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Intraocular lens (IOL) exchange in patients with anterior capsule contraction resulting from phimosis can complicate IOL exchange as the fibrotic anterior capsule must be cut to gain access to the IOL. Maintaining curvilinear capsulotomy is particularly important when the desired outcome is bag-to-bag IOL exchange. Similarly, when the posterior capsule is open, properly sized curvilinear anterior capsulotomy will allow for optic capture and further stability of the exchanged IOL. Secondary capsulotomy size ranged from 4.9 to 5.0 mm, and the energy was set at 4 to 10 μJ depending on diffusiveness of the anterior capsule. The femtosecond laser was adapted to create a secondary anterior capsulotomy to facilitate IOL exchange.

The Argentinian flag sign is a known complication in intumescent white cataracts, which arises instantly after an initial prick with a sharp hypodermic needle on a stretched out anterior capsule. Increased intralenticular pressure is believed to be responsible for propagation of the initial prick into a radial capsular tear. However, it is the linear cut configuration of the initial prick, created by the hypodermic needle on the tense anterior capsule, which spontaneously opens up and propagates toward the periphery along its margins. To overcome this, a new instrument was devised, sewing needle microcapsulotome, to puncture the capsule and create a single or multiple round openings with smooth margins, allowing the bag to decompress satisfactorily without yielding to disruptive intralenticular forces. This technique of sewing needle microcapsulotomy, to prevent the Argentinian flag sign, was found to be highly effective and safe in a series of surgeries on intumescent cataracts.

Background: The aim of this study was to develop a modified capsulorhexis technique featuring a new maneuver for the removal of subcortical fluid in fluid-filled mature cataracts to avoid high intralenticular pressure. Methods: This prospective interventional study included 33 eyes with mature cataracts and evidence of subcapsular fluid spaces by slit lamp examination. For each patient, 20% mannitol was administered intravenously according to the bodyweight 1 h preoperatively. Under peribulbar anesthesia, a 2.2-mm main incision was made, and the anterior chamber was filled with a dispersive ophthalmic viscosurgical device. Using a bent-tip cystotome, a 2-mm curved incision was made in the center of the anterior capsule, which released subcortical fluid and was drained through compression of the posterior lip of the main incision using a spatula. Then, fine gentle milking in all quadrants around the puncture on the anterior lens capsule from the periphery toward the site of puncture using the blunt-edged spatula further assists drainage of subcortical fluid and breaks fine septa inside the lens to remove fluid from intralenticular fluid pocket collections. Results: The study included 15 (45.5%) men and 18 (54.5%) women with a mean ± standard deviation (SD) of age of 63.2 ± 5.33 and 64.4 ± 6.21 years, respectively. The modified capsulorhexis technique was performed for 33 intumescent cataracts. Capsulorhexis was completed in all cases; capsulorhexis was easy in 31 (94%) eyes and difficult in 2 (6%) eyes. In the two difficult cases, radial extension occurred in one eye, and it was retrieved using the Little technique; the other case with radial tear was completed successfully using a retinal micro scissor from the other edge of the capsulorhexis until reaching an oval, continuous capsulorhexis. Conclusions: This modified capsulorhexis technique with compression on the posterior lip of the main incision and capsule milking allowed for a safe, continuous curvilinear capsulorhexis. Further comparative studies are necessary to confirm our preliminary results. How to cite this article: Ghoneim EM. Modified capsulorhexis for fluid-filled mature cataracts. Med Hypothesis Discov Innov Ophthalmol. 2021 Summer; 10(2): 17-24. https://doi.org/10.51329/mehdioptometry1422

Massive rotator cuff tears (RCT) have traditionally been a challenging clinical problem for shoulder surgeons. A broad variety of treatment options have been proposed to address this problem, but outcomes have been as variable as the techniques themselves. Superior capsular reconstruction has been presented as a way to restore the restraining effect of the superior joint capsule and balanced force couples in massive tears of the superior rotator cuff. The purpose of this article is to propose a technical modification of the superior capsular reconstruction in large to massive RCT, and, especially in anterior L-shaped RCT, using the long head of the biceps tendon autograft to reinforce the weakest area of the anterior capsule, not as an augmentation of the rotator cuff, but as a static stabilizer of the humeral head, allowing the rotator cuff repair to heal without tension., Technique Video Video 1 With the patient in the beach chair position and into the subacromial space, a bony trough is created from the anterolateral portal in line with the bicipital groove and the mobility of the biceps tendon is checked. After medial anchor insertion a double lasso loop is made to the biceps with the first strand to facilitate the transfer to its new location. Next the suture retriever is passed under the biceps tendon to grasp the second strand for atraumatic suture. After placing the second anchor, the same process is carried out as with the medial implant, but this time we take the first strand with a simple lasso loop. Next, the sutures are tied at 30° of abduction and the stability of the biceps is checked. Finally, the tendon tenotomy is performed in the bicipital groove. Once the anterior capsular reconstruction is finished, attention is paid to the rotator cuff, and its mobility is verified; in this case we have a delaminated tear. After placing the posterior anchor of the medial row, placement of a lasso loop was performed around the free edge of the deep layer. The free end of this lasso loop suture was then passed at the muscle-tendon junction through the superficial layer. The second free end of the suture is subsequently passed through both the deep and superficial layers of the cuff. Later, the most anterior anchor of the medial row is placed, and the same procedure is carried out as with the posterior anchor. Finally, a double row repair is performed with the suture limbs of the medial row and the integrity of the repair is checked.

To assess the accuracy and stability of iris-registered femtosecond laser-assisted anterior capsule axis markings (compensating cyclotorsion) along with refractive and visual outcomes after toric IOL implantation. This prospective case series included eyes with visually significant cataracts and regular corneal astigmatism ranging from 1.25D to 4.0D, which received FLACS and toric IOL implantation, at The Eye Institute of West Florida, Largo, Florida, USA. Preoperative iris registration was used in conjunction with a femtosecond laser platform to create cyclotorsion corrected axis marks at the capsulotomy edge to facilitate toric IOL axial alignment. Patients were examined one, seven and thirty days after surgery to assess capsulotomy marks axis, toric IOL axis along with visual and refractive outcomes. Eighteen eyes of 13 patients aged 74.35 ± 8.65 years were included. Mean pre-op CDVA was 0.24 ± 0.16 LogMAR, while mean post-op UDVA was 0.09 ± 0.09 LogMAR. Mean pre-op corneal astigmatism was 1.85 ± 0.41 D, decreasing to 0.24 ± 0.41 D of refractive astigmatism postoperatively (p 0.05), respectively. No capsule-related or any other type of complications was noted. Iris-registered femtosecond laser-assisted anterior capsule axis markings are safe and may be considered as an alternative option to the known axis marking techniques for toric IOL axial alignment at the time of cataract surgery.

The purpose of this systematic literature review is to analyse the role of the iliofemoral ligament (ILFL) as a hip joint stabilizer in the current literature. A total of 26 articles were included in the review. The ILFL is the largest hip ligament consisting of two distinct arms and is highly variable, both in its location and overall size, and plays a primary role in hip stability; in the case of hip dislocation, the iliofemoral ligament tear does not heal, resulting in a persistent anterior capsule defect. Clinically, the ILFL is felt to limit external rotation in flexion and both internal and external rotation in extension. The abduction–hyperextension–external rotation (AB-HEER) test is overall the most accurate test to detect ILFL lesions. Injuries of the ILFL could be iatrogenic or a consequence of traumatic hip instability, and can be accurately studied with magnetic resonance imaging. Different arthroscopic and open techniques have been described in order to preserve the ILFL during surgery and, in case of lesions, several procedures with good to excellent results have been reported in the existing literature. The current systematic review, focusing only on the ILFL of the hip, summarizes the existing knowledge on anatomy, imaging and function and contributes to the further understanding of the ILFL, confirming its key role in anterior hip stability. Future studies will have to develop clinical tests to evaluate the functionality and stability of the ILFL. Cite this article: EFORT Open Rev 2021;6:545-555. DOI: 10.1302/2058-5241.6.200112

Purpose To investigate factors related to the rotational stability of an acrylic toric intraocular lens (IOL). Setting Four ophthalmic surgical sites in Japan. Design Prospective case series. Methods The study included 120 eyes of 120 patients undergoing phacoemulsification and implantation of a toric IOL (AcrySof IQ, Alcon Laboratories, Inc.). At 1 hour postoperatively, the area of continuous curvilinear capsulorhexis (CCC) was measured, and the state of anterior capsule coverage on the IOL optic (total on or partial on) was recorded. The toric IOL axis orientation was assessed at the end of surgery and at 1 hour, 1 week, 1 month, and 6 months postoperatively. Multiple regression analysis was performed to explore any clinical factors relevant to IOL rotation from the end of surgery to 6 months postoperatively. The explanatory variables included age, anterior chamber depth preoperatively, axial length, type of corneal astigmatism (with-the-rule, against-the-rule, or oblique astigmatism), area of CCC, state of anterior capsule overlap on IOL optic (total coverage vs partial coverage), and surgical sites (surgeons). Results The multiple regression analysis in 110 eyes of 110 patients indicated that anterior capsule overlap on the IOL optic was the only variable associated with IOL rotation at 6 months postoperatively (P = .0482). The mean absolute rotation at 6 months was 1.96 ± 1.81 degrees in the total on group and 3.79 ± 3.12 degrees in the partial on group (P = .0004). Conclusions Rotational stability of a single-piece, acrylic toric IOL was better in eyes with total anterior capsule coverage than that in those with partial anterior capsule coverage on the IOL optic.

In order to avoid radial tearing of the anterior capsule while performing continuous circular capsulorhexis (CCC) in a white intumescent cataract, called the "Argentinian flag sign" when CCC is associated with a previous capsular stain with trypan blue, an initial puncture of the anterior capsule is performed with a 30G needle as the first step of the surgical procedure, that means, prior to any previous aperture of the anterior chamber. This act seems to allow the pressure of the intracrystalline space and the pressure of the anterior chamber to be equalized, as the liquefied content of the intumescent white cataract is released into a presumably hermetic anterior chamber, avoiding the dreaded anterior capsular radial tear. This technique, called "white-puncture", has been used in 174 cases without any associated complications.

This study aimed to analyze the anterior lens capsule specimens from both eyes of a patient with systemic sclerosis and compare them to the eyes of a control patient. No significant differences between systemic sclerosis and control eyes were observed in the results from the hematoxylin-eosin and picrosirius staining. In the samples obtained from both systemic sclerosis and control eyes, there were expressions of caspase, a molecule expressed in cell death by apoptosis. Heparanase was overexpressed in the systemic sclerosis sample compared to the control sample. Therefore, the anterior lens capsule of the patient with systemic sclerosis is probably affected by the disease since it showed marked expression of heparanase 1.

The article describes results of laser treatment applied in seven patients (eleven eyes) due to capsulorhexis margin shrinkage and the subsequent wrinkling of the anterior capsule in eyes with pseudophakia. Almost total loss of the anterior capsulorhexis aperture caused a significant decrease in visual acuity, to the level of counting fingers right in front of the eyes in three patients (four eyes). The laser cut of the anterior capsulorhexis margin using the Nd-Yag laser led to an immediate increase in the capsulorhexis size in each case. Visual acuity improved in the eyes with an extreme decrease in the capsulorhexis size. In the remaining eyes, where the decrease of the capsulorhexis size did not lead to the appearance of anterior capsule wrinkling, visual acuity did not change. The progressive decrease in the capsulorhexis size, accompanied by the appearance of white tissue on its margin, containing shrinking elements, constitutes an indication for the implementation of laser therapy.

To assess the m6A methylome in the anterior capsule of the lens of high myopia patients. MeRIP-seq and RNA-seq were performed to identify differences in the m6A methylomes and gene expression between anterior capsule of the lens of simple nuclear cataract patients (N) and nuclear cataract patients with high myopia (G). Expression of m6A-related enzymes was confirmed by quantitative real-time-PCR. ALKBH5 was downregulated in G. The observed m6A peak was identical to the conserved RRACH gmotif and was markedly correlated with two distinct coordinates. Differentially methylated genes were enriched in some pathways regulating the formation of extracellular matrix. These findings suggest that upregulation of m6A methylation may change fundus anatomy by regulating the composition of the extracellular matrix through encoding protein.

PURPOSE: To evaluate the effect of intraocular lens (IOL) optic overlapping on IOL stability and to determine the relationship between the capsulorhexis and IOL movement with the three-dimensional method of swept-source optical coherence tomography (SS-OCT). METHODS: This study identified patients with age-related cataracts and divided them into two groups according to their anterior capsule and IOL optic relationship: total anterior capsule overlap (360°) and partial anterior capsule overlap (< 360°). Standard SS-OCT radial scanning was performed in all eyes at 1 day, 1 week, 1 month, and 3 months after cataract surgery, respectively. The obtained photographs were used for the postoperative position measurements of capsulorhexis and IOL after three-dimensional reconstruction. RESULTS: This study included 46 eyes of 34 patients: total overlap group (n = 29) and partial overlap group (n = 17). The postoperative aqueous depth significantly decreased in the first week after surgery ( P < .001). The IOL tilt was greater in the partial overlap group than that in the total overlap group ( P = .014). The IOL moved significantly in the first week postoperatively (both P < .001). IOL decentration in the x-axis was greater in the partial overlap group than that in the total overlap group ( P = .024). The IOL and capsulorhexis both moved sharply in the first week (both P < .05). The IOL moved consistently with the capsulorhexis in the 3 months after surgery (all P > .05). CONCLUSIONS: The total overlap group showed better IOL centrality and stability. IOL movement may be driven by capsular bag contraction and fibrosis. Thus, it was demonstrated that postoperative IOL position and IOL performance were closely linked with proper size of central continuous curvilinear capsulorhexis. [ J Refract Surg . 2020;36(6):388–394.]

Recurrent multidirectional shoulder instability is a common clinical presentation in certain demographics and sporting groups. One such demographic is patients with connective tissue disorders (CTD) such as Ehlers-Danlos syndrome (EDS), in whom shoulder pathologies are exacerbated owing to ligamentous laxity. Features of this laxity can present as both anterior and posterior shoulder instability, which are problematic sources of shoulder pain. Many patients with these injuries require surgical anterior and/or posterior glenohumeral reconstruction. Surgical reconstruction for posterior capsular defects can be challenging and has higher failure rates compared with anterior capsular reconstruction methods. Management can be especially difficult for patients with CTDs, and there is a requirement for the development of novel surgical techniques. Human acellular dermal allografts have been found to be particularly useful for patients with CTDs compared with other methods that use the patient’s own tissue for the repair. This note and surgical video describe an all-arthroscopic technique for a combined anterior capsule augmentation and posterior glenohumeral capsular reconstruction, using a human acellular dermal allograft for EDS patients with multidirectional instability.

This study sought to evaluate pigment epithelial-derived factor (PEDF) levels in lens anterior capsule material taken during cataract surgery from patients with senile cataract with pseudoexfoliation.The study included 90 eyes of 86 patients who were diagnosed with, and underwent surgery for, cataracts. Sixty of the eyes included in the study had senile cataract. Thirty eyes of 30 young patients with other forms of cataract were included as a control group. Pseudoexfoliation was present in 21 patients with senile cataract. PEDF levels in the lens anterior capsule material - extracted with capsulorhexis in the classical phacoemulsification procedure - were measured by the enzyme-linked immunosorbent assay method and compared between the groups.The PEDF level in the lens anterior capsule in the senile cataract patient group was 149.36 ± 17.46 pg/ml. A statistically significant lower level of PEDF was found in the lens anterior capsule of patients with senile cataract compared with the other groups. In the patient group with pseudoexfoliation, the PEDF level in the lens anterior capsule was found to be statistically significantly lower than the patient group without pseudoexfoliation.PEDF levels decrease with senile cataract and pseudoexfoliation. These findings may clarify the pathogenesis of these conditions and point toward alternative treatment modalities.

Anterior capsule reconstruction (ACR) and latissimus dorsi transfers (LTs) have been proposed as solutions for irreparable subscapularis tears. The purpose of this study was to biomechanically assess the effects of ACR and LT separately and together for treatment of irreparable subscapularis tears.Eight cadaveric shoulders underwent 5 testing conditions: (1) intact, (2) irreparable subscapularis tear, (3) ACR, (4) ACR+LT, and (5) LT alone. Anteroinferior translation loads of 20, 30, and 40 N were applied. Range of motion and magnitudes of glenohumeral anterior and inferior translation at 0°, 30°, and 60° of abduction and at 30° and 60° of external rotation were measured for each testing condition.At 30° of abduction and 60° of external rotation, ACR and ACR+LT restored anterior and inferior translation to intact (P.702) for 30 and 40 N of anteroinferiorly directed force. LT alone did not restore anteroinferior stability at 30 N of distraction force at 30° of glenohumeral abduction and 60° of external rotation (P.001). However, ACR and ACR+LT led to significant decreases in total range of motion compared to intact at 0° and 30° of abduction (P.007).ACR with dermal allograft was able to restore anteroinferior stability in the setting of irreparable subscapularis tears but resulted in decreased total range of motion. LT alone was less effective than ACR in restoring glenohumeral stability. The addition of LT as a dynamic restraint did not increase the efficacy of ACR.

If a complication such as posterior capsular defect occurs (Fig. 3.1), the following procedure is recommended

This is a technique guide for open anterior capsule reconstruction in unstable native hips due to Ehlers–Danlos syndrome. Ehlers–Danlos syndrome is a connective tissue disease that predisposes an individual to hypermobility of their soft tissues and recurrent subluxations and dislocations of their joints. This may lead to constant instability, guarding of the hip, and subsequent arthritic changes and poor quality of life. We demonstrate anterior capsule reconstruction of the hip using an Achilles tendon allograft performed through a direct anterior approach to the hip (Heuter's approach). This technique guide outlines in detail the surgical steps required to accomplish this reconstructive procedure. Furthermore, a narrated surgical video is provided that clearly depicts the anticipated result of the increased constrained provided to the hip from the anterior capsule reconstruction using an Achilles tendon allograft.

To evaluate the maneuverability and efficacy of phacoemulsification and intraocular lens (IOL) implantation in eyes with corneal opacities after deep anterior lamellar keratoplasty (DALK), twelve eyes of 12 patients with mild to moderate corneal opacities after DALK and coexisting cataracts were analyzed retrospectively. Phacoemulsification and IOL implantation assisted with anterior capsule staining, as well as non-invasive optical fiber illumination, were performed on all eyes. No intraoperative or postoperative complications were noted. Mean corrected distance visual acuity (logMAR) improved from 1.24±0.17 to 0.73±0.22. Post-phaco intraocular pressure was maintained between 13 to 20 mm Hg in all cases throughout the follow-up period. Mean endothelial cell density decreased from 2258.42±205.94 to 1906.25±174.23 cells/mm(2). Phacoemulsification and IOL implantation are safe and valid in eyes with mild to moderate corneal opacities after DALK and coexisting cataracts when assisted with anterior capsule staining and non-invasive optical fiber illumination.