Purpose To evaluate the use of 2 dyes for staining the posterior capsule to enhance visualization during posterior continuous curvilinear capsulorhexis (PCCC). Setting Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. Methods Indocyanine green 0.5% (ICG) and trypan blue 0.1% were used to stain the posterior capsule for performing PCCC in 8 human eyes obtained postmortem. The eyes were prepared according to the posterior video technique of Miyake–Apple. After CCC and hydrodissection/delineation were performed, the nucleus was carefully delivered by hydroexpression. Cortical cleanup was completed by irrigation/aspiration. The posterior capsule was stained by instilling 1 microdrop of ICG (4 eyes) or trypan blue (4 eyes) in the capsular bag. A PCCC was then performed by 2 independent surgeons (4 eyes/surgeon) not familiar with this technique. Each surgeon also performed PCCC in 2 eyes without the use of dye. Results Both dyes facilitated the performance of PCCC after staining the otherwise transparent posterior capsule. It was easier to differentiate the stained posterior capsule flap from the underlying transparent anterior hyaloid phase of the vitreous. In addition, optic capture of an intraocular lens, with or without anterior vitrectomy, was easily accomplished because of the enhanced visualization by posterior capsule staining. Conclusion Posterior capsule staining can be successfully used to learn and perform the PCCC procedure, combined with optic capture, anterior vitrectomy, or both.

Dye-enhanced cataract surgery. Part 1: anterior capsule staining for capsulorhexis in advanced/white cataract.

Purpose of study To determine the efficacy of Nd:YAG vitreolysis and pars plana vitrectomy in the treatment of vitreous floaters. Methods This is a single centre retrospective study of 31 patients (42 eyes) who underwent 54 procedures, Nd:YAG vitreolysis or pars plana vitrectomy, for the treatment of vitreous floaters between January 1992 and December 2000. Main outcome measures were percentage symptomatic improvement following treatment and incidence of post-operative complications. Statistical analysis was performed using the Fisher exact test. Results Posterior vitreous detachment was the primary cause of floaters in all 42 eyes with co-existing vitreous veils in three eyes and asteroid hyalosis in two eyes. Thirty-nine of 42 eyes received Nd:YAG vitreolysis. Thirty-eight percent found Nd:YAG vitreolysis moderately improved their symptoms while 61.5% found no improvement. After an average of 14.7 months follow-up no post-operative complications were recorded. Fifteen eyes underwent a pars plana vitrectomy, one with combined phacoemulsification and posterior chamber implantation and 11 following unsuccessful laser vitreolysis. Pars plana vitrectomy resulted in full resolution of symptoms in 93.3% of eyes. One patient developed a post-operative retinal detachment which was successfully treated leaving the patient with 6/5 VA. Conclusion Patients’ symptoms from vitreous floaters are often underestimated resulting in no intervention. This paper shows Nd:YAG vitreolysis to be a safe but only moderately effective primary treatment conferring clinical benefit in one third of patients. Pars plana vitrectomy, while offering superior results, should be reserved for patients who remain markedly symptomatic following vitreolysis, until future studies further clarify its role in the treatment of patients with floaters and posterior vitreous detachment.

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Nd:YAG vitreolysis and pars plana vitrectomy: surgical treatment for vitreous floaters.

Intraoperative management of posterior capsule tears in phacoemulsification and intraocular lens implantation.

Purpose: To report a new intraocular lens (IOL) and an IOL implantation concept, the bag-in-the-lens implantation technique, designed to prevent posterior capsule opacification (PCO). Setting: The University of Antwerp, Department of Ophthalmology, Edegem, Belgium, and the Netherlands Ophthalmic Research Institute, Department of Morphology, Amsterdam, The Netherlands. Methods: After identical curvilinear capsulorhexes are created in both the anterior and posterior capsules, the capsules are inserted in a flange of the IOL, thus the term bag-in-the-lens as opposed to the currently used lens-in-the-bag technique. The IOL was implanted in an in vitro human capsular bag model and in 10 eyes of 9 patients with cataract. Lens epithelial cell (LEC) outgrowth and PCO formation were observed. Results: When both capsular blades were well stretched around the IOL optic, the in vitro capsular bag model showed LEC proliferation only within the space of the remaining lens bag. The LEC proliferation was limited, and there was no tendency toward proliferation approaching the visual axis. In all 10 eyes, the optical axis remained clear during a follow-up between 4 and 15 months. Conclusions: This new IOL prevented LEC proliferation in vitro and seems promising in vivo. Target patients are those at risk of PCO including those with congenital cataract, uveitis, diabetes, or cataract extraction combined with vitrectomy.

Bag-in-the-lens implantation of intraocular lenses

Purpose: To evaluate the results of phacoemulsification in eyes with posterior polar developmental cataract and to appraise the strategy for surgical management. Setting: Iladev Cataract & IOL Research Centre, Raghudeep Eye Clinic, Ahmedabad, India. Method: This prospective study comprised 25 consecutive patients. All surgerieswere performed by 1 surgeon. Endophacoernulsification was carried out after hydrodelineation. Hydrodissection or rotation was not attempted. A 2-port vitrectomy was performed when necessary. Results: Mean follow-up was 13.72 months (range 1 to 22 months). Nine patients (36%) developed posterior capsule rupture and 8 (32%) revealed plagues. An intraocular lens (IOL) was implanted in all 25 eyes. In of 9 cases with rupture, the haptics were placed, in the sulcus; in 1 case, the IOL was placed in the bag. One patient in the capsular rupture group developed macular edema 3 weeks postoperatively that responded to conservative treatment. Among 25 patients, 18 had a visual: acuity of 20/20 to 20/30 and 6, 20/80 to 20/120. These 6 patients had residual posterior capsule plaque. All except 2 patients with plaque, required a neodymium YAG capsulotomy. In these patients, visual acuity improved to 20/30. In 1 patient, with microcornea, acuity did not improve to beyond 20/120. Conclusion: This study confirms the predisposition to posterior capsule rupture in eyes with posterior polar cataracts. Careful surgical planning produces satisfactory technical and visual outcomes.

Phacoemulsification in eyes with posterior polar cataract.

Purpose: To evaluate the feasibility and risks of primary posterior capsulorhexis. Setting: Department of Ophthalmology, University Hospital of Liege, Belgium. Methods: Retrospective analysis of 319 patients with cataracts who had phacoemulsification or manual extracapsular cataract extraction with a simultaneous circular posterior capsulorhexis between August 1993 and April 1994. The number of intraoperative complications and the number of postoperative complications that could be related to the posterior capsule opening were looked at. Fluorescein angiography was performed in a random sample of patients. Results: Twelve intraoperative complications consisted of 5 irregular tears, 4 vitreous prolapses into the posterior capsulorhexis, and 3 vitreous prolapses into the anterior chamber; 11 occurred in eyes with positive posterior pressure. Postoperative complications consisted of 3 vitreous prolapses into the pupil and 1 retinal detachment. Two of the 3 late vitreous prolapses occurred in eyes in which the posterior capsulorhexis was larger than the intraocular lens (IOL) optic. The retinal detachment occurred in an eye with a 25.79 mm axial length. Fluorescein angiography of 49 cases revealed 3 with cystoid macular edema. Conclusions: Based on our results, we believe that primary posterior capsulorhexis can be a routine procedure during cataract surgery and IOL implantation in adults, except in cases of positive pressure. The diameter of the posterior capsulorhexis should be smaller than the diameter of the IOL optic.

Posterior capsulorhexis in adult eyes with intact and clear capsules.

Purpose To compare the clinical performance and safety of 2 ophthalmic viscosurgical devices (OVDs)—Twinvisc (OVD 1) and Duovisc (OVD 2)—in cataract surgery. Setting European multicenter study. Design Prospective randomized controlled study. Methods Patients with cataract had phacoemulsification and intraocular lens implantation in 1 eye. They were randomly assigned to receive OVD 1 or OVD 2. Preoperative and postoperative examinations over 3 months included mean intraocular pressure (IOP), incidence of IOP peaks (≥30 mm Hg and ≥24 mm Hg), endothelial cell count (ECC), corneal thickness, and intraocular inflammation. A subjective evaluation of the OVDs was performed. Results The study comprised 220 patients. The incidence of IOP peaks and the mean IOP were not statistically significantly different between the 2 groups at any of the follow-up visits. At 6 hours, the incidence of IOP spikes 30 mm Hg or higher was 6.5% and 7.2% in the OVD 1 and the OVD 2 groups, respectively (P = .846). For the IOP spikes 24 mm Hg or higher, the incidence was 16.8% and 25.2%, respectively (P = .128). Three months postoperatively there was no statistically significant difference in ECC and pachymetry between the 2 groups. Mild inflammation was noticed up to 7 days postoperatively after which it resolved in both groups. Subjectively, the OVD 2 was easier to use, whereas the OVD 1 had better cohesive and dispersive properties. Conclusions Both OVDs have similar performance and safety profiles in phacoemulsification cataract surgery. No clinically relevant differences were found between the 2 devices regarding transient IOP spikes, mean IOP, corneal endothelium injury, or inflammation.

Francoise Van Cauwenberge

Papers

Posterior capsulorhexis in adult eyes with intact and clear capsules.

Comparison of the performance and safety of 2 ophthalmic viscosurgical devices in cataract surgery.