Capsular bag intraocular lens fixation with retention of the anterior capsule

In-the-bag fixation of a posterior chamber intraocular lens (IOL) may be performed with greater protection of the uveal tract if the anterior capsule is retained so the IOL is almost completely enveloped in the capsular bag. A surgical technique for capsular bag fixation without anterior capsulectomy and a bulbous-tipped scratcher devised for use with this technique are described.     

In-the-bag secondary intraocular lens implantation in children

BACKGROUND: Surgery for congenital cataracts in early infancy usually includes a primary posterior capsulectomy and an anterior vitrectomy. Initially, most of these infants have aphakia after surgery. Over time, remaining equatorial lens epithelial cells produce new cortical fibers, resulting in a ring of cortex trapped between the lens equator and the fused anterior and posterior capsulectomy edges. A potential space is maintained between the anterior and posterior capsular leaflets. We describe a technique for placing a secondary intraocular lens (IOL) within the capsular bag. PATIENTS AND METHODS: Eight children, ranging in age from 11 months to 14 years, who originally had aphakia after cataract extraction were operated on with the intent to reopen the capsular bag and place an IOL in the bag. RESULTS: Secondary in-the-bag IOL implantation was successfully completed in 7 of 8 children. This was accomplished by reopening the capsular bag 360 degrees at the edge of the fused anterior and posterior capsulectomy remnants, using the previously published vitrectorhexis technique. Residual cortical material was aspirated, and an IOL was placed within the capsular bag. In 1 child, aged 14 years, the capsular bag was reopened, but the lens was placed in the ciliary sulcus because the new anterior capsule edge could not be visualized for 360 degrees . CONCLUSION: Placement of secondary IOLs within the capsular bag can be accomplished successfully for selected patients in the pediatric population. Surgeons operating on infantile cataracts without primary IOL placement can facilitate capsular IOL sequestration later by limiting the anterior and posterior capsulectomy to 4 to 5 mm and performing a generous anterior vitrectomy to help prevent secondary closure of the smaller capsulectomy.     

Spontaneous late dislocation of intraocular lens within the capsular bag in pseudoexfoliation patients

PURPOSE: To identify a delayed complication of cataract surgery in patients with zonular weakness caused by pseudoexfoliation syndrome. DESIGN: Retrospective observational case series. PARTICIPANTS: Eight eyes in seven patients with clinically diagnosed pseudoexfoliation syndrome who had undergone previous uncomplicated cataract extraction and placement of a posterior chamber intraocular lens. METHODS: This study evaluated eight cases of late spontaneous dislocation of posterior chamber intraocular lenses within the capsular bag in patients with pseudoexfoliation syndrome. Data were gathered retrospectively from patients' operative reports, medical records, and pathology reports. MAIN OUTCOME MEASURES: (1) Interval between original surgery and dislocation; (2) final best-corrected visual acuity and ocular outcome. RESULTS: All patients had a diagnosis of pseudoexfoliation syndrome and had previously undergone uncomplicated cataract surgery. No patient had any other predisposing factors that would lead to zonular dehiscence or weakness. Delayed dislocation of the entire capsular bag containing the intraocular lens (IOL) occurred spontaneously in all cases. Mean time from IOL implantation to dislocation was approximately 85 months (7 years and 1 month; range, 57-115 months) after surgery. Seven eyes were treated successfully with IOL exchange: six with placement of an anterior chamber IOL and one with scleral fixation of a posterior chamber IOL. The remaining case was treated by scleral fixation of the dislocated IOL. Gross pathology analysis of seven cases confirmed the presence of the IOL within the intact capsular bag. Six eyes have achieved final best-corrected visual acuity of 20/40 or better. CONCLUSION: Patients with pseudoexfoliation syndrome may be at risk for delayed spontaneous dislocation of IOL within the capsular bag after uncomplicated cataract surgery. Awareness of this newly recognized long-term complication may justify a reevaluation of surgical considerations for cataract removal in these patients.     

连续环形撕囊术后临床观察

目的 观察连续环形撕囊人工晶体状植入术后前房角和眼前段改变。方法 术后超过３月的１５２眼行前房角镜、眼压、散瞳前后裂隙灯等检查。随访时间平均１８．２月。结果 所有的人工昌状体襻都位于囊袋内。无１眼发生晶状体襻性周边虹膜前 。手术前后眼压,前房风度 和然素与非术眼无显著性差异。后囊浑浊７２眼占４７％,。需行激光治疗１０眼。结论连续环形撕囊术是迄今为止交夫工晶状 固定于囊袋内最稳定可靠的方法。     

Lens anatomical principles and their technical implications in cataract surgery. Part II: The lens nucleus

Preservation of the intact ("true") capsular bag, with no tears to the periphery, is essential to assure permanent in-the-bag fixation of the intraocular lens. Removal of a large nucleus using the open-system planned extracapsular cataract extraction (ECCE) technique is often associated with tearing of the capsulectomy or serious complications such as zonular rupture, vitreous loss, unintended intracapsular cataract extraction, or posterior lens prolapse. A closed-system planned ECCE technique which allows a safe removal of the lens while maintaining the integrity of the capsular bag is presented. Hydrodissection of the lens nucleus to an epinucleus and a central hard nucleus allows hydroextraction of the small hard core while pushing the posterior capsule backward. The positive pressure in the anterior chamber, provided by the anterior chamber maintainer, keeps the position of the lens steady in its natural location, and minimizes the stress on the zonular apparatus during nucleus delivery. The remaining epinucleus can be either hydroexpressed or aspirated. Fracturing the central core, when possible, enables removal of the lens material through a small limbal incision. Viscoelastic material can be combined with a low-flow, anterior chamber maintainer in a closed-system and provides a useful surgical tool.     

两种囊袋张力环巩膜固定方法在中重度晶状体不全脱位治疗中的应用研究

目的 比较一期改良式囊袋张力环(modified capsular tension ring,MCTR)巩膜固定或二期囊袋张力环(capsular tension ring,CTR)-囊袋复合体巩膜固定治疗中重度晶状体不全脱位的临床效果.方法 回顾性研究.收集我院2012年1月至2015年12月中重度(120°～270°)晶状体不全脱位患者30例43眼,均在局部麻醉下行超声乳化白内障吸出及MCTR或CTR和IOL囊袋内植入术,A组23眼均采用MCTR联合IOL植入术,一期巩膜固定;B组20眼均采用一期CTR联合IOL植入术,3～6个月后行二期CTR-囊袋复合体巩膜固定术.观察两组术后6个月最佳矫正视力、术后囊袋复合体的位置及并发症等情况.结果 术后6个月,A组87％患眼最佳矫正视力≥0.6,B组95％患眼最佳矫正视力≥0.6,两组相比差异无统计学意义(P＞0.05).术后所有CTR、IOL均位于囊袋内,囊袋中度收缩偏中心A组2眼,B组1眼,两组发生率相比差异无统计学意义(P＞0.05),均行YAG激光前囊膜松解后缓解.术后早期(1个月)并发症:前房渗出膜A组3眼,B组1眼;一过性高眼压A组5眼,B组2眼,两组两种并发症发生率相比差异均无统计学意义(均为P＞0.05).术后远期(6个月)并发症:后发性白内障A组3眼,B组1眼,两组相比差异无统计学意义(P＞0.05),均行YAG后囊切开术.结论 一期MCTR巩膜固定或二期CTR-囊袋复合体巩膜固定术后囊袋复合体的位置和稳定性均良好,对中重度晶状体脱位治疗均有效.     

Analysis of capsular bag defects and intraocular lens positions for consistent centration

Radial anterior capsular tears frequently occur in posterior-chamber iris-plane phacoemulsification cases. These tears extend to the capsular bag equator and can allow the knee of an in-the-bag posterior chamber intraocular lens (IOL) to unfold a smaller anterior capsular remnant. This unfolding can allow the knee of the IOL loop to extend beyond the capsular equator, leading to IOL decentration. Typical anterior capsular radial tear configurations along with guidelines for IOL design selection and orientation after recognition of these tears are presented. Proper IOL centration was achieved in 255 of 262 patients (97%) in a study observing these guidelines.     

选择性后房型人工晶状体植入前的后环形撕囊术

目的：探讨后囊膜增殖钙化的白内障摘出术后的后囊膜处理技术。方法：对42例(49只眼)后囊膜增殖钙化的白内障患者，于摘除白内障后在后囊膜旁中心处用破囊针头划出起始瓣，沿起始瓣边缘撕开一直径约3～4mm的类圆孔，再植入人工晶状体。结果：全部术眼后囊膜中央均有一透明类圆孔，术后无人工晶状体偏位或眼底异常改变。结论：后房型人工晶状体植入前的后环形撕囊术可使后囊膜增殖钙化的白内障获得视轴透明区，是安全有效地处置后囊膜混浊方法之一。     

Intraocular lens implantation in the absence of capsular support: a report by the American Academy of Ophthalmology

OBJECTIVE: This review was conducted to determine the safety and efficacy of open-loop anterior chamber, scleral-sutured posterior chamber, and iris-sutured posterior chamber intraocular lenses (IOLs) in eyes with inadequate capsular support for posterior chamber implantation in the capsular bag or ciliary sulcus. It also attempted to determine whether there is a preferred IOL or fixation site of choice in eyes with inadequate capsular support. METHODS: A literature search conducted for the years 1980 to 2001 yielded 189 citations related to IOL implantation in the absence of capsular support. An update search, conducted in March 2002, yielded an additional 28 articles. The Anterior Segment Panel members reviewed these abstracts and selected 148 articles of possible clinical relevance for review. Of these, 89 were considered sufficiently clinically relevant for the panel methodologist to review and rate according to the strength of evidence. A level I rating was assigned to properly conducted, well-designed, randomized clinical trials; a level II rating was assigned to well-designed cohort and case-control studies; and a level III rating was assigned to case series. Articles comparing the safety and efficacy of the IOL type and fixation site were further evaluated for the quality of the statistical methods used in the study. Studies with a rating of A or B were considered acceptable, C was borderline, and D and F were considered unacceptable as medical evidence. RESULTS: Forty-three articles with data concerning outcome of IOL insertion in eyes with inadequate capsular support had an evidence rating of level III or higher and were used in the final review of the safety and efficacy of one or more lens types and/or fixation sites. Seven articles had data about more than one lens type. Six had a statistical method rating of C or higher and were used to evaluate differences in visual outcomes and complication rates between lens types and fixation sites. CONCLUSIONS: The literature supports the safe and effective use of open-loop anterior chamber, scleral-sutured posterior chamber, and iris-sutured posterior chamber IOLs for the correction of aphakia in eyes without adequate capsular support for placement of a posterior chamber lens in the capsular bag or ciliary sulcus. At this time, there is insufficient evidence to demonstrate the superiority of one lens type or fixation site. Precise determination of small differences in visual outcome or complication rates will require a large prospective, randomized clinical trial.     

Capsular block syndrome caused by a reversed-optic intraocular lens

A 52-year-old man who had phacoemulsification and in-the-bag fixation of a posterior chamber intraocular lens (IOL) developed capsular block syndrome 1 day after reverse implantation of the IOL. After a neodymium:YAG (Nd:YAG) laser peripheral anterior capsulotomy, the distended capsular bag collapsed significantly and the artificial myopia partially resolved. An Nd:YAG laser peripheral anterior capsulotomy appeared to be an effective, simple, and minimally invasive method to treat this problem.     

Prospective experimental study of factors related to posterior chamber intraocular lens decentration.

The effect of posterior chamber intraocular lens (IOL) dimensions, design, style, loop fixation, and anterior capsular tears on decentration were investigated in an experimental model. Nine posterior chamber IOLs of various designs and styles with loop diameters between 12.0 and 14.0 mm and optic diameters between 5.0 and 7.0 mm were implanted in human eyes obtained post mortem. Symmetrical and asymmetrical fixation were investigated in eyes with and without radial tears using the Miyake posterior view technique. Location of IOL loops proved to be the most significant factor in IOL decentration. Decentration was least with symmetrical bag/bag fixation and no radial tears (mean = 0.20 +/- 0.05 mm). Asymmetrical bag/sulcus fixation in the presence of anterior capsular tears was associated with the highest decentration rate (mean 0.68 +/- 0.28 mm). Optic size and total loop diameter had no apparent effect on IOL centration in the immediate postoperative period.     

Effect of intraocular lens and anterior capsule opening type on posterior capsule opacification.

PURPOSE: To determine the effect of intraocular lens (IOL) type and anterior capsulectomy technique on the incidence of posterior capsule opacification. SETTING: Department of Ophthalmology, Medical Faculty, University of Ondokuz Mayis, Samsun, Turkey. METHODS: Three hundred two eyes of 294 patients were examined retrospectively after IOL implantation in the capsular bag performed between February 1991 and November 1996. Patients were divided into 3 groups according to IOL type: poly(methyl methacrylate) (PMMA); heparin-surface-modified PMMA (HSM PMMA); plate-haptic silicone. Envelope capsulectomy or continuous curvilinear capsulorhexis (CCC) was used. Mean follow-up was 27 months (range 12 to 33 months). RESULTS: Posterior capsule opacification developed in 47 cases (15.6%): 21.7% in the PMMA lens group after planned extracapsular cataract extraction (ECCE), 17.4% in the HSM PMMA lens group after planned ECCE, and 7.7% in the plate-haptic silicone lens group after phacoemulsification. Posterior capsule opacification occurred less in patients who had anterior capsulectomy using the CCC technique (11.5%) than in those having an envelope capsulectomy (24.5%) (P < .05). Posterior capsule opacification was significantly less in eyes with a capsular-bag-fixated plate-haptic silicone lens than in those with a PMMA or HSM PMMA IOL (P < .05). CONCLUSION: This study demonstrated that the anterior capsulectomy technique and the IOL type influence the incidence of PCO.     

Silicone plate-haptic posterior chamber intraocular lens implanted in the anterior chamber: report of a bilateral case and potential complications

BACKGROUND AND OBJECTIVE: To evaluate possible complications associated with implantation of a posterior chamber (PC) intraocular lens (IOL) in the anterior chamber. MATERIALS AND METHODS: We analyzed a plate-haptic silicone IOL that had been explanted from the anterior chamber of an 83-year-old female. Additionally, the lens was experimentally reimplanted into the anterior chambers of 3 human cadaver eyes. After fixation of the eyes (Karnovsky's solution), the anterior-posterior length, the white-to-white diameter, the angle-to-angle diameter, and the sulcus-to-sulcus diameter were measured. Two different techniques to cut the eyes were used: sagittal section and corneal buttonhole technique. The plate-haptic silicone lens was then implanted in the anterior chamber and sulcus ciliaris of the eyes. A Kelman multiflex IOL was used as a control for anterior chamber implantation. RESULTS: This experiment demonstrated that the plate-haptic silicone IOL lens is too small and thick for implantation in the anterior chamber and in the sulcus. The lens could easily rotate in the anterior chamber and also dislocate inferiorly, obstructing the visual axis by its edge. The thickness of the lens theoretically could also cause endothelial cell damage and mechanical iris irritation resulting in chronic uveal inflammation. CONCLUSION: This case and experiment should help surgeons realize the risk and potential for IOL-missizing complications that may be caused if a lens design for the capsular bag is implanted in the anterior chamber, especially if a plate-haptic PC-IOL design is used.     

Comparison of various capsulectomy techniques in cataract surgery. An experimental study]

Radial tears at the edge of an anterior capsulectomy are often associated with the occurrence of intraocular lens (IOL) loops coming out of the capsular bag with subsequent IOL decentration. We analyzed the incidence of radial tear formation in 40 human eyes obtained postmortem. These eyes were randomly assigned to four groups: "can opener," linear capsulotomy, capsulopuncture ("postage stamp"), and continuous curvilinear capsulorhexis (CCC). The CCC appeared to be much less likely to be associated with anterior capsular radial tears as opposed to the other three techniques. With the nucleus expression technique used in this study, radial tears occurred in all cases of "can opener," linear capsulotomy and capsulopuncture, whereas no tears occurred with the CCC technique. The results of this study show that CCC is currently the best available anterior capsulectomy procedure for minimizing the incidence of radial tears and sequelae such as decentration.     

Intraocular lens optic capture

A continuous curvilinear capsulorhexis (CCC) provides a tear-resistant opening that allows use of a technique of capturing the intraocular lens (IOL) optic through the capsulorhexis opening when the opening is at least 1.0 to 2.0 mm smaller than the optic diameter. The technique provides stability and long-term centration of the IOL and prevents vitreous from extending anterior to the IOL. This paper reviews the current variations of optic capture including (1) haptics in the sulcus and IOL optic capture through a CCC, (2) haptics in the sulcus and IOL optic capture through an anterior capsule opening and a posterior CCC (PCCC), (3) haptics in the capsular bag and IOL optic capture through a PCCC, (4) haptics in the capsular bag and IOL optic capture through an anterior CCC, (5) haptics in the sulcus and IOL capture through a capsular membrane opening, and (6) haptics posterior to the capsular bag and IOL capture through a capsular membrane opening.     

Anterior dislocation of an empty capsular bag in a pseudophakic eye: A rare case report

Spontaneous intraocular lens (IOL) dislocation is uncommon in the absence of any ocular areas with zonular weakness or trauma. There have been no reports of spontaneous capsular bag dislocation into the anterior chamber without an IOL. We report a rare, interesting case of spontaneous capsular bag anterior dislocation, without an IOL, into the anterior chamber with no history of genetic disease, ocular trauma, or pseudoexfoliation that might predispose to a zonular abnormality.     

Endocapsular closed chamber technique for disc lens implantation

A simple endocapsular technique for implantation of an 8 mm disc lens is described. Its main features are a scleral three-plane incision, a vertical-stab capsulotomy, cortical hydrodissection, a closed chamber technique during placement of the intraocular lens in the capsular bag, implantation under air and fluid, wherever feasible, and optional anterior capsulectomy with a 27-gauge needle bent at the tip. This technique requires no complicated equipment and allows atraumatic implantation of the disc lens with maximum control of anterior chamber depth.     

Posterior chamber intraocular lens dislocation with the bag.

We report a rare case of a 46-year-old man presenting with a luxation of a posterior chamber intraocular lens (IOL) with the capsular bag after ocular contusion. Preoperative axial length was 36.58 mm. After trauma, pars plana extraction of the dislocated IOL inside the capsular bag was performed using a forceps. Capsular fibrosis had probably weakened the zonules, which were ruptured by the trauma. This observation confirms the necessity of a large continuous curvilinear capsulotomy and meticulous cleaning of the anterior and posterior capsules to minimize postsurgical fibrosis and capsule contraction.     

Incomplete capsular bag distension syndrome after neodymium:YAG capsulotomy

We report a 60-year-old man with incomplete capsular bag distension syndrome 2 years after neodymium:YAG (Nd:YAG) laser capsulotomy for capsule opacification, which developed from extracapsular cataract extraction with intraocular lens (IOL) implantation performed 4 years before presentation to our clinic. The patient reported floaters of 15 days duration. Slitlamp examination showed shallowing of the inferior and medial anterior chamber. Dilated pupil examination showed a peripheral capsular bag inferiorly and medially behind the IOL. The bag was distended and filled with turbid fluid. The central and superior capsule was absent as a result of the previous Nd:YAG treatment. The IOL lie over the anterior capsule, and peripheral capsule leaves' edges were adhered. An Nd:YAG laser puncture of the incomplete capsular bag resolved the condition.     

Retained ophthalmic viscosurgical device material in the capsular bag 6 months after phacoemulsification

We present a 63-year-old man who developed low-grade endophthalmitis 6 months after phacoemulsification and implantation of a foldable posterior chamber intraocular lens (IOL). The capsular bag was distended, but shallowing of the anterior chamber was not observed. Chemical analysis of the clear fluid aspirated from the capsular bag behind the IOL revealed the presence of an ophthalmic viscosurgical device.