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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.

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.

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.

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.]

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.

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.

PURPOSE: To evaluate the frequency of anterior capsule tears and capsule edge irregularities in femtosecond laser anterior capsulotomy, including the effect of optimized vertical spacing settings. METHODS: Three thousand eight hundred thirty-four cases were examined and grouped according to the femtosecond laser capsulotomy settings using manufacturer default settings with a vertical spacing of 10, 15, and 20 µm. Capsulotomy edge irregularities and anterior capsule tears were recorded intraoperatively. RESULTS: The anterior capsule tear rates for the 10, 15, and 20 µm groups were 0.79%, 0.35%, and 0.09%, respectively. The capsule edge irregularity rates for the 10, 15, and 20 µm groups were 6.25%, 1.13%, and 1.15%, respectively. The treatment times for the 10, 15, and 20 µm groups were 1.6, 0.7, and 0.8 second, respectively. The risk reduction of anterior capsule tears positively correlated with the 15 and 20 µm group settings. The anterior capsule tear rate difference between the 10 and 20 µm group settings was statistically significant. Capsule edge irregularity rates were reduced in the 15 and 20 µm group settings. Eye movement was monitored in the 20 µm group and was observed in 9 of 13 patients with capsule edge irregularities. CONCLUSIONS: Anterior capsule tear rates are low with femtosecond laser cataract surgery. The rate can be further reduced with optimization of the settings, including an increase in vertical spacing. [ J Refract Surg . 2019;35(5):280–284.]

Purpose Herein, we elucidated the effect of anterior capsule polishing (ACP) during cataract surgery on the rate of neodymium: YAG (Nd: YAG) laser capsulotomy in multifocal intraocular lens (MIOL). Methods We extracted the medical records of patients who underwent phacoemulsification with MIOL between May 2016 and April 2017 from the files of the patients, and the follow-ups of fewer than 3 years were excluded. The participants were divided into the ACP group and the non- ACP group based on whether the anterior capsule was polished. The primary outcome was whether to perform Nd: YAG capsulotomy during the follow-up. We analyzed the time from IOL implantation to Nd: YAG laser capsulotomy using the Kaplan-Meier survival curves. Results The ACP group comprised 70 eyes and non-ACP group, 60 eyes. One year postoperatively, 7.14% of the eyes in the ACP group and 8.33% in the non-ACP group required Nd: YAG laser capsulotomy (P > 0.99). After 2 years, it was 24.29% and 18.33%, respectively (P = 0.52). After 3 years, it was 30.0% and 28.33% respectively (P = 0.85). There was no distinct difference in the probability for Nd: YAG laser between the ACP group and the non-ACP group evaluated using Kaplan-Meier survival curves (P = 0.81). Patients with implantation of diffractive MIOL (AT LISA tri 839MP) had a high probability of requiring Nd: YAG laser capsulotomy. Conclusion Polishing the anterior capsule had no remarkable effect on reducing the rate of Nd: YAG laser capsulotomy after phacoemulsification in MIOL.

To compare sutureless scleral tunnel phacotrabeculectomy with and without placement of anterior capsule remnant in the tunnel. In this comparative interventional case series, 41 eyes of 40 patients having open-angle glaucoma (OAG) underwent sutureless scleral tunnel phacotrabeculectomy (Group A) and 28 eyes of 24 patients underwent the same procedure with placement of anterior capsule remnant in the tunnel (Group B). Baseline intraocular pressure (IOP) and IOP at 1 day, 1 month and 6 months after surgery were recorded. IOP

Before and during the surgery, you should make sure the cornea is kept moist (a dry cornea compromises the surgeon’s visibility). Prior to surgery you might wish to ask the surgeon if they prefer that you drop sterile balanced salt solution (BSS) on the cornea when you feel it is necessary or wait for instructions from the surgeon.

Anterior capsule contraction syndrome (ACCS) is a rare, late complication of cataract surgery, associated with impairment of visual function. In this paper, we describe a new surgical technique to treat ACCS by femtosecond laser procedure. The femtosecond laser was used to perform an anterior capsulotomy with a customized size, in order to avoid IOL damage. After ophthalmic viscosurgical device injection in the anterior chamber, the anterior capsule flap was separated from the IOL surface by gentle hydrodissection. This manoeuvre enabled an easy and safe removal of the fibrotic material by vitreal microscissors. Our technique allowed a complete removal of the fibrotic material and opening of the capsule, with immediate complete visual acuity recovery without IOL damage. In conclusion, femtosecond laser appears to be safe and effective for treatment of ACCS with long-lasting efficacy.

This chapter reports about the surgical technique of IOL implantation in eyes with posterior capsular rent.

Descemet-stripping automated endothelial keratoplasty (DSAEK) combined with cataract surgery was performed in a 55-year-old man who had bilateral phakic intraocular lens (pIOL) implantation in Moscow, Russia, for high myopia when he was 26 years old. In 2015, he had DSAEK in Nagoya, Japan, after examinations showed the presence of bullous keratopathy in the right eye. In August 2017, he was referred to the Baptist Eye Institute in Kyoto, Japan, because the DSAEK graft had failed. The failed graft and the pIOL were extracted, after which lensectomy, IOL implantation, and anterior capsule staining were performed. A fresh DSAEK graft was attached to the posterior corneal surface via an air injection. By 6 months postoperatively, the corrected distance visual acuity had improved from 20/2000 to 20/20. These outcomes suggest that this surgical procedure would be safe, effective, and applicable in similar complicated cases.

Purpose To compare the expected versus actual position and dimension of corneal incisions during femtosecond laser–assisted cataract surgery. Setting Private Ophthalmic Clinic, Sydney, NSW, Australia. Design Retrospective case series. Methods Video recordings of femtosecond laser–assisted cataract surgery with a Lensx laser were reviewed. The deviation of the main and 2 secondary incisions from the expected position were correlated with globe tilt, globe displacement, and biometric data. The globe tilt was inferred from anterior capsule tilt. Globe displacement was measured. The Softfit contact lens thickness used in the patient interface was measured separately. Results The primary incision internal and external exits were within 142 μm ± 70 (SD) and 151 ± 75 μm of the planned position. The dimensions and position did not correlate with biometric variables. The superior secondary incision external exit was displaced centrally (321 ± 84 μm) and the internal exit was displaced peripherally (84 ± 102 μm). The inferior secondary incision external exit was displaced centrally (278 ± 142 μm) and the internal exit was displaced peripherally (190 ± 133 μm). Multivariate analysis showed that the external and internal exits of the superior (adjusted r2 = 0.36, P Conclusions The primary incisions were close to the expected dimensions. The secondary incision position was affected by eye tilt and eccentric docking. These could potentially be improved with optical coherence tomography guidance.

People with the long anterior zonule (LAZ) trait, which may have prevalence near 2%, have zonular fibers that extend more central than usual along the anterior capsule of the crystalline lens. The anomalous fibers can be observed in vivo with clinical slit lamp biomicroscopy after pharmacologic pupil dilation, and although minimally studied, the LAZ trait may have importance to glaucoma, retinal degeneration, and cataract surgery. To further characterize LAZ morphology, a custom computer program was used to trace LAZ fibers seen on retro-illumination photos acquired during previous study at an academic, urban eye care facility in Chicago, IL. There were 59 African-Americans (54 female; median age = 70 years, 53-91 years) included in the analysis. After initial review of the zonule tracings, we identified three basic LAZ patterns. We called one pattern (47% of right eyes) a "non-segmental LAZ pattern," which was predominated by fibers that could be visually traced to the dilated pupil border where they became obscured by the iris. Another pattern (35% of right eyes), the "segmental LAZ pattern," was predominated by fibers that appeared to terminate abruptly without detectable extension to the pupil border. The third pattern (18% of right eyes), the "mixed LAZ pattern," had a more equivalent mixture of the other two fiber morphologies. Compared to the "non-segmental" group, the "segmental" LAZ eyes had smaller central zonule-free zones (P < 0.0001), and they tended to exhibit fewer LAZ fibers (P = 0.07). These data improve understanding of LAZ clinical anatomy and may be helpful to future investigation. Anat Rec, 300:1336-1347, 2017. © 2017 Wiley Periodicals, Inc.

Purpose: To evaluate intraoperative complications during phacoemulsification of intumescent cataract using lens decompression technique. Methods: Participants with intumescent cataract scheduled for phacoemulsification were recruited and divided into two groups. In both groups, after the anterior capsule was stained with trypan blue, the anterior chamber was filled peripherally with a dispersive ophthalmic viscosurgical device (OVD) followed centrally by a higher viscosity cohesive OVD (Healon GV). In Group 2, a 25-gauge needle was then inserted into the lens center and liquid cortex aspirated by pulling back on the syringe plunger. The outcomes measured were the incidence of capsular radial tears and the incidence of conversion to extracapsular cataract extraction (ECCE). Results: In Group 1 (20 eyes), capsular radial tears occurred in four eyes, and in two eyes, the procedure had to be converted to ECCE. In Group 2 (20 eyes), no capsular radial tears or conversion to ECCE was reported. Conclusion: Lens decompression technique reduced the risk of capsular radial tears and conversion to ECCE during phacoemulsification of intumescent cataract.

Purpose: To determine the effect of anterior capsule polishing (APC) on the rate of posterior capsule opacification (PCO) as assessed by the need for laser posterior capsulotomy. Setting: University-based clinical practice, Jules Stein Eye Institute, Los Angles, California, USA. Methods: This study involved a retrospective review of eyes that underwent phacoemulsification and intraocular lens implantation between September 1991 and June 1999. Lens epithelial cells in the 763 study eyes were mechanically debrided or polished from the inside surface of the anterior capsules using a pair of Shepherd-Rentsch (Morning STAAR Inc.) capsule polishers. The 484 control eyes that had surgery earlier in the series were not polished. The rate of laser capsulotomy in the ACP and the non-ACP groups was compared using a Kaplan-Meier survival analysis. Multivariate regression was performed to determine if variables other than ACP influenced the need for laser posterior capsulotomy. Results: We identified 763 eyes that had ACP and 484 that did not. At the 24-month follow-up interval, 26.6% of the eyes in the ACP group had received a capsulotomy versus 19.50% in the non-APC. Next, a separate study was done using only one eye per patient, taking the patient as the unit of analysis. Again the capsulotomy rate was higher in the ACP group compared to the non-ACP (1.02 per 100 person-months of follow-up vs. 0.74 per 100 person-months of follow-up). Finally, a third Kaplan-Meier analysis was done on 52 patients that had one eye treated with the ACP procedure and the other eye with the non-ACP procedure. Although the log-rank test showed the statistical significant of this analysis to be borderline, the results again favored the non-ACP group with a lower capsulotomy rate. Multivariate analysis showed very similar results to the above univariate studies. The mean time to capsulotomy was 46 months for the polished group and 70 months for the unpolished group. The severity of cataract (p = 0.46) and the type of haptics (p = 0.86) did not influence the rate of capsulotomy. Plate haptic IOLS had a higher rate of capsulotomy than loop haptic IOLS (p = 0.001). Conclusions: Polishing of the anterior capsule with Shepherd-Rentsch polishers may unexpectedly increase the rate of posterior capsule opacification in eyes with round-edge silicone lenses.

Purpose: To analyze the outcomes of in-the-­bag toric intraocular lens implantation for anterior capsular tears during phacoemulsification. Methods: The cohort of this re­trospective, consecutive, interventional case series included eight patients. One patient was excluded as the tear was used to enlarge the rhexis. The mean preoperative astigmatism was -1.67D (± 0.98) and the mean preoperative unaided logMAR visual acuity was 0.62 (± 0.76). The mean angle between the anterior capsule tear and the closest intraocular lens haptic was 51.25° (range, 30°-90°). Results: The final unaided logMAR visual acuity was 0.16 (± 0.21) and the final cylinder was -1.1 D (± 0.59). The mean follow-up duration was about 2 ± 1.2 months. In this case series, no lens had to be explanted or rotated postoperatively. Placement of a toric intraocular lens in the presence anterior capsule tear was safe in all patients. An angle of at least 30° remained between the tear and the intraocular lens haptic. Conclusion: Placement of toric intraocular lens in the presence of an anterior capsule tear may be safe, at least in cases with a 30° angle between the anterior capsule tear and the intraocular lens haptic.

OBJECTIVES: To evaluate the development of posterior capsule opacification (PCO) and Nd:YAG capsulotomy rates following implantation of two hydrophobic acrylic IOLs. METHODS: In a randomized, controlled trial, 80 patients with bilateral senile cataract were implanted with the hydrophobic acrylic single-piece intraocular Lenses (IOLs) EyeCee One in one eye and iMics1 in the other. Outcomes of 39 patients (78 eyes) were evaluated after 3 years. Automated Quantification of After-Cataract (AQUA; for PCO occurrence), visual acuity, anterior fibrosis, capsule−optic edge interaction and distance between anterior and posterior capsule IOL surface were analysed. RESULTS: After a mean follow-up of 38 ± 1.95 months, Nd:YAG capsulotomy occurred at a rate of 15.4% and 46.2% in the EyeCee One and iMics1 groups, respectively (p

Finite element models of human crystalline capsular bag and zonular fibers are used to estimate the mechanical response of the capsule to the presence of a C-loop Intra-Ocular Lens (IOL) after cataract surgery, to assess the influence of capsulorhexis size, shape and location on IOL decentration and tilt. The model includes, in the anterior capsule, a hole with variable size, shape and position, which represents the rhexis obtained in a manual or laser-assisted manner. The IOL is not explicitly modelled, but its action is reproduced by means of a set of elastic ties, connecting the opposite sides of the bag and exerting the force corresponding to an expanded IOL. Numerical simulations show that IOL decentration and tilt are not related to the size of the rhexis. A decentered rhexis induces IOL decentration40 μm and a tilt12°; the combination of non-circular shape and decentering of the rhexis induces IOL decentration47 μm. While the introduction of a circular central rhexis causes an increment of the stresses in the capsule up to 100% relative to the physiological state, the combination of rhexis decentering and non-circular shape causes an additional 10% stress change. The values of IOL decentering and IOL tilt obtained from simulations are of scarce relevance in the clinical practice.

We describe in-the-bag nasal intraocular lens (IOL) optic truncation, a new technique for the treatment of negative dysphotopsia. After a plane is created between the nasal capsular bag and the IOL, micrograspers and intraocular scissors are used to amputate the nasal optic edge. The amputation is to reduce the optical impact of the IOL edge and nasal anterior capsule on the occurrence of negative dysphotopsia. The technique addresses many of the proposed mechanisms contributing to the development of negative dysphotopsia and can theoretically be used in all patients with chronic symptomatology. In the case we describe, the dysphotopsia resolved immediately after in-the-bag nasal IOL optic truncation. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

We describe a technique to reposition a decentered 4-haptic intraocular lens (IOL). Using an ophthalmic viscosurgical device, the haptic with the worst distortion is dissected from the capsular bag and pulled outside the bag. The opposite haptic (180 degrees away) is also dissected and placed in front of the anterior capsule. The remaining 2 haptics are left in the capsular bag. With this repositioning, the 2 haptics in the bag limit the IOL movement, the 2 haptics outside the bag are no longer distorted, and the IOL is centered. We present 2 cases in which this technique was used to reposition decentered 4-haptic IOLs.

AIM: To explore the application value of polishing anterior capsule and equator in the phacoemulsification and intraocular lens implantation. METHODS: Totally 112 cases of cataract patients in our hospital from May 2012 to January 2015 were selected as research objects. They were divided into unpolished and polished group according to whether the anterior capsule and equatorial part polished or not with the informed consents, 56 cases in each group. The patients were followed up for 18mo after phacoemulsification and intraocular lens implantation. The clinical efficacy of the two groups was compared.RESULTS: The complication rates of the two groups were 7.1% and 16.1%, that of the polished group was lower and the difference was statistically significant(PPCONCLUSION: Polishing anterior capsule and equator can significantly improve the effect of phacoemulsification combined with intraocular lens implantation in the treatment of cataract.

Purpose: To evaluate the impact of anterior capsular polishing on capsule opacification and contraction in eyes undergoing femtosecond laser-assisted cataract surgery (FLACS). Methods: This prospective interventional comparative analysis included patients undergoing FLACS between August 2016 and May 2017. The eyes were subdivided into three groups based on the extent of intraoperative anterior capsular polishing performed: complete 360-degree polishing; inferior 180-degree polishing; and no polishing. Visual acuity, posterior capsular opacification (PCO) score, anterior capsular opacification (ACO) grade, and capsulorhexis diameter were evaluated at 1-week, 6-months, and 1-year postoperative visits. Results: The study included 99 eyes of 90 patients. No significant differences were observed between the three groups in ACO grade and capsulorhexis contraction at all follow-up visits. There was a statistically significant difference in PCO grade among the groups at 6-month and 1-year follow-up but it was found to be clinically insignificant. One eye in the no polishing group underwent neodymium:yttrium-aluminum-garnet (Nd:YAG) capsulotomy at the 1-year follow-up visit. Conclusion: A lower incidence of PCO was demonstrated in the 360-degree polishing group, although it was visually insignificant. No significant difference in postoperative capsular contraction was demonstrated between the cohorts up to one-year follow-up.

Purpose: To investigate the intraoperative performance and the ultrastructural features of anterior capsulotomy performed with the improved Zepto precision pulse capsulotomy (PPC) device. Setting: Launceston Eye Institute, Launceston, Tasmania, Australia. Design: Prospective, consecutive case series. Methods: Intraoperative observation of performance and complications were made on consecutive eyes having capsulotomies with the improved PPC device. The capsulotomy specimens were examined under scanning electron microscope and compared with manual continuous curvilinear capsulorhexis and femtosecond laser–assisted cataract surgery specimens. Results: The study comprised 52 eyes. Intended capsulotomy occurred in 50 eyes with 2 device failures. Complete free-floating capsulotomies were achieved in 48 eyes (96%). Anterior capsule tears occurred in 2 eyes (4%). Conclusions: The ability of the PPC device to create complete free-floating capsulotomies improved; however, the radial tear rate remained high. The ultrastructural features in ex vivo human capsulotomy specimens still showed areas of irregular capsule margin with frayed edges.

We describe a technique for pediatric traumatic cataract management in cases in which part of the anterior capsule has been ruptured. The technique requires creating a 2-incision push-pull capsulorhexis in the intact anterior capsule. The capsulorhexis is made in a manner that converts the edge of the ruptured anterior capsule into a band of capsule that holds the intraocular lens (IOL) in the bag, reducing the incidence of early, intermediate, or late postoperative lens-iris capture. It also reduces the chances of IOL displacement.

Purpose. To evaluate the effect of anterior capsule polishing in patients with high myopia after cataract surgery. Setting. The Eye Hospital of Wenzhou Medical University, Zhejiang, China. Design. Prospective study. Methods. High myopic patients with a bilateral cataract who underwent phacoemulsification with 360° anterior capsular polishing in one eye and without polishing in the contralateral eye were recruited. The following parameters were recorded at 1, 3, and 6 months postoperatively, including the area and diameter of the anterior capsule opening (area and D), IOL tilt and decentration, refraction, and postoperative aqueous depth (PAD). Results. Paired samples of 38 eyes of 19 patients were enrolled. The area decreased significantly in both the polished group and unpolished group, whereas the diameter reduced more in the unpolished group. The IOL tilt and decentration at 3-month and 6-month follow-up showed significant differences between two groups. In the unpolished group, the IOL decentration firstly appeared between one-month to three-month visit, while the refraction error, PAD, and IOL tilt were significantly different between the three-month and six-month visits. Conclusion. 360° anterior capsule polishing can effectively reduce the extent of the anterior capsule contraction and increase the stability of IOL. The study was registered at http://www.clinicaltrials.gov, and the clinical trial accession number is NCT 03142269.

Refractive errors are one of the most common ophthalmologic problems. Implantable contact lens (ICL) implantation has received attention for its excellent and rapid visual and refractive results in eyes with high myopia. There are still concerns about complications such as anterior capsule opacity, cataracts,1,2 pupillary block glaucoma,3,4 chronic inflammation,5 pigmentary dispersion syndrome,6,7 and pigmentary glaucoma.8 We report an interesting case of a patient who had undergone ICL implantation presenting as a case of pupillary block glaucoma and how the patient was effectively managed.

Purpose To compare the 3-year postoperative anterior (ACO) and posterior (PCO) capsule opacification and the level of anterior capsule retraction after implantation of 2 single-piece hydrophobic acrylic intraocular lens (IOL) models. Setting Hospital of St. John of God, Vienna, Austria. Design Comparative randomized controlled double-blind clinical trial. Methods Eyes with bilateral cataract were evaluated. Each patient had an Acrysof SA60AT (interrupted optic edge) IOL implanted in 1 eye (Group A) and a Tecnis ZCB00 (continuous optic edge) IOL implanted in the fellow eye (Group B). One and 3 years postoperatively, PCO was evaluated using Evaluation of Posterior Capsule Opacification software and the ACO level and capsule-retraction level were evaluated and graded subjectively. Results The study evaluated 100 eyes of 50 patients ranging from 61 to 80 years. Postoperatively, there were no statistically significant differences in PCO between Group A and Group B at 1 year (0.06 ± 0.12 [SD] and 0.07 ± 0.13, respectively; P = 4.35) or 3 years (0.23 ± 0.36 and 0.22 ± 0.32, respectively; P = .66). In Group A and Group B, ACO was present in 18.0% of eyes and 2.7% of eyes, respectively, at 1 year ( P = .03) and in 92.0% and 24.0%, respectively, at 3 years ( P Conclusion Both IOLs had similarly low PCO rates 3 years postoperatively, although more ACO and capsule retraction were observed in eyes with the interrupted optic edge IOL. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

The appearance of a dark shadow in the temporal periphery, otherwise known as negative dysphotopsia, continues to be a problem for some patients after routine uncomplicated cataract surgery. Etiologies include type and design of intraocular lens (IOL), anatomical features and dimensions of the eye, pupil size, angle kappa, relationship of the optic to the anterior capsule, and the position of the optic/haptic junction of the IOL. Although the primary etiology remains controversial, it is clear that the cause is multifactorial. All of the factors should be considered when attempting to prevent or treat this phenomenon.

In the event of an inadequate capsular bag support, an intraocular lens can be fixated by suturing one or both haptics to the iris. For suture fixation of intraocular lens to iris, a three-piece intraocular lens is selected [1]. The intraocular lens power selected is the same as that for sulcus fixation. In the setting of a partial capsular support, as the situation usually is when this method of intraocular lens fixation is selected, one of the haptics is centered over the remnant anterior capsule and the other haptic is fixated to the posterior aspect of the iris. For suturing, a 10–0 polypropylene, on a long curved needle, is preferred [1]. The prerequisites for selecting this technique are a normal iris architecture and thorough anterior vitrectomy to clear all vitreous in and around the pupil.

Intraocular lens (IOL) implantation in cases lacking sufficient capsular support is challenging to the anterior segment surgeon. If the anterior capsule is intact and with no tears at the capsulorhexis margin, then a sulcus fixation is preferred by most surgeons; however, square-edged one-piece hydrophobic lenses should be avoided. If there is no capsular support to ascertain stable fixation, then other alternatives are used, such as scleral fixation of a three-piece IOL, either by suturing or by placing the haptics in a scleral tunnel, iris fixation using sutures or iris claw lenses, and anterior chamber angle supported IOLs.

Perhaps the greatest fear of cataract surgeons is that of suddenly noticing a posterior capsular rent in what hitherto seemed to be a perfect “refractive” cataract surgical procedure. “Refractive,” because today all cataract surgeries aim to correct the patients’ underlying refractive errors, whether they are planned as clear lens extractions or procedures to restore functional vision for disabled patients with bilateral dense brunescent or mature cataracts. Since the first ultrasonic biometers became available in the early 1980s, we have progressively refined our “standard” techniques to enable ophthalmic surgeons to ever more accurately enhance refractive results from cataract surgery. We have evolved to have extremely high expectations, perhaps the highest of any medical or surgical procedure currently performed. We regularly hear our patients say that they see better after our surgery than they ever have before. Ultrahigh expectations contribute to the surgeon’s already high anxiety about increased risk for complications when a capsular rent appears, often bordering on panic, especially now that capsular tears are becoming much less common, approaching 1 % of cases or less.

Pediatric cataract surgery poses a significant challenge for the cataract surgeon, in part because an elastic anterior capsule can make capsulorhexis difficult. With the use of femtosecond laser-assisted cataract surgery (FLACS), however, the continuous curvilinear capsulorhexis can be made with predictable size, circular shape, centration, and accuracy. In addition, topical anesthesia can be used for the FLACS docking procedure in cooperative children above 6 years of age, using transparent adhesive polyurethane film segments.

Objective We describe a simplified method to detect anterior lenticonus. Three eyes of 2 patients with anterior lenticonus, plus 16 eyes from 16 healthy controls underwent Scheimpflug imaging of their anterior segment with Pentacam. The anterior capsule apex angle was manually identified and automatically measured by AutoCAD. Results The mean angle was 173.06° (SD: 1.91) in healthy subjects, and 158.33° (SD: 3.05) in anterior lenticonus eyes. The angle obtained from patients was more than 3 SD steeper than those from healthy subjects. Conclusions The apical angle calculation method seems to discriminate well between normal eyes and eyes suspected of having anterior lenticonus.

The aim of the present study was to detect senile nuclear cataract lens density and provide a quantitative measurement of lens density for the long-term clinical observation of cataracts. An Anterior Segment Analysis System was used to detect the lens density of 422 simple senile cataract eyes and normal contralateral eyes. The density values were taken at the optical axis at various depths measured from the anterior capsule. The differences in lens density at various photographic orientations and in various nuclear grading groups were investigated. The density at 90º orientation was larger than that at 30 and 150º (P0.05). In the grade 4 group, the decrease was more evident. The average density values at all the depth points showed a tendency to increase with increasing nuclear grade. Measuring the density of the anterior half of the lens at 90º orientation is therefore more reliable compared with that of the posterior half and at other orientations. Results of the present study have shown that the Anterior Segment Analysis System may be used to detect senile nuclear cataract lens density and provide a quantitative measurement of lens density for long-term clinical observation of cataracts.

We report the case of a 52-year-old woman who developed bilateral anterior and posterior subcapsular cataracts with anterior capsule fibrosis 12 years after exposure to intensive radiation therapy. The woman had uneventful cataract surgery and gained 20/20 corrected distance visual acuity in both eyes. Hematoxylin–eosin staining of the anterior capsule revealed significant subcapsular scar formation in the context of fibroblast proliferation. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

There is no widely accepted classification system for pediatric cataracts. Generally speaking, cataracts are classified according to the etiology, age of onset, morphology, location, or degree of lens opacity. Since opacity may occur in any part of the lens, the morphological manifestation of pediatric cataract is diverse and complex. Based on the abundant patient resources and first-hand clinical data from the “Cataract Children’s Home” of Zhongshan Ophthalmic Center, this chapter discusses the classification and morphological manifestation of pediatric cataracts using a large number of precious slit-lamp microscopic images.

Successful immunization and vitamin A supplementation programs have seen the prevalence of childhood blindness in Sub Saharan Africa (SSA) fall and have also seen cataract become the leading cause of childhood blindness.

To evaluate the efficacy of autologous anterior lens capsule (ALC) in phacotrabeculectomy.In this prospective, randomized case control study, after obtaining institutional ethical clearance and informed consent, 88 eyes posted for phacotrabeculectomy were divided into ALC and non-ALC groups. Combined phacoemulsification, with posterior chamber intraocular lens implantation and trabeculectomy, was performed in both groups. Anterior lens capsule transplantation was done in the first group beneath the sclera flap. Follow-up of three months was carried out and the morphology of bleb, intraocular pressure (IOP), requirement for additional medications, and complications were compared between the two groups.Statistical difference favoring the ALC group was seen in IOP reduction (p0.05) at each follow-up, qualified success rate and failure rate at the three-month follow-up (p = 0.006), but no difference in bleb morphology was seen.ALC implantation is beneficial in maintaining filtration in a combined surgery with minimal complications.

To evaluate and compare the 5-year postoperative anterior (ACO) and posterior capsule opacification (PCO), the occurrence of glistenings, and the level of anterior capsule retraction after implantation of 2 designs of 1-piece hydrophobic acrylic IOLs.Hospital St. John, Vienna, Austria.Randomized controlled prospective case series.Patients had an Acrysof SA60AT IOL (Group A) implanted in 1 eye and a Tecnis ZCB00 IOL (Group B) implanted in the fellow eye. At 1, 3, and 5 years, the PCO level was evaluated with the Evaluation of Posterior Capsule Opacification software. The level of ACO and capsule retraction was graded subjectively. Glistenings were scored as present or not present.Fifty eyes of 25 patients were evaluated after 5 years. No significant differences in PCO scores were found between the 2 groups at all follow-up visits (1 year: 0.06 ± 0.12 [SD] versus 0.07 ± 0.13, P = .35; 3 years: 0.23 ± 0.36 versus 0.22 ± 0.32, P = .66; 5 years: 0.36 ± 0.41 versus 0.36 ± 0.54, P = .98). A significant increase in PCO score was found between 3 and 5 years (P .01). Anterior capsule opacification was present in Group A and Group B in 18.0% and 2.7% of eyes (P = .03), in 92.0% and 24.0% of eyes, and in 100% and 52% of eyes (P .01) at 1, 3, and 5 years, respectively. Glistenings (5 years 100%) were observed in Group A.Both IOLs had a comparable PCO rate 5 years after surgery, although more ACO and retraction as well as glistenings were observed in Group A.

We describe a technique for the penetrating keratoplasty (PKP) triple procedure that uses 29-gauge dual-chandelier illumination during creation of a non-open-sky continuous curvilinear capsulorhexis (CCC). The chandeliers are inserted through the pars plana into the vitreous cavity through the bulbar conjunctiva at the 3 o'clock and 9 o'clock positions. We compared this approach with that of a core vitrectomy, in which a single 25-gauge port is inserted into the vitreous cavity transconjunctivally through the upper temporal pars plana. The area of halation around the corneal opacity was significantly smaller in the 29-gauge group than in the 25-gauge group. The reduction in halation improved visibility of the anterior capsule and enabled the surgeon to perform CCC with greater safety. The 29-gauge chandelier system was more suitable than the 25-gauge chandelier system for the non-open-sky CCC component of the PKP triple procedure.

Purpose: To study the effect of anterior capsule polishing during phacoemulsification on the incidence of post operative YAG laser capsulotomy. Method: A retrospective controlled study of 159 patients who underwent uncomplicated phacoemulsification with anterior capsular polishing between October 1998 and March 2000. 169 age matched patients who underwent phacoemulsification but without anterior capsule polishing served as controls. Main outcome measure: Incidence of visually significant YAG capsulotomy, which improved the Snellen acuity for more than 1 line or at least 1 line with subjective improvements in symptoms. Results: 2.51 % of patients with anterior capsular polishing (Group 1) had YAG capsulotomy compared to 7.1% of patients in control group at one year. However, after two years, 11.3% of patients in Group I had YAG capsulotomy compared to 12.4% in Group 2. Conclusion: Anterior capsular polishing during cataract surgery may delay the opacification of posterior capsule during the early postoperative period. But does not decrease the incidence of YAG capsulotomy after two years.

The high rate of complications associated with intracapsular cataract extraction (ICCE) surgery was the impetus for a safer surgical technique. The optimal technique would reduce the size of the incision, minimize corneal trauma, preserve the posterior capsule, and allow for posterior chamber IOL implantation. Thus, in the late 1960s, extracapsular cataract extraction (ECCE) quickly supplanted intracapsular cataract surgery as the dominant cataract surgery technique [1, 2]. In a similar fashion, different anterior capsular opening styles emerged to take advantage of the benefits of ECCE techniques. Each capsular opening technique developed either out of necessity (e.g., limited access to capsular stains, OVDs, etc.) or with refinements in surgical technique.

Even if occasionally other feedback types also come into play, the VR surgeon relies almost entirely on visual feedback to operate in the vitreous cavity. It is thus crucial that all elements that have a role in providing for optimal visual feedback are properly addressed. These elements include the viewing system (microscope, BIOM, contact lens), the cornea, the AC, the pupil (how it is made and kept wide), the lens and the IOL, and the vitreous cavity itself. In addition, the surgeon must avoid interfering with quality of the image by incorrectly manipulating the eyeball.

We describe a technique that prevents the Argentinean flag sign in white cataract. The technique is based on the intumescent cataract having 2 rather than 1 pressurized compartments within the crystalline lens, the anterior and the posterior. The pressure that pushes the nucleus upward, which is the movement responsible for a radial tear of the anterior capsule, does not come from the vitreous but from the posterior intralenticular pressurized compartment. We also present a nomenclature system to help the phacoemulsification surgeon distinguish the 3 types of senile white cataracts and prevent intrasurgical complications peculiar to each one.

A technique that uses an implanted intraocular lens (IOL) to create a barrier for the management of posterior capsule rupture is described. When a rupture occurs, surgery is halted and a dispersive ophthalmic viscosurgical device (OVD) injected into the anterior chamber to prevent vitreous prolapse. The remaining nucleus is maneuvered into the anterior chamber away from the pupillary space. The posterior capsule tear is converted into a continuous curvilinear capsulorhexis where possible. Dissociated anterior vitrectomy is performed as indicated, keeping the large nuclear fragments trapped in the OVD-filled anterior chamber. An IOL is implanted in the capsular bag or sulcus with optic capture through the anterior capsulorhexis. Using reduced parameters, phacoemulsification of the remaining fragments is completed over the IOL, which functions as a barrier to seal off the vitreous cavity. Residual nuclear fragments and vitreous are cleared from beneath the optic by placing the vitreous cutter under the optic, recapturing the optic before the instruments are removed from the eye. Financial Disclosure The author has no financial or proprietary interest in any material or method mentioned.

The purpose of the present study was to elucidate the effect of posterior capsule opacification (PCO) on the straylight domain of visual function. PCO is heterogeneous with regard to morphology and severity; both aspects contribute to its functional effect. The isolated impact of capsule areas with specific morphology and severity on straylight was studied in-vitro by recording forward light-scatter. Forward light-scatter by four different capsule types, i.c. anterior capsule (AC), clear posterior capsule (PC), fibrotic and regeneratory PCO, was recorded at several visual angles with a goniometer, using different wavelengths. Angular (theta(a)) and wavelength dependencies (lambda(b)) were studied by determining exponents a and b. Recorded straylight values of isolated capsule areas varied between 10 x below to 10 x above the value normal for the human eye, depending on the capsule's condition (clear to opacified). The angular dependence of light scattered by clear PCs was weaker, whereas in the other capsule types it was stronger than in the normal eye. On average, the wavelength dependence of light scattered by different capsule types was similar, but the variation was considerable. At the smallest visual angles, increased angular and decreased wavelength dependence was found, especially in fibrotic and regeneratory PCO. It was concluded that the range of straylight values found in-vitro in lens capsules properly corresponded to that found previously in in-vivo pseudophakics. Surprisingly, the wavelength dependence of PCO indicated that small-particle light-scattering is important in PCO. Refractile effects were more important at small visual angles, as indicated by the combined stronger angular and weaker wavelength dependence. Crown Copyright (C) 2011 Published by Elsevier Ltd. All rights reserved