule, and no membrane growth was noted.

CONCLUSIONS

Anterior capsule opacification is an index of IOL biocompatibility. The natural location of lens epithelial cells (LECs) precludes the possibility of the IOL's design influencing the anterior capsule behavior. The local response of LECs varies according to the IOL studied. This may be related to the chemical and physical properties of the materials used in the different IOLs.

Biocompatibility of hydrophilic intraocular lenses

PURPOSE

To assess the biocompatibility of 3 hydrophilic acrylic intraocular lenses (IOLs) by evaluating the postoperative cell reaction on the IOL surface, anterior capsule opacification (ACO) rate, and presence of membrane growth over the anterior IOL surface.

SETTING

University Eye Clinic of Trieste, Trieste, Italy.

METHODS

In this prospective study, 73 patients were randomized to receive 1 of 3 types of hydrogel IOLs after phacoemulsification: Storz Hydroview H60M, Corneal ACR6D, or Ioltech Stabibag. To analyze and photograph the anterior IOL surface, slitlamp biomicroscopy and specular microscopy were performed 7, 30, 90, and 180 days after surgery. Small, epithelioid, and giant inflammatory cell reaction was evaluated. In addition, ACO and membrane growth on the anterior IOL surface were assessed.

RESULTS

Low inflammatory cell adhesion was observed on the anterior surface of all 3 IOLs. The Stabibag group had a significantly higher grade of small inflammatory cell reaction 7 and 30 days after surgery. A significantly higher rate of ACO was observed in the ACR6D group. The Hydroview and ACR6D groups had a significantly higher percentage of membrane growth from the capsulorhexis edge onto the anterior IOL surface than the Stabibag group.

CONCLUSIONS

Clinically, the 3 hydrophilic IOLs behaved in a different manner, showing the different forms of biocompatibility. Results indicate that a different chemical composition determines correspondingly different protein absorption on IOL surfaces. This might result in a different adhesion pattern and spreading of lens epithelial and inflammatory cells.

Posterior continuous curvilinear capsulorhexis with hydrogel and silicone intraocular lens implantation: development of capsulorhexis size and capsule opacification

PURPOSE

To evaluate the influence of primary posterior continuous curvilinear capsulorhexis (PCCC) on capsule opacification development and capsular bag changes within the first year after cataract surgery with 2 intraocular lenses (IOLs) of comparable design but different material.

SETTING

Department of Ophthalmology, University of Vienna, Medical School, Vienna, Austria.

METHODS

Thirty-seven patients with age-related cataract had bilateral small incision cataract surgery with a PCCC performed after capsular tension ring insertion. One eye was randomly assigned to receive a hydrogel IOL and the other eye, a silicone IOL. Standardized digital retroillumination photographs were taken 1 day, 1 week, and 1, 3, 6, and 12 months after surgery to evaluate changes in the dimensions of the anterior and posterior capsulorhexis opening area and the presence of anterior and posterior capsule opacification.

RESULTS

The area of the anterior continuous curvilinear capsulorhexis (ACCC) opening was significantly reduced during the first 6 postoperative months. The shrinkage was more pronounced (-25%) in the silicone IOL group than in the hydrogel IOL group. Ten percent of eyes with a silicone IOL had marked shrinkage of the ACCC. The area of the PCCC did not change in eyes with a hydrogel IOL but was larger (+20%) in eyes with a silicone IOL. Anterior ongrowth was observed in 60% in the hydrogel group and in no eye in the silicone group. Anterior capsule fibrosis was observed in 90% in the silicone group and in 20% in the hydrogel group. Total closure of the PCCC was not observed within the first year, but posterior ongrowth was observed in 40% in the hydrogel group and 10% in the silicone group.

CONCLUSIONS

Anterior capsulorhexis shrinkage with concomitant posterior capsulorhexis enlargement was observed in eyes with a silicone IOL. The hydrogel IOL induced more ongrowth on the anterior and posterior IOL surfaces, whereas the silicone IOL induced more anterior capsule fibrosis. Total closure of the PCCC was not observed within the first year after surgery.

Risk factors for anterior capsule contraction syndrome with polypropylene or poly(methyl methacrylate) haptics

PURPOSE

To determine the effect of haptic composition on the development of anterior capsule contraction syndrome (CCS) requiring neodymium: YAG anterior capsulotomy.

SETTING

Ophthalmology practice in Lancaster, Pennsylvania, USA.

METHODS

This retrospective study covered a 30 month period during which 1 surgeon discontinued implanting AMO SI-30NB intraocular lenses (IOLs) with polypropylene haptics (n = 216) in favor of SI-40NB IOLs with poly(methyl methacrylate) (PMMA) haptics (n = 127). The transition was motivated by the suspicion that the PMMA haptics would maintain the capsulorhexis opening better and reduce the need for an anterior capsulotomy.

RESULTS

Three eyes with SI-30NB IOLs (1.4%) required anterior capsulotomies; 2 eyes had preoperative pseudoexfoliation syndrome and required the capsulotomy within 3 months of surgery. Three eyes with SI-40NB IOLs (2.4%) required anterior capsulotomies within 4 months; 2 eyes had preoperative pseudoexfoliation syndrome and 1 had traumatic zonular weakness. The incidence of anterior capsulotomy did not differ significantly between the 2 IOL populations (P > .5), although preoperative pseudoexfoliation syndrome was a significant risk factor in both groups (P < .005).

CONCLUSIONS

The polypropylene haptics of the SI-30NB IOL and the PMMA haptics of the SI-40NB IOL did not differ significantly in their ability to prevent CCS requiring anterior capsulotomy. Regardless of IOL haptic composition, eyes with preoperative zonular weakness associated with pseudoexfoliation syndrome or ocular trauma can develop CCS within 3 months of surgery and should, therefore, be followed closely in the early postoperative weeks to minimize the sequelae of anterior capsule fibrosis.