Spontaneous full thickness macular hole development and closure in a patient with nucleus dislocation due to hypermature cataract: a case report.

Spontaneous posterior capsule rupture with lens-nucleus dislocation is a very rare entity, as is the development and spontaneous closure of a full thickness macular hole (FTMH) after vitrectomy. The occurrence of these two entities in one eye has not been previously described. A 79-year-old woman was referred because of the right eye intermittent pain and progressive visual loss. Best corrected visual acuity (BCVA) with correction for aphakia was 20/20. Intraocular pressure was normal with therapy. The cornea, anterior chamber, and vitreous were clear. Gonioscopy was normal. The capsular bag was clear, with rolled-up anterior and posterior lens capsule, and the nucleus dislocated in the vitreous. As surgery waiting time was prolonged due to administrative problems, the patient's intraocular pressure (IOP) increased and cystoid macular edema (CME) with lamellar macular hole developed. The patient underwent pars plana vitrectomy with endophacofragmentation and epiretinal membrane peeling. Postoperative optical coherence tomography was normal, BCVA was 20/40, and IOP was normal with topical therapy. One month after surgery, the eye was without signs of inflammation and IOP started rising in spite of maximum therapy. CME reoccurred and progressed to a FTMH, which started closing spontaneously in one month. One year after surgery, IOP normalized and FTMH closed completely. A dislocated crystalline lens in a quiet eye with normal BCVA, which rapidly developed into intractable glaucoma and FTMH, is an unusual finding. The deterioration was followed by spontaneous IOP normalization and macular hole closure. Such unexpected disease course, suggesting a possible autoimmune reaction, has not yet been described.

Unusual case of ruptured posterior lenticonus.

A 14-year-old boy presented with a report of sudden-onset loss of vision in the right eye for the previous 10 days. The patient was diagnosed with a total cataract and ruptured posterior lenticonus. Lenticular aspiration was performed with an irrigation/aspiration probe. This was followed by anterior vitrectomy and implantation of 1-piece intraocular lens (IOL) in the capsular bag. Postoperatively, the patient had a good visual outcome with no evidence of intraocular inflammation. Although ruptured posterior lenticonus is a rare condition, it can be encountered in day-to-day-practice. In such cases, implantation of a 1-piece IOL can be safely performed if the anterior vitreous is meticulously removed.

Surgical and visual outcomes of posterior dislocated lens fragments after cataract surgery during 5-years at a tertiary eye hospital of North India.

OBJECTIVE: To determine the surgical and visual outcomes of posteriorly dislocated lens fragments in the vitreous cavity in patients undergoing cataract surgery. METHODS: A total of 149 eyes of 149 patients from 2013 to 2018 were included in the study. The primary cataract surgery was performed either at the base hospital and its peripheral centres or referred from elsewhere. Pars plana vasectomy and nucleus removal was performed along with implantation of intraocular lens, wherever possible. Success was defined as best corrected visual acuity (BCVA) ≥ 6/12 at 3 months follow up. Poor visual outcome was defined as per WHO guidelines as BCVA ≤ 3/60. RESULTS: Posterior capsular rupture and dislocation into vitreous cavity most frequently occurred during phaco-fragmentation in cases of phacoemulsification and during nucleus delivery in cases of small incision cataract surgery. Early vitrectomy was performed within 3 days in 36.2% of cases and within 14 days in 63.8% of cases. Successful visual outcome was achieved in 85.2% of patients at 3 months follow up after vitrectomy. Iatrogenic retinal break occurred in five patients during vitrectomyand five patients had retinal detachment. Poor visual outcome was observed in 12eyes, out of which glaucomatous optic neuropathy seen in 5 cases, cystoid or diabeticmacular edema in 4 cases and age related macular degeneration in 3 cases. CONCLUSION: Posterior dislocation of lens can be successfully managed in majority of cases with vitreoretinal surgical intervention. The timing of vitrectomy whether performed early or late did not affect the visual outcome. The most important predictorof final visual acuity after PPV for retained lens fragments is a less complicated clinical course without any associated complications such as retinal detachment, cystoidmacula edema and glaucoma. Expertise of the primary cataract surgeon could not be assessed in this study, though surgeon grade with more experience is an important factor in the assessment of complications during the cataract surgery.

Remnant extraction by using an intraocular lens injector with essential flow.

PURPOSE: To describe a new technique for remnant removal in cases of posterior capsular rupture during cataract surgery and Soemmering ring extraction during intraocular lens (IOL) removal. METHODS: An IOL injector, inserted into the anterior chamber, provides a new exit for residual lens fragments. Passive fluid flow, supplied by an anterior chamber maintainer or some ocular viscoelastic device (OVD) injection, delivers the residual fragments into a lumen of the injector in assistance with a second device such as a phaco-chopper and vitreous cutter. RESULTS: Soemmering rings can be removed safely through small incisions even when under the iris. Nucleus fragments in anterior chamber can be removed safely. Fragments that fall into the vitreous cavity can float up for removal by passive flow. CONCLUSIONS: This new technique, remnant extraction through lens injector with essential flow, has several practical advantages over existing methods including reduced OVD injection and smaller incision size. It may offer an alternative to existing methods of remnant removal in cases of posterior capsular rupture during cataract surgery and Soemmering ring extraction.

United Kingdom National Ophthalmology Database Study of Cataract Surgery: Report 3: Pseudophakic Retinal Detachment.

PURPOSE: To investigate time to pseudophakic retinal detachment (RD) after cataract surgery with posterior capsule rupture (PCR) to provide an evidence-based guide for postoperative management. DESIGN: Retrospective case series. PARTICIPANTS: A total of 61 907 eyes of 46 824 patients undergoing cataract surgery. METHODS: Subanalysis of the United Kingdom Royal College of Ophthalmologists' National Ophthalmology Database from 13 sites where data on both cataract and vitreoretinal surgery were recorded on the same electronic medical records system. Overall, 61 907 cataract operations were performed between October 2006 and August 2010. Analyses were restricted to cases with at least 3 months of potential postoperative follow-up. RESULTS: Pseudophakic RD surgery was performed on 131 eyes of 129 patients (0.21%; 95% confidence interval [CI], 0.18%-0.25%). Of these, 36 were in eyes that had PCR during cataract surgery (3.27%; 95% CI, 2.37%-4.50%) and 95 were in eyes that did not have PCR (0.16%; 95% CI, 0.13%-0.19%). For eyes that progressed to RD surgery, the median time to pseudophakic RD surgery was 44 days for eyes with PCR, and 6.3 months for eyes without PCR. For all eyes (both with and without PCR), pseudophakic RD occurred earlier in cases performed by a trainee cataract surgeon. CONCLUSIONS: Pseudophakic RD occurs earlier after cataract surgery complicated by PCR. Surgeon grade is a risk factor for pseudophakic RD. Posterior vitreous detachment and RD symptoms should be discussed with patients who undergo cataract surgery and have PCR to facilitate early attendance, and careful dilated postoperative examination for retinal tears is recommended in the first 2 months after surgery.

Confidence of ophthalmology specialist trainees in the management of posterior capsule rupture and vitreous loss.

PurposeTo ascertain ophthalmology trainee confidence in managing posterior capsule rupture (PCR) and vitreous loss.MethodsAn electronic survey was distributed to ophthalmology trainees in a single UK postgraduate training Deanery. Data collected included the stage of training, number of completed cataract operations, cumulative PCR rate, number of PCRs personally managed by the trainee, previous vitrectomy experience during vitreoretinal rotations, and attendance at advanced phacoemulsification courses. Trainees self-evaluated their confidence in managing PCR with vitreous loss, including the management of specific aspects of the procedure.ResultsAcross training grades, only 9.1% (2/22) felt confident managing PCR without senior support. Respondents were most confident with fluidic parameters and IOL considerations, but 77.3% (17/22) lacked confidence in avoiding a dropped nucleus. Eleven respondents had completed >350 cases (mean 576; range 383-1087). In this subgroup, mean cumulative PCR rate was 2.1% (range 0.9-4.9%), and trainees personally managed a mean 3.5 cases of PCR (range 1-7). Only 18.2% felt they could manage PCR and vitreous loss without senior support, and 45.5% stated they were not confident in avoiding a dropped nucleus. The most experienced trainee (1087 cases) had personally managed PCR just six times, and three trainees with >350 cases had only managed PCR once each.ConclusionsThe Royal College of Ophthalmologists' requirement of 350 completed cases appears insufficient for independent cataract surgery, as opportunities to manage complications as a trainee are scarce. A competency-based assessment framework may be preferable, with a more targeted approach to training incorporating surgical simulation within the formal curriculum.

Bilateral rupture of the posterior capsule and intraocular lens dislocation from excessive eye rubbing.

UNLABELLED: We report an unusual case of a 36-year-old woman with severe atopic eczema who developed sudden-onset reduction of vision in the right eye following excessive eye rubbing 9 years after cataract surgery. Examination identified posterior capsule rupture with dislocation of the intraocular lens (IOL) posteriorly into the vitreous cavity in the right eye and posterior capsule rupture with mild dislocation of the IOL in the bag in the left eye. To our knowledge, this is the first reported case of simultaneous bilateral posterior capsule rupture following uneventful surgery and secondary to eye rubbing. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Results of pars plana vitrectomy after complicated phacoemulsification surgery.

PURPOSE: To identify the causes and outcomes of pars plana vitrectomy (PPV) in patients undergoing phacoemulsification with intraoperative complication and to analyze whether the interval between phacoemulsification and PPV interferes with best-corrected final visual acuity. METHODS: This descriptive and retrospective analytical study was conducted in Paraná Eye Hospital in 2013. Data were collected from medical records of 38 patients who underwent complicated phacoemulsification and also required PPV. RESULTS: The most frequent complication as a result of phacoemulsification was posterior capsule rupture, observed in 35 patients (92.10%), followed by capsular bag detachment, in three patients (7.89%). Twenty-eight patients (73.68%) had cortical fragments that were removed during PPV. Twelve patients (31.57%) had their intraocular lens repositioned. PPV was performed on the same day of phacoemulsification in one patient (2.63%), within 1 week in 15 patients (39.47%), between 1 week and 1 month in 13 patients (34.21%), and 1 month after phacoemulsification in 9 patients (23.68%). CONCLUSION: This study is in agreement with worldwide literature, asserting that major complications of phacoemulsification are posterior capsule rupture and capsular bag detachment, and in addition, there is an improvement in the final visual acuity in almost half the cases, even when there are complications during modern cataract surgery, when complementary appropriate treatment is provided.

Intraoperative management of posterior capsular rupture.

PURPOSE OF REVIEW: Posterior capsular rupture (PCR) and vitreous loss are inevitable complications encountered in cataract surgery across all levels of surgical experience and in spite of technological advances to improve safety. Thus, cataract surgeons must always be prepared to practice safe and effective intraoperative management strategies for capsular rupture. RECENT FINDINGS: Novel approaches for lens fragment removal, vitrectomy, and lens implantation have expanded the available options for cataract surgery in the setting of an open posterior capsule. Intraoperative PCR management strategies should prioritize safety and strive to minimize vitreous traction, stabilize anterior chamber volume, maintain capsular and zonular integrity, and protect the corneal endothelium and other anterior segment structures. SUMMARY: With appropriate management of PCR and vitreous, surgeons may still deliver safe and satisfactory visual outcomes for modern cataract surgery.

Accuracy of 3 imaging modalities for evaluation of the posterior lens capsule in traumatic cataract.

PURPOSE: To compare the accuracy of 3 imaging modalities for preoperative evaluation of the posterior lens capsule in traumatic cataract. SETTING: Farabi Eye Hospital, Tehran, Iran. DESIGN: Case series. METHODS: The study comprised eyes with traumatic cataract opaque enough to prevent visualization of the posterior lens capsule on slitlamp examination. To detect posterior lens capsule rupture before surgery, imaging was performed with 20 MHz echography (Eye Cubed), anterior segment optical coherence tomography (AS-OCT) (Visante model 1000), and Scheimpflug imaging (Pentacam). All patients subsequently had cataract extraction, and the intraoperative findings of the posterior lens capsule were compared with the preoperative findings of the imaging modalities. RESULTS: The study enrolled 21 eyes of 21 patients (20 men, 1 woman) with a mean age of 31.5 years ± 1.45 (SD). The nature of trauma was blunt (5 eyes) or sharp (16 eyes). To detect posterior lens capsule rupture, the sensitivity and specificity were, respectively, 80% and 86% for 20 MHz echography, 71% and 77% for AS-OCT, and 62% and 57% for Scheimpflug imaging (95% confidence intervals: sensitivity, 30.00-90.32; specificity, 54.81-92.95). Insufficient resolution for posterior lens capsule evaluation occurred in 33.3% cases for AS-OCT and 57.1% cases for Scheimpflug imaging. The accuracy of 20 MHz echography, AS-OCT, and Scheimpflug imaging was 76.1%, 61.9%, and 42.9%, respectively. CONCLUSION: In the evaluation of the posterior lens capsule in eyes with traumatic cataract, 20 MHz echography had higher accuracy than AS-OCT and Scheimpflug imaging. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

2013 update on the management of posterior capsular rupture during cataract surgery.

PURPOSE OF REVIEW: Posterior capsular rupture (PCR) is an infrequent complication of cataract surgery that can lead to significant ocular morbidity and permanent vision loss. In the setting of PCR, the primary objective is the safe and thorough evacuation of vitreous and lens fragments from the anterior segment. The secondary objective is the stable placement of an intraocular lens (IOL) selected for best refractive outcomes. Expedited referral to vitreoretinal specialists is recommended for management of posteriorly dislocated lens material and surveillance for retinal injury. It is the intention of this review to present current guidelines for the management of PCR. RECENT FINDINGS: There are new techniques available to anterior and posterior segment surgeons in the setting of PCR. Endoillumination may facilitate visualization during anterior vitrectomy and the IOL may be used as a pupillary barrier to prevent loss of lens fragments. When secondary procedures are needed, early return to the operating room and small-gauge pars plana techniques may reduce patient morbidity. SUMMARY: When approached carefully and systematically, patients may have good outcomes in the setting of PCR. Recent advancements in instrumentation and technique encourage further study and may lead to new standards of care.

Clinical outcomes of intraocular lens scaffold surgery: a one-year study.

PURPOSE: To evaluate the safety and 1-year outcome of the intraocular lens (IOL) scaffold technique in eyes with soft to moderate nuclear remnants after intraoperative posterior capsule rupture (PCR). DESIGN: Single-center, retrospective, interventional, noncomparative, consecutive case series. PARTICIPANTS: A total of 20 eyes of 20 patients who had intraoperative PCR underwent IOL scaffold surgery in a tertiary clinic. METHODS: A retrospective analysis of medical records of a consecutive series of patients who underwent IOL scaffold surgery from August 2011 to February 2013 was reviewed. All surgeries were performed by a single surgeon, and a 3-piece, 6.0-mm optic, acrylic, foldable IOL with a modified C-loop haptic configuration was implanted in all eyes. MAIN OUTCOME MEASURES: The preoperative and postoperative parameters evaluated were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), specular microscopy, gonioscopy, ultrasound biomicroscopy, central macular thickness, intraocular pressure (IOP), and anterior and posterior segment inflammation. The final visual outcome at 1 year was evaluated. RESULTS: At 1-year follow-up, the mean postoperative UDVA and CDVA in Snellen's decimal equivalent was 0.58 ± 0.15 and 0.90 ± 0.17, respectively. The IOL was placed in the sulcus for 14 eyes and in the capsular bag for 3 eyes, and glued intrascleral fixation of IOL was performed in 3 eyes. The mean postoperative refractive error at the final examination was -0.4 ± 0.05 diopter (standard error of mean). Postoperative CDVA of 20/20 and 20/30 was achieved in 75% (15 eyes) and 25% (5 eyes), respectively. There was no correlation between preoperative specular count and percentage loss of cells (P = 0.602; r(2)=0.015). The mean central macular thickness at 1 year was 182.5 ± 11.79 µm. Clinical macular edema was observed in 1 of 20 eyes (5%). CONCLUSIONS: The IOL scaffold provided an effective, relatively noninvasive means of emulsifying moderate to soft nuclear remnants in eyes with intraoperative PCR, with a good visual outcome and a favorable complication rate.

Reverse optic capture of the single-piece acrylic intraocular lens in eyes with posterior capsule rupture.

BACKGROUND AND OBJECTIVE: To evaluate the clinical results of reverse optic capture (ROC) with single-piece posterior chamber intraocular lenses (PC-IOLs) in cases of phacoemulsification cataract and IOL surgery with posterior capsular rupture. PATIENTS AND METHODS: Preoperative diagnosis, intraoperative events, surgical parameters, intraoperative and postoperative complications, and preoperative and postoperative visual acuity and refraction of 16 eyes that underwent ROC were reviewed and analyzed. The fellow eye of 12 patients undergoing uneventful phacoemulsification without optic capture served as the control group. RESULTS: Over a mean of 19 months' follow-up, 94% of eyes in the ROC group and 92% in the control group achieved a best-corrected visual acuity of 20/25 or better. Ninety-four percent of eyes in the ROC group and 100% in the control group had postoperative spherical equivalent ± 1.00 D of the intended refraction. Refraction was stable between 1 month and final follow-up in both groups. In all eyes with ROC, the IOL remained well centered with a securely captured optic. There were no vision-threatening complications throughout the follow-up. CONCLUSION: The comparable outcomes in both groups suggests that optic capture of a single-piece acrylic IOL through an anterior capsulorhexis merits consideration for IOL placement in selected cases of insufficient posterior capsule support.

Pseudo anterior capsule barrier for the management of posterior capsule rupture.

UNLABELLED: 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 economic cost of posterior capsule tear at cataract surgery.

PURPOSE: To estimate the direct financial burden to healthcare purchasers of a posterior capsule tear (PCT) during cataract surgery. METHODS: A retrospective data analysis of cataract surgeries was performed. Patients who had surgery in the 2-year period from April 2005, with a maximum follow-up, to April 2009 were identified. Patients previously under review for ocular comorbidity apart from cataract were excluded. Each case with PCT was matched with an uncomplicated cataract operation performed on the same list by the same grade of surgeon. For both groups, we extracted details of all additional subsequent visits and interventions. Data on the cost of visits and procedures were provided by the Department of Health. We then compared this data between groups. RESULTS: A total of 100 patients with PCT were matched with 100 controls. The preoperative parameters of the two groups were similar. The cases required a median of 3 (mean 3.6, range 0-24) additional postoperative visits compared with 0 (mean 0.19, range 0-8) for controls, with a median duration of follow-up of 74 (mean 129.5, range 6-1316) days for cases compared to 21 (mean 26.1, range 0-308) days for controls (p=0.000). The average cost of extra visits was £ 475.0 (SD £ 697.8) for cases and £ 69.2 (SD £ 51.0) for controls (p<0.001). CONCLUSIONS: Based on the National Health Service national tariff, a PCT during cataract surgery results in significant additional financial cost to healthcare purchasers. A full cost analysis would be required to estimate the additional cost of a PCT for the healthcare provider.

Imaging late capsular block syndrome: ultrasound biomicroscopy versus Scheimpflug camera.

UNLABELLED: We describe 2 patients with late capsular block syndrome whose anterior chamber morphology was evaluated with ultrasound biomicroscopy and Scheimpflug imaging before and after neodymium:YAG laser capsulotomy. Pretreatment ultrasound biomicroscopy examination showed significant capsular bag distension in both patients. Scheimpflug imaging failed to capture the posterior capsule displaced far behind the intraocular lens. Automatic anterior chamber depth measurements were incorrect with Scheimpflug imaging in 1 patient. Ultrasound biomicroscopy seems to be superior to Scheimpflug imaging in eyes with extremely distended capsular bags. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Capsular block syndrome associated with femtosecond laser-assisted cataract surgery.

UNLABELLED: We report intraoperative capsular block syndrome occuring during the first 50 femtosecond laser-assisted cataract surgeries performed in our facility. Two patients had uneventful combined laser fragmentation, capsulotomy, and corneal incision procedures. In both cases, following transfer to the operating room and manual removal of the laser-cut capsulotomy, posterior capsule rupture was noted during hydrodissection, resulting in posterior dislocation of the lens. Pars plana vitrectomy, removal of the crystalline lens, and sulcus implantation of an intraocular lens were performed in both patients with good visual outcomes. Femtosecond laser-assisted cataract surgery changes the intraoperative environment with the generation of intracapsular gas and laser-induced changes in the cortex. With awareness of the changed intraocular environment following laser lens fragmentation and capsulotomy and a modification of the surgical technique, no additional cases of intraoperative CBS have been seen in more than 600 laser-assisted cataract surgery procedures performed to date at our facility. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosure is found in the footnotes.