Post-traumatic lens absorption with an intact lens capsule.

A 29-year-old man presented with longstanding, stable, unilateral vision loss in the setting of a remote paintball injury. His examination was notable for a sensory exotropia as well as multiple foci of posterior synechiae, segments of white lenticular material and islands of lenticular cells within a grossly intact capsule, and severe zonular compromise in the affected eye. The majority of the nuclear lens material was absent. The patient was diagnosed with post-traumatic lens absorption and underwent synechialysis, capsulotomy, excision of remnant lenticular material, and placement of a sulcus lens, with significant improvement in visual acuity and ocular alignment following surgery. Our report uniquely highlights identification of a Soemmering's ring in an absorbed lens in the presence of an intact anterior and posterior capsule as well as successful refractive and sensorimotor outcomes following surgical repair despite delay in treatment of many years.

Comparison of the therapeutic effects of lens capsular flap transplantation and autologous retinal transplantation in the management of refractory macular holes.

PURPOSE: To report the comparison of the therapeutic effects of lens capsular flap transplantation (LCT) and autologous retinal transplantation (ART) in refractory macular hole (MH) treatment. METHODS: Thirty-one patients (31 eyes) with refractory MH were retrospectively reviewed. The patients were divided into two groups based on the surgical procedures: the LCT group (13 eyes) and the ART group (18 eyes). Patients were monitored for a minimum of 6 months. Best corrected visual acuity (BCVA), hole closure rate, postoperative central foveolar thickness (CFT), and some complications (e.g. graft loss or dislocation, postoperative retinal detachment, or postoperatively elevated intraocular pressure) were the primary outcome measures. RESULTS: The mean preoperative MH diameter was 1104 ± 287 µm in the LCT group and 1066 ± 297 µm in the ART group (t = 0.353, P = 0.727). The MH was closed in 12 patients (92.3%) of the LCT group and 17 patients (94.4%) of the ART group (χ2 = 0.057, P = 0.811); the MHs of 10 patients (76.9%) in the LCT group and 11 patients (61.1%) in the ART group were completely closed (χ2 = 0.864, P = 0.353). The BCVA improved from 2.3 ± 1.0 logMAR preoperatively to 1.3 ± 0.9 logMAR postoperatively in the LCT group and 2.3 ± 0.9 logMAR preoperatively to 1.0 ± 0.6 logMAR postoperatively in the ART group (postoperative BCVA vs preoperative BCVA in the LCT group: t = 4.374, P = 0.001; postoperative BCVA vs preoperative BCVA in the ART group: t = 5.899, P = 0.000018). The visual improvement was 1.3 ± 0.9 logMAR in the ART group and 1.0 ± 0.8 logMAR in the LCT group (t = - 1.033, P = 0.310). The postoperative CFT was 139.7 ± 48.3 µm in the LCT and 199.2 ± 25.1 µm in the ART group (t = - 4.062, P = 0.001). Graft dislocation emerged in 2 patients (15.4%) in the LCT group and 1 patient (5.6%) in the ART group. CONCLUSIONS: Applications of LCT and ART may both enhance anatomical and visual outcomes in refractory MH cases. The ART group exhibited a more optimal postoperative CFT than the LCT group one.

Epicapsular Stars in an Asymptomatic Patient.

This case report discusses a diagnosis of epicapsular stars during a routine ophthalmologic examination in an asymptomatic female patient aged 14 years.

Association of CUL4B with the pathogenesis of age-related cataract.

PURPOSE: Age-related cataract (ARC) is the most common cause of visual impairment and blindness in older adults. However, the role of CUL4B in the ARC remains unclear. Therefore, we investigated CUL4B expression and its effects on apoptosis. MATERIALS AND METHODS: CUL4B expression levels were detected by a quantitative real-time polymerase chain reaction from the anterior lens capsules of patients with ARC and HLE-B3 cells treated with different concentrations of H2O2. CUL4B expression was silenced by siRNA transfection to evaluate apoptosis. CUL4B and apoptotic proteins B cell lymphoma 2 (Bcl-2), myeloid cell leukemia 1 (Mcl-1), caspase-3, cleaved caspase-3, Bax, Bak, and Bid were assessed using western blot analysis. Apoptosis was monitored using the TUNEL assay. RESULTS: CUL4B expression was downregulated in the anterior lens capsules (P < 0.0001) and H2O2-treated HLE-B3 cells (P = 0.0405). CUL4B protein levels were significantly lower in 100 µmol/L (P = 0.0012) and 200 µmol/L (P = 0.0041) H2O2-treated HLE-B3 cells than in the untreated cells. CUL4B expression was significantly knocked down at the mRNA (P = 0.0043) and protein levels (P = 0.0002) in HLE-B3 cells. Bcl-2 (P = 0.0199), Mcl-1 (P = 0.0042), and caspase-3 (P = 0.0142) were significantly downregulated, whereas cleaved caspase-3 (P = 0.0089) and Bak (P = 0.009) were significantly upregulated in the knockdown group. The TUNEL assay showed a greater induction of apoptosis. CONCLUSIONS: CUL4B downregulation promotes the apoptosis of lens epithelial cells. Our study may help in understanding the role of CUL4B in ARC pathogenesis.

Transient anterior subcapsular vacuolar lens opacities after Tanito microhook trabeculotomy: report of six cases.

OBJECTIVE: To present six cases exhibiting transient anterior subcapsular vacuolar lens opacities following early postoperative Tanito microhook trabeculotomy (TMH) performed by the same surgeon. METHODS: Six patients who underwent lens-sparing TMH at Meizankai Shimizu Eye Clinic from November 2021 to May 2023, and developed anterior subcapsular vacuolar lens opacities postoperatively were reviewed. Detailed records of surgeries, follow-up findings were collected and reported. RESULTS: In all six cases, anterior vacuolar subcapsular lens opacities were observed on the day after surgery, gradually decreasing without affecting visual acuity or contrast sensitivity. In all cases, without any specific interventions, the opacities disappeared by 21 months postoperatively. CONCLUSION: Anterior subcapsular cataracts, characterized by a vacuolar appearance and transient existence, should be recognized as an early complication of ab interno glaucoma surgery, possibly linked to use of distributed ophthalmic viscosurgical devices and excessive anterior chamber irrigation leading to traumatic cataracts on the lens surface.

[Treatment of early capsular blockage syndrome with Nd:YAG laser anterior capsulotomy containing neodymium-doped yttrium aluminum garnet in a case].

A 62-year-old female patient presented with no improvement in vision 10 days after undergoing cataract extraction in the right eye. The unaided visual acuity in the right eye was 0.1, and examination with a slit lamp revealed the presence of the intraocular lens with an increased gap between the intraocular lens and the posterior capsule. Anterior segment optical coherence tomography showed a distance of 3.236 mm between the posterior capsule and the posterior surface of the intraocular lens. Based on the medical history, ocular examination, and auxiliary examinations, a diagnosis of right eye capsular blockage syndrome was made. Nd:YAG laser capsulotomy was performed at the anterior capsule outside the optical zone of the intraocular lens. One week later, the posterior capsule adhered to the posterior surface of the intraocular lens, and there was a significant improvement in vision compared to before the procedure.

Intraoperative trypan blue central landmark and its use in capsulotomy and capsulorhexis centration.

PURPOSE: To compare 3 capsulotomy centration methods. SETTING: Private clinic, Zlin, Czech Republic. DESIGN: Prospective, consecutive case series. METHODS: 180 eyes undergoing cataract surgery had anterior capsule staining with microfiltered 0.4% trypan blue solution before selective laser capsulotomy. The first 60 eyes (Group 1) had mydriatic dilated pupil centered capsulotomies. The next 60 eyes (Group 2) were centered on the trypan blue central landmark (TCL). The final 60 capsulotomies (Group 3) were centered on the patient fixated coaxial Purkinje reflex (CPR). Measurements between key anatomical landmarks and the TCL, CPR capsulotomies, and implanted intraocular lens (IOL) center were made. RESULTS: The TCL, observed in >94% of eyes in the study, coincided with the CPR with a displacement of <0.1 ± 0.1 mm. Group 1 capsulotomies were noticeably decentered on the IOLs by 0.3 ± 0.2 mm. The Group 2 symmetrical IOL relationship was maintained with a decentration of 0.15 ± 0.1 mm. Group 3 had a similar decentration with the IOLs with 0.15 ± 0.1 mm. Verification with IOLMaster 700 data and CALLISTO Eye System showed that the CPR and the TCL were coincident with the measured visual axis. CONCLUSIONS: The clearly visible TCL served as an alternate landmark to the patient fixated CPR, and being on the anterior capsule was not sensitive to tilt. Further patient compliance was not required. Both were superior to dilated pupil centration, to achieve symmetric IOL coverage. This has application for both capsulotomies and capsulorhexes.

Angle-closure glaucoma associated with vitreous prolapse after neodymium-doped yttrium-aluminumgarnet laser posterior capsulotomy.

Capsulotomy with neodymium-doped yttriumaluminum-garnet (Nd:YAG) laser is an effective treatment for posterior capsule opacification following cataract surgery. A wide opening of the posterior capsule associated with the ruptured anterior hyaloid can cause anterior chamber vitreous prolapse. Two patients who developed angle-closure glaucoma associated with vitreous prolapse following Nd:YAG laser posterior capsulotomy were successfully treated with antiglaucoma medication and peripheral iridotomies. Patient identification for potential risk factors and a careful postoperative follow-up are essential to avoid these serious complications.

Sideways sculpting - A novel technique in eyes with posterior polar cataracts.

Posterior polar cataracts (PPCs) have long been a concern for cataract surgeons due to their natural proclivity for posterior capsule rupture. Although problems can be avoided, there is no surgical procedure that can completely eliminate the possibility of posterior capsular rupture. Research reports a higher percentage of capsule rupture and related complications post surgical intervention. The sideways sculpting technique is a novel method to alleviate unnecessary tension on the posterior capsule. To disseminate this novel technique to practicing ophthalmologists to reduce the risk of complications related to polar cataracts. This video presents the creation of sculpting or trench at the center of the nucleus, sideways movement of the phacotip trench, rotation of the nucleus, and phacoemulsification steps while operating a dense PPC. Step-by-step demonstration of sideways sculpting and an overview of its significance. Video Link: https://drive.google.com/file/d/17ukCjdr9DlEgguCgfh0DPAPYxCCEzirq/view?usp=sharing .

Model of zonular forces on the lens capsule during accommodation.

How the human eye focuses for near; i.e. accommodates, is still being evaluated after more than 165 years. The mechanism of accommodation is essential for understanding the etiology and potential treatments for myopia, glaucoma and presbyopia. Presbyopia affects 100% of the population in the fifth decade of life. The lens is encased in a semi-elastic capsule with attached ligaments called zonules that mediate ciliary muscle forces to alter lens shape. The zonules are attached at the lens capsule equator. The fundamental issue is whether during accommodation all the zonules relax causing the central and peripheral lens surfaces to steepen, or the equatorial zonules are under increased tension while the anterior and posterior zonules relax causing the lens surface to peripherally flatten and centrally steepen while maintaining lens stability. Here we show with a balloon capsule zonular force model that increased equatorial zonular tension with relaxation of the anterior and posterior zonules replicates the topographical changes observed during in vivo rhesus and human accommodation of the lens capsule without lens stroma. The zonular forces required to simulate lens capsule configuration during in vivo accommodation are inconsistent with the general belief that all the zonules relax during accommodation.

Lens capsule pathological characteristics in cases of intraocular lens dislocation with atopic dermatitis.

PURPOSE: To explore lens capsule pathological characteristics in intraocular lens (IOL) dislocation after cataract surgery in patients with atopic dermatitis (AD). SETTING: University hospital department of ophthalmology. DESIGN: Case series with clinicopathological correlations. METHODS: Lens capsules and surrounding tissues excised during surgery from eyes with AD (AD group) and eyes without AD (non-AD group) with IOL dislocation were histologically evaluated. Hematoxylin and eosin staining was used to assess abnormal changes in lens epithelial cells (LECs). Masson trichrome staining distinguished the fibrous metaplasia around the lens capsule into high-density and low-density fibrosis. Capsular splitting (thinning) was identified in both stained preparations. RESULTS: The IOL dislocation morphology in the AD group (10 eyes of 10 patients) included 7 cases of capsular bag dislocation (CBD) and 3 cases of dead bag syndrome (DBS), with an average duration to IOL dislocation of 11.5 ± 5.6 years. All patients in the non-AD group (12 eyes of 12 patients) had CBD, averaging 10.2 ± 5.7 years to dislocation. Abnormal LECs, low-density fibrosis, and capsular splitting were observed in 9 (90), 9 (90), and 6 (60) of the patients in the AD group compared with 6 (50), 3 (25), and 2 (18), respectively, in the non-AD group (total n [%]). CONCLUSIONS: Compared with the non-AD group, the AD group exhibited higher frequencies of morphological changes in LECs, low-density fibrosis around the lens capsule, and capsular splitting characteristics of DBS. These results suggest LEC degeneration and increased lens capsule fragility occurred in patients with AD.

Safety and efficacy of capsular tension ring and capsular hook implantation for managing ectopia lentis in Marfan syndrome: real-world study.

PURPOSE: To evaluate the safety and efficacy of capsular tension ring and capsular hook (CTR-CH) implantation in Marfan syndrome (MFS) patients with ectopia lentis (EL). SETTING: Eye and ENT Hospital of Fudan University, Shanghai, China. DESIGN: Retrospective propensity score-matched cohort study. METHODS: This study included patients with MFS who had in-the-bag intraocular lens (IOL) implantation assisted by CTR-CH or modified CTR (MCTR). The safety analysis focused on the resurgery rate. The efficacy analysis compared the corrected distance visual acuity (CDVA) and the incidence of laser capsulotomy after propensity score matching (PSM). RESULTS: This study encompassed 148 eyes that had the CTR-CH procedure and 162 eyes that received MCTR implantation. In the CTR-CH group, the median age at the time of surgery was 5 years, with a mean follow-up duration of 1.81 ± 0.4 years. 5 eyes (3.38%) required a second surgery because of retinal detachment (2, 1.35%), IOL decentration (2, 1.35%), and CH dislocation (1, 0.68%). The resurgery rate was comparable with that of the MCTR group ( P = .486). After PSM, a total of 108 eyes were recruited in each group. Postoperative CDVA was significantly improved in both groups (both P < .001), but comparable between the groups ( P = .057). The posterior capsular opacification took place earlier ( P = .046) while the anterior capsular opacification required laser capsulotomy at a later stage ( P = .037) compared with the MCTR group. CONCLUSIONS: The CTR-CH procedure was a feasible, safe, and efficient approach for managing EL in patients with MFS.

A potential role for inflammatory cytokines in a rare late-onset capsular block syndrome: a case report.

BACKGROUND: Late-onset capsule block syndrome (CBS) is a rare complication of cataract phacoemulsification and the implantation of a posterior chamber intraocular lens (PCIOL), which manifests six months to years after surgery. The hallmark of CBS is the formation of an opaque liquid substance between the implanted intraocular lens (IOL) and the posterior capsule. However, its pathogenesis remains unclear. CASE PRESENTATION: A 64-year-old female patient with chronic angle-closure glaucoma (axis length < 21 mm) underwent trabeculectomy surgery combined with phacoemulsification and PCIOL. After a 4-year follow-up, a decline in visual acuity occurred in her right eye due to the location of opaque fluid in the visual axis and distension of the capsular bag. The initial course of action was to release the trapped fluid. Neodymium: yttrium-aluminum-garnet (Nd: YAG) laser capsulotomy could not be employed due to her non-dilating pupil and high extension of the posterior capsule. Subsequently, anterior capsule peeling and anterior segment vitrectomy surgery were performed. The depth of the anterior chamber (ACD), the distance between the face of the retro-IOL and the posterior capsule, the best-corrected visual acuity (BCVA), and the visual quality (VQ) were measured both before and after surgery. Inflammatory cytokine levels in the opaque substances (OS) trapped between the PCIOL and the posterior capsule were assessed using a flow cytometer and compared to normal statistical data in aqueous humor. After surgery, the patient experienced a significant improvement in BCVA and VQ. The distance between the face of the retro-IOL and the posterior capsule was on the verge of disappearing. However, ACD did not differ between pre- and post-operatively. Interleukin-8 (IL-8) and basic fibroblast growth factor (BFGF) concentrations were higher in the OS than in aqueous humor, especially in the former. However, the concentration of vascular cell adhesion molecule (VCAM) in the OS was lower than in aqueous humor. CONCLUSIONS: Anterior segment vitrectomy surgery proved to be a successful treatment for late-onset CBS, presenting a challenging case. In the human lens, inflammatory cytokines originating from the opaque substances may contribute to abnormal metabolism in the sealed area, a consequence of late-onset CBS.

Pupil versus 1st Purkinje capsulotomy centration with femtosecond laser: Long term outcomes with a sinusoidal trifocal lens.

PURPOSE: To assess the role of femtosecond laser-assisted capsulotomy centration in the long-term intraocular positioning of a multifocal intraocular lens. DESIGN: Prospective comparative study. METHODS: A total of 60 eyes of 30 patients underwent femtosecond laser-assisted Refractive Lens Exchange (RLE). For every patient, capsulotomy centration was randomly performed according to pupil centre (PC) in one eye and first Purkinje reflex (FPR) in the other. The intraocular lens (IOL) positioning, visual acuities, spherical equivalent, internal aberrometry and quality of vision were assessed and compared at 3 years' follow-up between groups (PC and FPR). RESULTS: Intraocular lens positioning showed a statistically significant difference between groups, with a closer centration to the visual axis in the FPR patients (p < 0.001). Internal aberrometry showed higher values in the PC capsulotomy centration group (p < 0.01). CONCLUSIONS: FPR centered capsulotomy is associated to a closer centration of the IOL to the visual axis.

[Intraoperative Complications in Cataract Surgery]. / Intraoperative Komplikationen der Kataraktchirurgie.

Cataract surgery is frequently and successfully performed in the developed world. The indications for the operation have shifted on one hand towards healthier patients seeking freedom from glasses and on the other hand towards more complex cases. How should the patient be informed? What complications can occur intraoperatively, and what treatment options are available for these complications?This article offers a focus on conditions such as zonulopathy and pseudoexfoliation that can pose challenges to cataract surgery. It discusses the use of specialized tools such as capsular tension rings and capsular hooks and precise maneuvers to minimize stress on weakened zonules in order to ensure in-the-bag fixation of the IOL.Furthermore, the article addresses appropriate actions towards intraoperative complications such as anterior or posterior capsule ruptures and loss of nuclear fragments into the vitreous cavity.Exploring innovative advancements, this article presents the latest alternatives for intracapsular lens fixation, such as sutureless scleral fixation and emerging lens designs in cases where there is insufficient capsular support.Ultimately, the primary objective remains delivering optimal outcomes even for complex cases, and minimizing post-surgical issues. Numerous tools and techniques are available.

Improvements to a GLCM-based machine-learning approach for quantifying posterior capsule opacification.

BACKGROUND: Posterior capsular opacification (PCO) is a common complication following cataract surgery that leads to visual disturbances and decreased quality of vision. The aim of our study was to employ a machine-learning methodology to characterize and validate enhancements applied to the grey-level co-occurrence matrix (GLCM) while assessing its validity in comparison to clinical evaluations for evaluating PCO. METHODS: One hundred patients diagnosed with age-related cataracts who were scheduled for phacoemulsification surgery were included in the study. Following mydriasis, anterior segment photographs were captured using a high-resolution photographic system. The GLCM was utilized as the feature extractor, and a supported vector machine as the regressor. Three variations, namely, GLCM, GLCM+C (+axial information), and GLCM+V (+regional voting), were analyzed. The reference value for regression was determined by averaging clinical scores obtained through subjective analysis. The relationships between the predicted PCO outcome scores and the ground truth were assessed using Pearson correlation analysis and a Bland-Altman plot, while agreement between them was assessed through the Bland-Altman plot. RESULTS: Relative to the ground truth, the GLCM, GLCM+C, and GLCM+V methods exhibited correlation coefficients of 0.706, 0.768, and 0.829, respectively. The relationship between the PCO score predicted by the GLCM+V method and the ground truth was statistically significant (p < 0.001). Furthermore, the GLCM+V method demonstrated competitive performance comparable to that of two experienced clinicians (r = 0.825, 0.843) and superior to that of two junior clinicians (r = 0.786, 0.756). Notably, a high level of agreement was observed between predictions and the ground truth, without significant evidence of proportional bias (p > 0.05). CONCLUSIONS: Overall, our findings suggest that a machine-learning approach incorporating the GLCM, specifically the GLCM+V method, holds promise as an objective and reliable tool for assessing PCO progression. Further studies in larger patient cohorts are warranted to validate these findings and explore their potential clinical applications.

Impact of anterior capsule polishing on capsule opacification and capsule bend after age-related cataract surgery.

PURPOSE: To investigate the effect of anterior capsule polishing on postoperative capsule opacification and capsular bend in patients with age-related cataract displaying normal axial length. SETTING: Eye Hospital of Wenzhou Medical University at Hangzhou. DESIGN: Prospective self-controlled trial. METHODS: Patients with age-related cataracts aged 56 to 84 years displaying normal axial length were enrolled. Before surgery, a coin-toss method was used to randomly select 1 eye for intraoperative 360 degrees anterior capsule polishing (polishing group); the contralateral eye received no treatment (control group). Capsular bend index (CBI), anterior capsule opacification (ACO), posterior capsule opacification (PCO), and anterior capsule opening area (ACOA) were recorded at 1 week, 1 month, 3 months, 6 months, and 12 months postoperatively using swept-source optical coherence tomography and slitlamp examination. RESULTS: 21 patients (42 eyes) were enrolled. Within-group comparisons showed that both groups had significant differences in CBI between 1 week and 1 month postoperatively, and between 6 months and 12 months postoperatively ( P < .05). Between-group comparisons revealed a significant difference in CBI at 1 week postoperatively ( P < .05); at 12 months postoperatively, there was a significant difference in ACOA ( P < .05). There were no significant between-group differences regarding ACO or PCO at any timepoint ( P > .05). CONCLUSIONS: For patients with age-related cataracts and normal axial length, 360 degrees anterior capsule polishing can delay early capsular bag deformation without increasing the risks of ACO and PCO. This approach can also limit contraction of the anterior capsule opening.