Phacoemulsification in bilateral anterior lenticonus in Alport syndrome: A case report.

RATIONALE: To report the visual status and results of phacoemulsification cataract surgery in a young patient with Alport syndrome associated with bilateral anterior lenticonus. The milestone of this report is the use of anterior segment optical coherence tomography (AS-OCT) to confirm the central protrusion of the anterior surface of the crystalline lens. PATIENT CONCERNS: A 23-year-old young woman presented with severe progressive visual loss in both eyes, which started several years ago. DIAGNOSES: Refractive status was indicative of high myopia with astigmatism and vision was not improved with optimal correction to better than 0.1 in the right eye and 0.2 in the left eye (visual acuities given in decimal notation). Slit-lamp examination showed transparent cornea, anterior lenticonus and posterior sub-capsular cataract in both eyes. The classical appearance of oil droplet was evident using retro-illumination on the slit lamp. INTERVENTIONS: The natural lenses were replaced with intraocular lens (IOL). OUTCOMES: An excellent refractive status achieved associated with an uncorrected distance visual acuity 0.9 and 0.8 in the right and left eye, respectively. LESSONS: AS-OCT is a valuable device for confirming the budging of the anterior crystalline lens surface.

Second-wave hydrodissection for aspiration of cortical remains after femtosecond laser-assisted cataract surgery.

We describe the technique of second-wave hydrodissection (the first wave being the initial cortical cleaving hydrodissection) performed after the removal of the cataract nucleus in femtosecond laser-assisted cataract surgery. After femtosecond laser application, the cortex is typically found adhered to the anterior capsule. Under high magnification, a steady stream of a balanced salt solution is directed toward the anterior capsule using a hydrodissection cannula. Full cleavage of the remaining cortex is observed by noting the appearance of a dark inner circle by the capsulotomy edge once the balanced salt solution wave has separated the cortex from the capsule. Irrigation/aspiration (I/A) of the cortical remains after the second wave is faster than I/A without this step in femtosecond laser-assisted cataract surgery.

A modified-simple technique of removing the lens cortex during cataract surgery.

We describe here a surgical technique of removing the remaining cortex after phacoemulsification without performing the conventional irrigation/aspiration (I/A) procedure. In this technique, the remaining cortex attached to the posterior capsule was separated and dissected into several pieces by continuous irrigation with balanced salt solution, which was supplied through a syringe attached to a bent, blunt-tip needle. Approximately, 10 s of manual irrigation separated most of the remaining cortex from the posterior capsule. Then, the capsular bag was inflated with an ophthalmic viscoelastic device (OVD), and this pushed the separated cortex toward the capsular fornix mechanically. An intraocular lens was inserted into the capsular bag, following which the remaining cortex and OVD were removed concomitantly using an automated I/A handpiece. This technique is a simple and easy maneuver to remove the cortex from all areas, including the subincisional area, and reduce the possibility of a posterior capsule tear.

Pars Plana Lensectomy After Femtosecond Laser-Assisted Cataract Surgery.

The use of femtosecond laser during cataract surgery is increasing, as it may potentially improve accuracy, safety and refractive outcomes. However, posterior capsule rupture with retained lens material can occur, necessitating vitreoretinal intervention. The authors report the first videographically documented case of removal of retained lens material after femtosecond laser-assisted cataract surgery.

In-office use of the intrector for the removal of retained lens cortex.

PURPOSE: To report a case and technique for the removal of retained lens cortex material in an office-based procedure using a portable battery-powered vitrectomy system. METHODS: Case report. RESULTS: An 88-year-old man underwent uncomplicated office-based vitrectomy for the removal of retained lens material with good anatomical and visual outcomes. CONCLUSION: The authors report a case of the removal of retained cortex material using an office-based vitrector. Clinicians should be aware of this technique for selected patients.

Hydrodissection-free phacoemulsification surgery: mechanical cortical cleaving dissection.

UNLABELLED: We describe hydrodissection-free phacoemulsification surgery (hydro-free phaco), which eliminates conventional cortical-cleaving hydrodissection during cataract surgery. To replace hydrodissection, we devised a mechanical cortical-cleaving dissection technique that is performed during phacoemulsification. The new technique prevents the high pressure within the endocapsular space or the posterior chamber-anterior hyaloid membrane barrier area that is common with hydrodissection. This reduces hydrodissection-related complications such as posterior capsule rupture, anterior hyaloid membrane tear, extension of zonule fracture, and pseudoexpulsive hemorrhage. Using this technique, phacoemulsification was performed effectively without complications in 547 of 550 cataract eyes. We propose this technique to prevent hydrodissection-related complications in eyes with a high risk for complications. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.

Cortex removal after laser cataract surgery and standard phacoemulsification: a critical analysis of 800 consecutive cases.

PURPOSE: To evaluate the ease of anterior cortex removal and hydrodissection of the lens in femtosecond laser-assisted cataract surgery compared with standard phacoemulsification. METHODS: In the femtosecond laser-assisted cataract surgery group (400 eyes), a femtosecond laser was used for capsulotomy and followed by lens fragmentation. In the standard group, the capsulorhexis was performed manually. In both groups, a normal hydrodissection was set, the nucleus was aspirated with or without ultrasound phacoemulsification energy, and residual cortex removal and posterior capsule polishing were performed using bimanual irrigation/aspiration. The primary end point was the time (in seconds) required for the removal of the cortex from instrument insertion in the eye until aspiration tip removal. Secondary end points were the effective phacoemulsification time, quality of the anterior capsule, and anterior or posterior capsule ruptures. RESULTS: Cortex removal time measured 30 ± 13 seconds (range: 10 to 76 seconds) for the standard group and 27 ± 10 seconds (range: 9 to 72 seconds) for the femtosecond laser-assisted cataract surgery group (P < .005). After laser-assisted capsulotomy, one capsule was still adherent following removal by forceps. No anterior or posterior capsular tears were observed in either group. CONCLUSIONS: In femtosecond laser-assisted cataract surgery, the biaxial cortex removal time was comparable with the time in standard phacoemulsification.

Hurricane cortical aspiration technique: one-step continuous circular aspiration maneuver.

UNLABELLED: We describe a modification of the original standard radial aspiration technique. The modified technique--hurricane 1-step continuous circular cortical aspiration--has the potential to improve this part of phacoemulsification surgery with benefits in surgical time and possible decreases in fluid, corneal edema, and traction on the zonular fibers through better distribution of tractional forces. The first results were encouraging and without complications. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Simple fixation and storage protocol for preserving the internal structure of intact human donor lenses and extracted human nuclear cataract specimens.

PURPOSE: Increased use of phacoemulsification procedures for cataract surgeries has resulted in a dramatic decrease in the availability of cataractous nuclear specimens for basic research into the mechanism of human cataract formation. To overcome such difficulties, a fixation protocol was developed to provide good initial fixation of human donor lenses and extracted nuclei, when available, and is suitable for storing or shipping cataracts to laboratories where structural studies could be completed. METHODS: Cataractous lens nuclei (n=19, ages 12 to 74 years) were obtained from operating suites after extracapsular extraction. Transparent human donor lenses (n=27, ages 22 to 92 years) were obtained from the Ramayamma International Eye Bank. After the dimensions were measured with a digital caliper, samples were preserved in 10% formalin (neutral buffered) for 24 h and followed by fixation in 4% paraformaldehyde (pH 7.2) for 48 h. Samples were stored cold (4 °C) in buffer until shipped. Samples were photographed and measured before further processing for transmission electron microscopy. RESULTS: The dimensions of the samples varied slightly after short fixation followed by 1 to 5 months' storage before transmission electron microscopy processing. The mean change in the axial thickness of the donor lenses was 0.15±0.21 mm or 3.0±5.4%, while that of the extracted nuclei was 0.05±0.24 mm or 1.8±7.6%. Because the initial concern was whether the nuclear core was preserved, thin sections were examined from the embryonic and fetal nuclear regions. All cellular structures were preserved, including the cytoplasm, complex edge processes, membranes, and junctions. The preservation quality was excellent and nearly equivalent to preservation of fresh lenses even for the lens cortex. Cell damage characteristic of specific nuclear cataract types was easily recognized. CONCLUSIONS: The novel fixation protocol appears effective in preserving whole donor lenses and cataractous nuclei over a wide age range. Dimensions varied only 2%-3%, and fiber cell damage correlated well with standard fixation. These methods enable researchers and clinicians in remote settings to preserve donor lenses and rare examples of extracapsular extractions for detailed examination at later times.

Neodymium-yttrium-aluminum-garnet laser lysis of retained cortex after phacoemulsification cataract surgery.

PURPOSE: To describe the use of the neodymium-yttrium-aluminum-garnet (Nd:YAG) laser to lyse residual cortex after phacoemulsification cataract surgery and report the complications and outcomes of treatment. DESIGN: Interventional, retrospective case series. METHODS: Consecutive patients who underwent Nd:YAG laser treatment for residual cortex at the Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan were identified by review of laser logs from 2005 to 2011. The medical records were reviewed, and the course and complications of treatment were recorded. The main outcome measures were improvement in subjective vision and corrected distance visual acuity. RESULTS: Eighteen eyes of 18 patients, mean age 66 ± 11 years, were included. Eight eyes (44%) had intraoperative posterior capsule rupture. Before treatment with the Nd:YAG laser, all patients had subjective visual complaints, with 6 patients reporting counting fingers or worse visual acuity. Eleven patients (61%) were successfully treated with 1 session of cortical lysis, while 5 patients underwent 2 and 2 patients underwent 3 or more treatments. Five patients (28%) had elevated intraocular pressure (IOP) within 1 day of treatment, and 1 patient developed cystoid macular edema. All patients had resolution of subjective visual symptoms, and at final follow-up corrected distance acuity was 20/25 or better in 13 patients (72%). CONCLUSIONS: The Nd:YAG laser can be used to lyse residual cortex after uncomplicated cataract surgery or cases with intraoperative posterior capsular rupture, and results in an improvement in subjective and corrected distance visual acuity. Elevated IOP is a common complication.

Double aspiration/single irrigation system for bimanual lens cortex removal in cataract surgery.

The authors describe a bimanual double aspiration/single irrigation system (DASIS) for cataract surgery that efficiently and safely performs aspiration of the entire cortex, including subincisional space. DASIS uses standard and common instruments such as an irrigation/aspiration handpiece in one hand and a single-aspiration handpiece in the other, joined with a short silicone tube using a three-way stopcock. DASIS allows access to 360° of the cortex without a hand exchange, reducing wound leakage and maintaining chamber stability.

X-ray induced cataract is preceded by LEC loss, and coincident with accumulation of cortical DNA, and ROS; similarities with age-related cataracts.

PURPOSE: To compare age-related cataractous (ARC) changes in unirradiated mice lenses to those induced by head-only X-irradiation of 3 month-old mice. METHODS: lens epithelial cells (LECs) as well as partially degraded cortical DNA were visualized in fixed sections using 4',6-diamidino-2-phenylindole (DAPI) staining, and in fresh lenses using the vital stain Hoechst 33342. reactive oxygen species (ROS) activity was also visualized directly in fresh lenses using the vital dye Dihydrorhodamine (DHR). In fixed lenses an antibody specific for 8-OH Guanosine (8-OH-G) lesions was used to visualize DNA oxidative adducts from ROS damage. Alpha smooth muscle actin was visualized using specific antibodies to determine if myofibroblasts were present. Fluorescence was quantified using Laser Scanning Confocal Microscopy (LSCM). The degree of lens opacity and cataract formation was determined by slit lamp, or from digitalized images of light reflections taken with a low magnification light microscope. RESULTS: Using DNA- and ROS-specific vital fluorescent dyes, and laser scanning confocal microscopy we have previously described 4 changes in the aging rodent lenses: 1) a significantly decreased density of surface LECs in lenses from old compared to younger mice and rats; 2) a very large increase in retained cortical nuclei and DNA fragments in the secondary lens fibers of old rodent lenses; 3) increased cortical ROS in old rodent lenses; 4) increased cataract concomitantly with the cortical DNA and ROS increases. In the current study we report that these same 4 changes also occur in an accelerated fashion in mice given head-only X-irradiation at 3 months of age. In addition to vital staining of fresh lenses, we also examined sections from fixed eyes stained with DAPI or hematoxylin and eosin (H&E) and found the same loss of surface LECs and accumulation of undigested nuclei and debris in secondary lens fibers occur with age or following X-irradiation. In addition sections from fixed-eyes were examined for ROS damage to DNA with antibodies specific for 8-OH-G lesions. The frequency of 8-OH-G lesions increased dramatically in lenses from old unirradiated mice over 24 months of age, and similarly in X-irradiated lenses by 9-11 months post irradiation. The accumulation of cortical nuclei was not the result of conversion or invasion by myofibroblasts as tested by antibodies to a marker for such cells, alpha smooth muscle actin. CONCLUSIONS: X-irradiation damage induces a large decrease in surface LECs over a period of 3-11 months post X-irradiation of young mice. These changes are similar in extent to those seen in 24-29 months-old control mouse lenses with age-related cataracts. In 24+ month-old unirradiated mice the secondary lens fibers are not able to degrade nuclei or nuclear DNA efficiently and accumulate large numbers of cortical nuclei and nuclear fragments as well as ROS and 8-OHG lesions. X-irradiated lenses develop the same abnormalities in a more accelerated fashion. The extensive loss of LECS and accumulation of undegraded nuclei, ROS, and ROS damage may play a causal role in cataract generation in both unirradiated old mice and in previously irradiated young adult mice.

Phacoemulsification with viscodissection in posterior polar cataract: minimizing risk of posterior capsule tear.

We retrospectively evaluated the efficacy of viscodissection in decreasing the risk of posterior capsule tear during phacoemulsification surgery in 23 eyes with posterior polar cataract. Eyes were randomly assigned to two groups prior to emulsification: cortical viscodissection (Group 1) or non-viscodissection (Group 2). The visual acuities similarly improved in all eyes in the two groups. Posterior capsule tear occurred in one eye in Group 1 and five eyes in Group 2 (p < 0.05). On the basis of these results, the viscodissection technique was safer and more efficient than the non-dissection technique.

Modified capsular tension ring for cortical removal after implantation.

We describe a modification of the original 14C Morcher capsular tension ring. The new ring, the Henderson capsule tension ring (HCTR, Morcher), is an open C-shaped loop made of poly(methyl methacrylate). It has 8 equally spaced indentations of 0.15 mm to improve the ease of removing nuclear and cortical material while maintaining equal expansion of the capsular bag. The HCTR is currently under review by the U.S. Food and Drug Administration.

Management of the hard posterior polar cataract.

I describe a technique for managing the posterior polar cataract with a dense nucleus by initially sculpting a central trough to the depth of the polar opacity. The nucleus is partially cracked in the periphery, avoiding the polar opacity, and then chopped into quadrants without rotating. Next, the phaco tip engages the core of the nuclear quadrant while a cleavage plane is manually dissected along the lenticular lamellae using a Nagahara phaco chopper, with the tip rotated slightly so it points somewhat toward the equator of the lens, to a depth estimated to leave a nuclear shell, sparing the polar cataract. The nucleus is peeled away from the outer nucleus shell, which is kept in place by the phaco chopper. The intact nuclear plate is removed last and any capsular defect managed accordingly. This technique minimizes the risk for losing a nuclear fragment into the vitreous cavity.

Effect of cortical cleaving hydrodissection on posterior capsule opacification in age-related nuclear cataract.

PURPOSE: To evaluate the effect of multiquadrant cortical cleaving hydrodissection on the development of posterior capsule opacification (PCO) after phacoemulsification. SETTING: Iladevi Cataract and IOL Research Center, Ahmedabad, India. METHODS: A prospective randomized triple blind clinical trial was conducted in 86 eyes (86 patients) having phacoemulsification. Eyes were assigned randomly to Group 1, multiquadrant cortical cleaving hydrodissection and hydrodelineation (n = 48 eyes), or Group 2, no multiquadrant cortical cleaving hydrodissection, only hydrodelineation (n = 38 eyes). Age-related nuclear sclerosis (grading system of 1 to 5) and age greater than 50 years were included. Diabetes mellitus and associated eye diseases were excluded. Standard phacoemulsification with implantation of an AcrySof MA30BA intraocular lens (IOL) was done in both groups. High-resolution digital retroillumination images of the posterior capsule were analyzed at 4 years using POCOman software. Seven patients dropped out (8.1%). Outcome measures were incidence and percentage area of PCO. Test of proportions, independent sample t test, and 95% confidence intervals (CIs) were noted. RESULTS: In Groups 1 and 2, the mean age was 58 years +/- 4 (SD) and 57 +/- 5 years, respectively (P = .702; 95% CI, 1.90-2.81); mean follow-up was 48.4 +/- 2.5 months and 49.3 +/- 1.9 months, respectively (P = .687; 95% CI, 1.186-0.7856); incidence of PCO was 11 of 44 (25%) and 12 of 35 (34.3%), respectively (P = .317; 95% CI, 0.359-0.0889); percentage area of PCO was 14.3% and 25.6%, respectively (P = .006; 95% CI, -19.19 to -3.44). One of 44 eyes (2.27%) and 2 of 35 eyes (5.7%) in the groups, respectively, had a neodymium:YAG capsulotomy. CONCLUSION: Although no difference was noted in the incidence of PCO, in eyes that had PCO, the percentage of the area of the central posterior capsule involved by PCO was significantly lower in eyes that had multiquadrant cortical cleaving hydrodissection than in those that did not.

Decrease in complications during cataract surgery with the use of a silicone-tipped irrigation/aspiration instrument.

PURPOSE: To compare rates of vitreous loss during cataract surgery when a silicone-tipped irrigation/aspiration (I/A) instrument is used for cortex removal as opposed to a metal tip. SETTING: Parkland Memorial Hospital, Dallas, Texas, USA. METHODS: A retrospective chart review of all patients who had cataract extraction by phacoemulsification by third-year ophthalmology residents between September 2000 and February 2004 was conducted. A silicone-tipped I/A instrument was used to remove cortex for all surgeries beginning in September 2002, whereas a metal I/A tip was used previously. RESULTS: Of the 1072 cases performed with a metal I/A tip, there were 13 cases of vitreous loss during cortex removal (rate 1.2%) and 26% of all vitreous loss during that time occurred during cortex removal. Of the 805 cases performed with a silicone I/A tip, there was a single case (0.1%) of vitreous loss during cortex removal (P=.004); only 4% of all vitreous loss during that time occurred during cortex removal (P=.011). CONCLUSION: The overall incidence of vitreous loss during cortex removal and the ratio of vitreous loss during cortex removal to all cases of vitreous loss were significantly decreased using the silicone-tipped I/A instrument.