Endophthalmitis following Nd:YAG laser posterior capsulotomy

We report the development of Propionibacterium acnes endophthalmitis following Nd:YAG laser posterior capsulotomy. The patient previously underwent uncomplicated extracapsular cataract extraction with intraocular lens insertion and was free of inflammation prior to laser capsulotomy. Diagnostic vitrectomy and aqueous tap were performed, and P. acnes was isolated from the aqueous in thiol broth media after nine days of incubation under anaerobic conditions. The patient was managed with topical and systemic antibiotics and steroids. Complete resolution of inflammation with return of vision to 20/25 was achieved without removal of the intraocular lens or lenticular remnants.     

More assured in-the-bag placement of C-loop posterior chamber intraocular lenses

A bimanual technique for inserting C-loop intraocular lenses using a lens haptic loop to guide the superior lens haptic into the capsular bag is presented. The technique eliminates several shortcomings of conventional techniques, allowing more assured in-the-bag placements of C-loop intraocular lenses.     

Ciliary sulcus reconstruction for posterior implantation in the absence of an intact posterior capsule

Secondary implantation of a posterior chamber intraocular lens in an aphakic eye devoid of an intact posterior capsule requires a special surgical approach. When lens capsule remnants remain in the periphery, the ciliary sulcus can be reconstructed to accommodate a posterior chamber lens. The fibrotic lens or capsular residues that often remain adherent to the posterior surface of the iris are divided with sharp intraocular scissors, and a shelf is created that is sufficient to support the lens haptics. A series of 28 cases, including 16 involving young children, demonstrates the feasibility and the favorable visual results obtainable with this surgical technique.     

Effectivity of laser ridge intraocular lenses

Two hundred fifty intraocular lenses with varying sizes of laser ridges were implanted following extracapsular cataract surgery to determine the effectivity of the laser ridge in creating a space between the intraocular lens and the posterior capsule. Six weeks post-operatively, the distance between the intraocular lens and the posterior capsule was judged as adequate in 92% of cases with a .35 mm ridge, 88% cases with a .25 mm ridge, and 80% of those with a .15 mm ridge. A group of non-angulated, non-ridged lenses placed out of the capsular bag had an adequate space in 82% of cases, and a group of non-angulated, non-ridged lenses placed in the capsular bag had only 44% adequate spaces. Intraocular lenses with laser ridges should be used to enhance the space between the intraocular lens and the posterior capsule, thus increasing the safety of postoperative Nd:YAG laser posterior capsulotomy.     

Types of posterior capsular breaks and their surgical implications

We studied the pathogenesis, clinical features, and management of posterior capsular breaks in 28 cataract patients during planned extracapsular cataract extraction and intraocular lens implantation surgery. In the age-related cataract group (17 cases), the posterior capsular breaks were fresh, caused by the irrigation-aspiration cannula. Located in the upper part of the posterior capsule, they had thin margins and tended to enlarge with continued irrigation. Nine (52.9%) of these breaks could be plugged with viscoelastic, and after dry aspiration, a posterior chamber lens was implanted successfully. Posterior capsular breaks in traumatic cataracts (11 cases) were preexisting but were detected only during surgery. Centrally located, they had thick fibrosed margins and remained the same size during irrigation- aspiration. The minimal vitreous herniation seen in four (35.3%) of these cases was managed by automated partial anterior vitrectomy through the break. A posterior chamber intraocular lens was implanted in all these cases.     

Propionibacterium acnes endophthalmitis seven months after extracapsular cataract extraction and intraocular lens implantation

We present a case of endophthalmitis caused by Propionibacterium acnes seven months following extracapsular cataract extraction and intraocular lens implantation. The markedly delayed clinical course of endophthalmitis associated with this organism appears to be highly stereotypical. Recognition and treatment of this complication of cataract surgery allows an excellent chance at cure.     

Posterior chamber intraocular lens implantation in the absence of posterior capsular support

Because of the high incidence and great variety of complications associated with anterior chamber intraocular lenses, we have developed a technique for the implantation of a posterior chamber intraocular lens in the absence of posterior capsular support. The posterior chamber IOL is placed in the ciliary sulcus by suturing the superior haptic to the iris and the inferior haptic to the sclera at the ciliary sulcus. We have used this technique successfully in both complicated extracapsular surgery and secondary intraocular lens implantation.     

Endocapsular hypopyon: a clinical sign of localized endophthalmitis

Chronic intraocular infection following cataract extraction and intraocular lens (IOL) implantation has been documented by several authors. We report a case of chronic, bacterial endophthalmitis that clinically correlates with previous pathologic studies in which the focus of infection was sequestered in the capsular sac between the IOL and the posterior lens capsule. Successful management did not require IOL removal.     

Anterior lens capsulotomy using the holmium YAG laser in pig cadaver eyes.

Anterior lens capsulotomy was performed on pig cadaver eyes using the evaporation and coagulation functions of the holmium YAG laser. Laser energy ranging from 50 to 80 mJ was delivered to the lens-capsule surface by a 26-gauge fiber-optic quartz needle probe. In eight of 10 eyes, a tear-free, 4.0-millimeter-diameter circular capsulotomy was achieved, through which endocapsular phacoemulsification and aspiration were performed and a posterior chamber intraocular lens with a 6.5-millimeter-diameter optic was placed inside the lens capsule. Throughout the procedure, capsular integrity was maintained in all eight eyes, with no tearing at the capsular margin.     

A technical variation of posterior chamber IOL implantation

In posterior chamber intraocular lens (IOL) implantation, one of the most delicate phases is placing the loops in the capsular bag or in the ciliary sulcus. We describe a technique to simplify the phase of IOL insertion by tying the superior loop with a nylon suture. No changes to the lens and no special instruments are required.     

Reactive membrane on a foldable silicone lens implant in the posterior chamber of a human eye

A foldable silicone posterior chamber intraocular lens implant caused irritation and glaucoma postoperatively in the eye of a diabetic patient who subsequently was treated with steroids and a laser capsulotomy. Because the lens implant was loose in the capsular bag and caused considerable glare, it was removed about 4 months after placement. Pathologic study revealed the entire surface of the implant to be covered by a continuous and firmly adherent protein membrane with excrescences and of irregular thickness. Sessile macrophages found on the membrane were not firmly attached.     

A comparison of ciliary sulcus and capsular bag fixation of posterior chamber intraocular lenses

We compare indications, advantages, and disadvantages of ciliary sulcus and lens capsular bag (lens capsular sac) fixation of posterior chamber intraocular lenses (IOLs). Our findings suggest that, whenever possible, it is efficacious to implant the loops of posterior chamber IOLs within the capsular bag. This positions the lens optic and the supporting loops in the natural anatomical position, sequestered from highly vascular uveal tissue and the blood aqueous barrier. This should minimize the potential for complications that may be associated with iris-ciliary body contact. Considering the rapid increase in the number of implantations of IOLs now being performed (approximately 700,000 per year in the United States alone), a possible reduction of even 1% in clinically significant complications would make this effort worthwhile. Widespread application of in-the-bag implantation is predicated on the assumption that the surgeon is proficient with this procedure and that careful follow-up of patients does not reveal any significantly increased incidence of lens dislocation due to zonular rupture.     

"Equator ring" for maintenance of the completely circular contour of the capsular bag equator after cataract removal

We designed an "equator ring," a flexible silicone rod with a groove on its inner surface, to maintain the circular contour of the capsular bag equator after cataract removal. After cataract extraction, the ring is inserted in the bag through a 5.0-mm circular capsulorhexis or 4.5-mm linear "dumbbell" opening. Then a conventional posterior chamber intraocular lens (PC-IOL) is inserted, with the IOL loops in the groove. The ring not only allows complete maintenance of the circular contour of the capsular bag equator for most conventional PC-IOLs, but also may prevent invasion of metamorphosed lens epithelial cells into the posterior capsule.     

Accommodative intraocular lens with spring action--Part 2. Fixation in the living rabbit.

After cataracts in 10 eyes of 8 pigmented or albino rabbits had been removed by phacoemulsification, a specially designed 10.0 x 8.5-millimeter accommodative intraocular lens with spring action ("spring IOL") was implanted through a 4.5- to 5.0-millimeter "dumbbell" linear anterior capsular opening. The average follow up was 11 +/- 8 months. All the spring IOLs were almost completely fixed in the capsular bag, and the anterior and posterior capsules remained transparent. However, due to limitations specific to the rabbit, no accommodative power could be detected; also, we observed lens epithelial cells and subsequent fibrous production proceeding from the equatorial area into the area between the optics.     

A new technique for transscleral fixation of a posterior chamber intraocular lens in the absence of capsular support during penetrating keratoplasty

In the setting of penetrating keratoplasty for the rehabilitation of aphakic or pseudophakic bullous keratopathy, a posterior chamber intraocular lens is frequently implanted in the absence of capsular support. Some surgeons have advocated transscleral fixation over iris fixation of the intraocular lens. Problems faced during such a procedure, however, include the obstructed approach of the suture needle behind the iris, and the exposed or eroded knot of the polypropylene suture. To circumvent both problems, we propose an ab externo technique that takes advantage of the work of Duffey et al and avoids the use of partial thickness scleral flaps.     

Cortex at the 12 o'clock position and the role of peripheral iris opening.

Performing a peripheral iridectomy is a safe and effective means of atraumatically removing cortex at the 12 o'clock position. It prevents pupillary block as well as adhesions between the iris and capsule. Also, it serves to position the anterior capsular flap and the superior edge of the intraocular lens.     

Development and treatment of cataract in myopic eye with phakic intraocular lens Fyodorov in the posterior chamber

This is a case report of a female patient who, due to high myopia, had silicone phakic intraocular lens type Fyodorov with plate-haptics implanted in the posterior chamber (PC pIOLs). The anterior subcapsular cataract (ASC) resulted in significant reduction of visual acuity and, therefore, the patient, after 16 years of the first surgery, underwent another surgical intervention. She had the pIOLs explantation, phacoemulsification and implantation of the flexible intraocular lens (IL) in the capsular bag. Explantation of the pIOLs, cataract surgery by phacoemulsification and IOL implantation were carried out through the same clear corneal incision and the intraoperative course was uneventful. The visual acuity of the operated eye was equal to pre-cataract period.     

Diagnosis and treatment of mysterious light streaks seen by patients following extracapsular cataract extraction

Complaints of light streaks, such as might be seen with a Maddox rod or Bagolini lens, are becoming more common with the trend toward extracapsular cataract surgery. The light streaks are usually a result of high plus cylinders somewhere in the patient's optical system. Windshields, spectacles, contact lenses, lashes, an excessive tear meniscus, intraocular lens scratches, and posterior capsular opacification are possible causes that can be easily identified and treated.     

Total pupillary capture with a foldable silicone intraocular lens

We report a case of total pupillary capture on the 1st postoperative day in a patient who had undergone phacoemulsification and placement of a silicone foldable posterior chamber intraocular lens. Anterior displacement of the lens optic resulted in 2.25 diopters of induced myopia. Dilation of the pupil corrected the lens capture and reversed the induced myopia, yielding a refraction of plano. Higher rates of pupillary capture have been associated with sulcus fixation and nonangulated flexible (polypropylene) haptics. Contraction of the capsular bag on the flexible polypropylene haptics of this silicone lens is thought to force the optic anteriorly, increasing the probability of lens capture by the iris.     

Cataract extraction and diabetic retinopathy

A prospective study of the effect of cataract extraction and intraocular lens implantation on insulin-dependent diabetics is presented. Cataract extraction was performed on 138 patients with diabetic retinopathy. The patients were randomly selected for intracapsular or extracapsular extraction and for the administration of topical indomethacin or placebo. In a second group, 103 diabetic patients received intraocular lens implants, which were anterior-chamber-angle fixated, iris supported, iridociliary sulcus supported, or placed in the capsular bag. Random selection determined who among the extracapsular cases would have on-the-table capsulotomy or six-month-postoperative capsulotomy. The study indicated that a greater progression of diabetic changes occurred in both the posterior and the anterior segment of the eye after intracapsular extraction than after extracapsular extraction, especially if the capsulotomy was performed six months postoperatively. Furthermore, the study indicated that in-the-bag implantation without on-the-table capsulotomy was a safe procedure; anterior-chamber-angle-fixated lenses exhibited a higher incidence of diabetic changes in the anterior and posterior segments than the other lenses.