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Posterior capsulorhexis combined with optic buttonholing: an alternative to standard in-the-bag implantation of sharp-edged intraocular lenses? A critical analysis of 1000 consecutive cases.

Menapace R - Graefes Arch. Clin. Exp. Ophthalmol. (2008)

Bottom Line: Intraoperative removal of the central posterior capsule has been shown to be effective in further reducing LEC immigration.Postoperative pressure course was almost identical to that found after standard in-the-bag implantation of the IOL, as was flare, and macular thickness and morphology.Anterior LEC abrasion significantly reduced both the residual fibrosis and regeneratory LEC proliferation.

View Article: PubMed Central - PubMed

Affiliation: Department of Ophthalmology, University of Vienna Medical School, Waehringer Guertel 18-20, Vienna 1090, Austria. rupert.menapace@meduniwien.ac.at

ABSTRACT

Background: Current after-cataract prevention relies on optimizing the natural barrier effect of the optic rim against lens epithelial cell (LEC) migration. However, deficiencies in circumferential capsular bag closure caused by the intraocular lens (IOL) haptic or delayed secondary re-division of the fused capsules by Soemmering s ring formation lead to primary or secondary barrier failure. Consequently, surprisingly high posterior laser capsulotomy rates have been reported long-term, even with optimal capsular surgery and the most widespread hydrophobic acrylic IOLs, considered to be the most advanced. Intraoperative removal of the central posterior capsule has been shown to be effective in further reducing LEC immigration. However, efficacy has turned out to be limited because of the propensity of LECs to use the posterior optic surface as an alternative scaffold.

Technique: in pediatric cataract surgery, buttoning-in of the optic into an adequately-centered posterior capsulorhexis opening has been described previously. This technique was further elaborated and applied as the standard technique in a large series of adult eyes. In general, the diameter aimed at was 5-6 mm for the anterior, and 4-5 mm for the posterior capsulorhexis. Between September 2004 and June 2007, 1000 consecutive cases have thus been performed and systematically evaluated. One hundred and fifty eyes additionally underwent extensive anterior LEC abrasion. Another sub-series investigated the option of further reducing capsular fibrosis by creating an anterior capsulorhexis larger than the optic.

Evaluation: special scrutiny was applied to detect postoperative vitreous entrapment. Regeneratory and fibrotic after-cataract formation were both meticulously followed-up. Postoperative pressure course, anterior segment inflammation, macular thickness and morphology, as well as axial optic stability and optic centration, were evaluated in intraindividual comparison studies.

Results: A low rate of vitreous complications was found, which can be avoided by appropriate surgery. Vitreous entanglement occurred in six eyes, and vitreous herniation after PPCCC over-sizing in two. In three, anterior vitrectomy was performed. There was only one single case of retinal detachment-supposedly unrelated to the technique itself-and no case of cystoid macular edema. Retro-optical regenerate formation was completely abolished, while fibrosis was drastically reduced by the posterior capsule sandwiched in between the anterior LEC layer on the backside of the anterior capsule and the anterior optic surface, thereby blocking contact-mediated myofibroblastic LEC transdifferentiation. Additional capsular polishing further reduced residual fibrosis emerging from the anterior capsule contacting the optic adjacent to the haptic junction, as well as regeneratory LEC re-proliferation on the posterior capsule overlying the optic. Postoperative pressure course was almost identical to that found after standard in-the-bag implantation of the IOL, as was flare, and macular thickness and morphology. As opposed to bag-fixated IOLs, no axial movement of the optic was detected. IOL optics always perfectly centered even when the capsular opening was not optimally centered. Due to the exquisite stretchability and elasticity of the posterior capsule, the 6-mm IOL optic could safely be buttoned-in in a posterior capsulorhexis of 4 mm and smaller.

Conclusions: Posterior optic buttonholing (POBH) is a safe and effective technique which not only excludes retro-optical opacification, but also withholds capsular fibrosis by obviating direct contact between the anterior capsular leaf and the optic surface. Anterior LEC abrasion significantly reduced both the residual fibrosis and regeneratory LEC proliferation. Apart from pediatric cataract, POBH is currently recommended for eyes with pseudoexfoliation syndrome, high axial myopia, peripheral retinal disease, and multifocal IOL implantation. Toric IOLs and magnet-driven accommodative IOL systems are other potential applications. Generally, POBH holds promise for becoming a routine alternative to standard in-the-bag IOL implantation in the future.

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Retraction of scarcely overlapping PPCCC rim from optic rim due to fibrosis emerging from ACCC larger than optic allows for delayed vitreous herniation
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Related In: Results  -  Collection


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Fig6: Retraction of scarcely overlapping PPCCC rim from optic rim due to fibrosis emerging from ACCC larger than optic allows for delayed vitreous herniation

Mentions: Surgical complications In a preliminary evaluation of the first 376 consecutive cases performed during the first year (Menapace R. Routine posterior optic buttonholing for after-cataract prevention: The better alternative to the sharp edge optic? Breaking News Session, XXIIIth Congress of the ESCRS, 10.−14.9.2005, Lisbon) no case of cystoid macular edema (CME), and only one case of retinal detachment (RD) were encountered. Since the latter occurred only 4 months after surgery in a highly myopic eye with an intact anterior hyaloid surface, the causative role of POBH is questionable. The RD emerged from a group of small round holes in the superotemporal quadrant, and was repaired by cryopexy and gas injection. In only three cases could buttoning-in not be performed as planned because of a too small or decentered PPCCC. However, even with a suboptimally centered PPCCC the optic always perfectly centered permanently. During surgery, there was no case of vitreous prolapse into the anterior chamber, and therefore no need for an anterior vitrectomy. Postoperatively, four eyes presented with a minor, and two eyes with a major vitreous entrapment without apparent vitreous traction. These cases happened at a time when the surgical procedure was still being elaborated, and the importance of performing a complete circumferential viscodissection of anterior hyaloid and posterior capsule prior to the optic buttoning-in manoeuvre to preclude vitreous incarceration was not yet fully recognized. One of the two patients with major entrapment underwent bimanual anterior vitrectomy in topical anesthesia through the pre-existing paracentesis openings while the optic was temporarily desenclavated. The other patient declined the proposed reintervention. No CME or RD ensued in any of these eyes in the 3-year follow-up period. The technique, results, and complications of the first 500 consecutive cases have been extensively published in a peer-reviewed journal [12]. In a later sub-series which investigated the effect of creating an ACCC opening larger than the optic diameter to further reduce anterior capsule fibrosis especially at the haptic–optic junction, two other cases of delayed vitreous herniation into the anterior chamber occurred when a relatively large but still overlapping PPCCC was secondarily distended by posterior capsule contraction due to fibrosis emerging from the edge of the ACCC rim outside the optic, thus exposing the optic edge and creating a gap in the capsular diaphragm along the optic rim (Fig. 6). Consequently, due to the saccadeous eye movements, mobile vitreous incrementally crept into the anterior chamber. Using bimanual vitrectomy, with the infusion inserted through one of the pre-existing paracentesis openings and the vitrectome through a pars plana sclerotomy, the floppy vitreous strand was retracted into the vitreous cavity and excised. Except for these few cases, no further cases of vitreous entrapment or herniation were encountered in the second 500 consecutive cases. In two other cases of the above-mentioned sub-series, spontaneous desenclavation of the optic without vitreous presentation was noted the day after surgery due to a too largely dimensioned PPCCC. There was no case of endophthalmitis in the 1000 cases performed up to June 2007. The results of the first 150 cases—which may represent the learning curve—and the subsequent 850 cases are summarized in Table 1.Fig. 6


Posterior capsulorhexis combined with optic buttonholing: an alternative to standard in-the-bag implantation of sharp-edged intraocular lenses? A critical analysis of 1000 consecutive cases.

Menapace R - Graefes Arch. Clin. Exp. Ophthalmol. (2008)

Retraction of scarcely overlapping PPCCC rim from optic rim due to fibrosis emerging from ACCC larger than optic allows for delayed vitreous herniation
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2367393&req=5

Fig6: Retraction of scarcely overlapping PPCCC rim from optic rim due to fibrosis emerging from ACCC larger than optic allows for delayed vitreous herniation
Mentions: Surgical complications In a preliminary evaluation of the first 376 consecutive cases performed during the first year (Menapace R. Routine posterior optic buttonholing for after-cataract prevention: The better alternative to the sharp edge optic? Breaking News Session, XXIIIth Congress of the ESCRS, 10.−14.9.2005, Lisbon) no case of cystoid macular edema (CME), and only one case of retinal detachment (RD) were encountered. Since the latter occurred only 4 months after surgery in a highly myopic eye with an intact anterior hyaloid surface, the causative role of POBH is questionable. The RD emerged from a group of small round holes in the superotemporal quadrant, and was repaired by cryopexy and gas injection. In only three cases could buttoning-in not be performed as planned because of a too small or decentered PPCCC. However, even with a suboptimally centered PPCCC the optic always perfectly centered permanently. During surgery, there was no case of vitreous prolapse into the anterior chamber, and therefore no need for an anterior vitrectomy. Postoperatively, four eyes presented with a minor, and two eyes with a major vitreous entrapment without apparent vitreous traction. These cases happened at a time when the surgical procedure was still being elaborated, and the importance of performing a complete circumferential viscodissection of anterior hyaloid and posterior capsule prior to the optic buttoning-in manoeuvre to preclude vitreous incarceration was not yet fully recognized. One of the two patients with major entrapment underwent bimanual anterior vitrectomy in topical anesthesia through the pre-existing paracentesis openings while the optic was temporarily desenclavated. The other patient declined the proposed reintervention. No CME or RD ensued in any of these eyes in the 3-year follow-up period. The technique, results, and complications of the first 500 consecutive cases have been extensively published in a peer-reviewed journal [12]. In a later sub-series which investigated the effect of creating an ACCC opening larger than the optic diameter to further reduce anterior capsule fibrosis especially at the haptic–optic junction, two other cases of delayed vitreous herniation into the anterior chamber occurred when a relatively large but still overlapping PPCCC was secondarily distended by posterior capsule contraction due to fibrosis emerging from the edge of the ACCC rim outside the optic, thus exposing the optic edge and creating a gap in the capsular diaphragm along the optic rim (Fig. 6). Consequently, due to the saccadeous eye movements, mobile vitreous incrementally crept into the anterior chamber. Using bimanual vitrectomy, with the infusion inserted through one of the pre-existing paracentesis openings and the vitrectome through a pars plana sclerotomy, the floppy vitreous strand was retracted into the vitreous cavity and excised. Except for these few cases, no further cases of vitreous entrapment or herniation were encountered in the second 500 consecutive cases. In two other cases of the above-mentioned sub-series, spontaneous desenclavation of the optic without vitreous presentation was noted the day after surgery due to a too largely dimensioned PPCCC. There was no case of endophthalmitis in the 1000 cases performed up to June 2007. The results of the first 150 cases—which may represent the learning curve—and the subsequent 850 cases are summarized in Table 1.Fig. 6

Bottom Line: Intraoperative removal of the central posterior capsule has been shown to be effective in further reducing LEC immigration.Postoperative pressure course was almost identical to that found after standard in-the-bag implantation of the IOL, as was flare, and macular thickness and morphology.Anterior LEC abrasion significantly reduced both the residual fibrosis and regeneratory LEC proliferation.

View Article: PubMed Central - PubMed

Affiliation: Department of Ophthalmology, University of Vienna Medical School, Waehringer Guertel 18-20, Vienna 1090, Austria. rupert.menapace@meduniwien.ac.at

ABSTRACT

Background: Current after-cataract prevention relies on optimizing the natural barrier effect of the optic rim against lens epithelial cell (LEC) migration. However, deficiencies in circumferential capsular bag closure caused by the intraocular lens (IOL) haptic or delayed secondary re-division of the fused capsules by Soemmering s ring formation lead to primary or secondary barrier failure. Consequently, surprisingly high posterior laser capsulotomy rates have been reported long-term, even with optimal capsular surgery and the most widespread hydrophobic acrylic IOLs, considered to be the most advanced. Intraoperative removal of the central posterior capsule has been shown to be effective in further reducing LEC immigration. However, efficacy has turned out to be limited because of the propensity of LECs to use the posterior optic surface as an alternative scaffold.

Technique: in pediatric cataract surgery, buttoning-in of the optic into an adequately-centered posterior capsulorhexis opening has been described previously. This technique was further elaborated and applied as the standard technique in a large series of adult eyes. In general, the diameter aimed at was 5-6 mm for the anterior, and 4-5 mm for the posterior capsulorhexis. Between September 2004 and June 2007, 1000 consecutive cases have thus been performed and systematically evaluated. One hundred and fifty eyes additionally underwent extensive anterior LEC abrasion. Another sub-series investigated the option of further reducing capsular fibrosis by creating an anterior capsulorhexis larger than the optic.

Evaluation: special scrutiny was applied to detect postoperative vitreous entrapment. Regeneratory and fibrotic after-cataract formation were both meticulously followed-up. Postoperative pressure course, anterior segment inflammation, macular thickness and morphology, as well as axial optic stability and optic centration, were evaluated in intraindividual comparison studies.

Results: A low rate of vitreous complications was found, which can be avoided by appropriate surgery. Vitreous entanglement occurred in six eyes, and vitreous herniation after PPCCC over-sizing in two. In three, anterior vitrectomy was performed. There was only one single case of retinal detachment-supposedly unrelated to the technique itself-and no case of cystoid macular edema. Retro-optical regenerate formation was completely abolished, while fibrosis was drastically reduced by the posterior capsule sandwiched in between the anterior LEC layer on the backside of the anterior capsule and the anterior optic surface, thereby blocking contact-mediated myofibroblastic LEC transdifferentiation. Additional capsular polishing further reduced residual fibrosis emerging from the anterior capsule contacting the optic adjacent to the haptic junction, as well as regeneratory LEC re-proliferation on the posterior capsule overlying the optic. Postoperative pressure course was almost identical to that found after standard in-the-bag implantation of the IOL, as was flare, and macular thickness and morphology. As opposed to bag-fixated IOLs, no axial movement of the optic was detected. IOL optics always perfectly centered even when the capsular opening was not optimally centered. Due to the exquisite stretchability and elasticity of the posterior capsule, the 6-mm IOL optic could safely be buttoned-in in a posterior capsulorhexis of 4 mm and smaller.

Conclusions: Posterior optic buttonholing (POBH) is a safe and effective technique which not only excludes retro-optical opacification, but also withholds capsular fibrosis by obviating direct contact between the anterior capsular leaf and the optic surface. Anterior LEC abrasion significantly reduced both the residual fibrosis and regeneratory LEC proliferation. Apart from pediatric cataract, POBH is currently recommended for eyes with pseudoexfoliation syndrome, high axial myopia, peripheral retinal disease, and multifocal IOL implantation. Toric IOLs and magnet-driven accommodative IOL systems are other potential applications. Generally, POBH holds promise for becoming a routine alternative to standard in-the-bag IOL implantation in the future.

Show MeSH
Related in: MedlinePlus