- Email: [email protected]
Assessment of intraoperative complications in intumescent cataract surgery using 2 ophthalmic viscosurgical devices and trypan blue staining
ARTICLE
Assessment of intraoperative complications in intumescent cataract surgery using 2 ophthalmic viscosurgical devices and trypan blue staining Fritz H. Hengerer, MD, PhD, H. Burkhard Dick, MD, PhD, Thomas Kohnen, MD, PhD, Ina Conrad-Hengerer, MD
PURPOSE: To evaluate intraoperative complications during capsulorhexis and phacoemulsification in intumescent white cataracts using 2 ophthalmic viscosurgical device (OVD) techniques. SETTING: Ruhr University Eye Clinic, Bochum, Germany. DESIGN: Case series. METHODS: Patients with eyes with intumescent white cataract were recruited and placed in 2 groups. After capsule staining using trypan blue, a central indentation of the anterior lens capsule was created in the eyes in Group 1 using a medium-viscosity OVD (Healon 1.0%) and in the eyes in Group 2 using both medium-viscosity (1.0%) and high-viscosity (2.3%) OVDs. Then a continuous curvilinear capsulorhexis (CCC) was performed. The outcomes measured were the horizontal and vertical diameters of the CCC, the deviation from the target diameter, and intraoperative complications. RESULTS: In Group 1 (21 eyes), deviation from the target CCC diameter occurred in 12 eyes (10 oversized, 2 undersized), and in Group 2 (20 eyes) deviation occurred in 6 eyes (4 oversized, 2 undersized). In Group 1, capsule tears appeared in 2 eyes and in 1 eye, the procedure had to be converted to extracapsular cataract extraction with anterior vitrectomy. In Group 2, there were no capsule tears. CONCLUSION: Using 2 different OVDs and placing the high-viscosity OVD centrally led to safe indentation of the anterior lens capsule and reduced the risk for CCC enlargement and capsule tear during surgery. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2015; 41:714–718 Q 2015 ASCRS and ESCRS
In standard cataract surgery, achieving a complete and curvilinear capsulorhexis of a precise size and shape is very important for a successful approach. A safe anterior segment situation must be established intraoperatively by using ophthalmic viscosurgical devices (OVDs) or fluid irrigation to stabilize the anterior chamber. Even a skilled surgeon who is aware of the potential drawbacks in routine and nonroutine cases pays particular attention when performing surgery in eyes with white intumescent cataracts. Such lenses do not permit the red reflex because of the whitening 714
Q 2015 ASCRS and ESCRS Published by Elsevier Inc.
and further liquefaction of the entire parts, leading to a rise in internal pressure. Before surgery, analyzing the lens structure using anterior segment imaging with B-scan ultrasound (US) or optical coherence tomography (OCT) might provide additional information about swelling of the lens and a concomitant rise in pressure. Brazitikos et al.1 developed an ultrasonographybased classification system to grade these lenses into 3 types according to the internal acoustic reflections. Having access to this knowledge could influence a http://dx.doi.org/10.1016/j.jcrs.2014.06.039 0886-3350
COMPARISON OF TWO OVDS IN INTUMESCENT CATARACT SURGERY
715
surgeon to change the initial surgical approach from a standard procedure to 1 that handles these challenging situations in different ways. Several recently published approaches to operating on these cases use different types of OVDs or staining dyes in combination with viscosurgery to enhance the outcome and minimize the risk profile of an uncontrolled opening of the anterior lens capsule.2–5 Other authors describe using different endodiathermy devices to create a continuous curvilinear capsulorhexis (CCC) in such cases.6–10 Dick et al.11 used trypan blue staining to decrease the elasticity of the anterior capsule in regular cases. The present prospective study compared 2 surgical approaches and evaluated their intraoperative complications and their safety and efficacy. In both study groups, trypan blue staining was used before the OVD application. In 1 group a medium-viscosity OVD was used, and in the other group 2 OVDs were used, 1 medium-viscosity and 1 high-viscosity. PATIENTS AND METHODS This case series included only eyes with an intumescent white cataract12 without red reflex and a dilated pupil size of at least 6.0 mm (Figure 1, A). This retrospective trial adhered to the tenets of Declaration of Helsinki. All surgeries were performed by 1 surgeon between November 2010 and July 2011. The exclusion criteria were a history of serious coexisting ocular disease (eg, pseudoexfoliation syndrome, uncontrolled glaucoma, or ocular tumors), poorly dilating pupils (pupil size !6.0 mm), known zonular weakness, ocular trauma, and age younger than 22 years. A physician performed a full ophthalmological examination on each patient using a BQ 900 slitlamp (Haag-Streit AG). Preoperative intraocular lens (IOL) power calculations were performed using noncontact partial coherence interferometry (PCI) (IOLMaster, Carl Zeiss Meditec AG) readings for axial length (AL) and corneal radii. In difficult cases, an additional US A-scan measurement for AL was performed, followed by IOL calculation using the values from PCI that contributed to the corneal radii value. In all eyes, small-incision phacoemulsification was performed using topical anesthesia. The 2-step clear corneal main incision was made at 12 o’clock using a 2.75 mm metal keratome (2.75 mm angled slit knife, Alcon Surgical, Inc.). The single-plane side-port incisions were made at 9 o' clock
Submitted: March 16, 2014. Final revision submitted: May 20, 2014. Accepted: June 8, 2014. From the Department of Ophthalmology (Hengerer, Kohnen), Goethe University, Frankfurt, and the Department of Ophthalmology (Dick, Conrad-Hengerer), Ruhr University, Bochum, Germany. Corresponding author: Fritz H. Hengerer, MD, PhD, Department of Ophthalmology, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany. E-mail: [email protected].
Figure 1. A: Preoperative image of an intumescent white cataract. B: The anterior chamber peripherally filled with medium-viscosity OVD (1.0%) and a central bulk of high-viscosity OVD (2.3%) to achieve a flattened anterior lens capsule.
and 3 o’clock using a 1.2 mm metal keratome (dual bevel, 1.2 mm angled side-port knife, Alcon Surgical, Inc.). In all cases, the anterior lens capsule was stained using trypan blue stain (Visionblue Staining Solution, Dutch Ophthalmic, USA) under air fill, as described previously.13 The target vertical and horizontal diameters of the CCC ranged from 4.5 to 5.5 mm. In the eyes in Group 1, a medium-viscosity OVD (Healon 1.0%) was instilled in the anterior chamber to protect the endothelium; care was taken not to overfill the anterior chamber. The CCC was performed using a bent 19-gauge needle through a side-port incision. The intended size of the capsulorhexis was 5.0 mm. After the capsule was punctured centrally, the leaf of the opened capsule was grasped using a Koch capsulorhexis forceps (Geuder AG) and the capsulorhexis was created circularly. In the eyes in Group 2, the anterior chamber was filled peripherally with the medium-viscosity OVD and then a central bulk of high-viscosity OVD (Healon5) was carefully placed in the anterior chamber to achieve a flattened and, later, centrally indented anterior lens capsule (Figure 1, B). Meticulous care was taken to not overfill the anterior chamber or apply too much pressure on the capsule zonular fibers. The CCC was opened centrally using a bent 19-gauge needle and, in most eyes in this group, the capsulorhexis was performed using only the needle while aiming for a centered, sized result. In 8 eyes (40%), a Koch capsulorhexis forceps was introduced to finish the procedure and extract the capsule leaf (Figure 2).
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COMPARISON OF TWO OVDS IN INTUMESCENT CATARACT SURGERY
liquefied cortex and lens material before establishing a central groove, and then to crack the nucleus using a Neuhann chopper (Geuder AG). The phaco-chop technique was followed by removal of the remaining cortex material through the nasal and temporal incisions using bimanual irrigation/aspiration (I/A), and then by polishing the posterior capsule. In all cases, regular vacuum settings were used (600 mm Hg maximum). In uncomplicated cases in both groups, a 3-piece hydrophilic acrylic IOL was implanted in the eye using mediumviscosity OVD to protect the corneal endothelium. After bimanual I/A of the OVD, the paracenteses were hydrated and the eyes covered with a patch. Postoperative medication followed a standard regimen for 4 weeks.
Statistical Analysis Figure 2. Capsulorhexis using a microforceps after staining with trypan blue.
An Engel spatula (Geuder AG) was used to measure the achieved diameter of the capsular bag opening vertically and horizontally in both groups. This device is 0.6 mm in diameter and has a ruler marked with 0.1 mm steps. It was introduced horizontally through the side port and vertically through the main incision and was placed over the middle of the capsulotomy. Then, US phacoemulsification was performed without further hydrodissection or delineation using a Stellaris phacoemulsification system (Bausch & Lomb) in both study groups. A standard microflow needle with an angulation of 30 degrees at the opening was used. The phaco settings were 60% maximum phaco power, 100 cm bottle height, and 600 mm Hg maximum vacuum created by the venturi pump. The preferred technique was to aspirate the
All descriptive statistical analysis was conducted using SPSS software (version 19.0, SPSS, Inc.). A t test was used to compare the mean values. A P value less than 0.05 was considered statistically significant.
RESULTS The initial 44 eyes of patients recruited for analysis were placed in 2 groups of 22 eyes each. In Group 1 the mean patient age was 72.9 years G 11.6 (SD) (range 48 to 89 years) and in Group 2, 69.0 G 12.9 years (range 44 to 86 years). Three eyes were excluded for preoperative capsule rupture, 1 in Group 1 and 2 in Group 2. Treatment was performed in 11 right eyes and 10 left eyes in Group 1 and in 10 right eyes and 10 left eyes in Group 2. Group 1 comprised 9 men and 12 women. Group 2 comprised 10 men and 10 women. Table 1
Table 1. Preoperative, intraoperative, and postoperative data in the 2 study groups. Group 1 (n Z 21)
Group 2 (n Z 20)
Parameter
Mean G SD
Range
Eyes (n)
Mean G SD
Range
Eyes (n)
P Value
Preop lens thickness (mm)* Preop axial length (mm) Capsulorhexis diameter (mm) Horizontal Vertical Capsulorhexis size (n) Over target Under target Within target Capsule tear (n) Dropped nucleus (n) Vitreous loss (n) Posterior capsule rupture (n) Phacoemulsification (n) ECCE (n) IOL implantation (n)
4.2 G 0.66 23.51 G 0.98 d 5.20 G 0.54 5.43 G 0.42
3.0, 5.3 d d 4.0, 6.0 4.6, 6.0
d d d d d
4.1 G 0.58 23.36 G 0.86 d 4.96 G 0.37 5.18 G 0.34
2.7, 5.3 d d 4.5, 5.8 4.7, 5.9
d d d d d
.420 d d .117 .042
d d d d d d d d d d
d d d d d d d d d d
10 2 9 2 0 1 1 20 1 21
d d d d d d d d d d
d d d d d d d d d d
4 2 14 0 0 0 0 20 0 20
d d d d d d d d d d
ECCE Z extracapsular cataract extraction; IOL Z intraocular lens *A-scan
J CATARACT REFRACT SURG - VOL 41, APRIL 2015
COMPARISON OF TWO OVDS IN INTUMESCENT CATARACT SURGERY
shows preoperative, intraoperative, and postoperative data in the 2 study groups. Surgically induced capsule tears occurred in 2 eyes in Group 1 and in no eye in Group 2. One of the eyes with a capsule tear could not be treated using phacoemulsification, and the technique was changed to extracapsular cataract extraction (ECCE). That eye developed a posterior capsule rupture followed by vitreous loss, so an IOL was implanted in the ciliary sulcus. In all other eyes in both groups, an IOL was implanted successfully in the capsular bag. Three months after surgery, there were no postoperative complications such as decentration of the IOL or a rise in intraocular pressure. DISCUSSION This trial compared 2 viscosurgical approaches to creating a CCC in eyes with intumescent white cataracts and evaluated the intraoperative complications and the measured size and centration of the achieved capsulorhexis. Intumescent white cataracts remain a surgical challenge because of the lack of a red reflex; several papers have been published recently that report approaches and results. One reported that ultrastructural analysis of anterior capsules of intumescent white cataracts showed no increase in thickness but that extrusions of basement membrane filaments at the basement membrane–epithelial border could be a structural cause of tensile weakness.14 Some studies used different types of dyes and OVDs in combination to achieve a successful outcome for the surgical approach2–5; others used diathermy or high-frequency diathermy to create an anterior capsulotomy.6–10 Gimbel and Willerscheidt5 described a 2-stage CCC technique that started centrally and later could be enlarged to the required diameter. Bhattacharjee et al.15 first released the intralenticular pressure under OVD protection of the anterior chamber and used high magnification of the operating microscope without further staining of the lens capsule before performing the CCC manually using an endoilluminator and a capsule forceps. Another used an assisted slit illuminator placed near to the operating microscope to enhance visualization of the anterior lens capsule.16 Even neodymium:YAG laser capsulotomy has been reported to reduce the risk for inadvertently enlarging the anterior capsulorhexis in eyes with intumescent cataract.17,18 In the present study, the overall complication rate was higher in Group 1, which used only mediumviscosity OVD, than in Group 2, which received an additional high-viscosity OVD to reduce capsule tension. In all eyes, staining with trypan blue stain helped in visualizing the anterior capsule and in decreasing elasticity. Three eyes showed wrinkles in the anterior
717
capsule where a posterior capsule rupture had occurred before surgical intervention. These 3 eyes had the highest complication rate with regard to capsule tear and difficulty handling the remaining parts of the lens capsule. In 1 of them, the surgical technique was changed to ECCE to avoid dropping the nucleus, and the conversion to ECCE led to the complete extraction of the lens parts and an anterior segment vitrectomy because of vitreous prolapsing through the posterior opening of the remaining capsule. In this eye, the IOL was implanted successfully in the sulcus. Using the additional high-viscosity OVD in Group 2 allowed creation of a more precise capsule opening with a diameter closer to the target diameter. Indenting the prestained anterior lens capsule yielded a more controlled procedure and made it easier to circle the capsulorhexis, minimizing the risk for uncontrolled extension to the periphery. Furthermore, it better protected against the egress of liquefied lens material, thus allowing better visualization of the surgery and significantly minimizing the number of capsular bag complications. In all eyes except 1, phacoemulsification was performed safely using a phaco-chop technique. In the exception, conversion was made to ECCE to extract the whole lens material without further support of the posterior capsular bag, as discussed above. In most cases, the IOL was implanted in the capsular bag, but in 3 eyes it was placed in the sulcus because of rupture of the posterior capsule before surgery. In conclusion, the approach of using trypan blue staining and OVD is reliable and safe. The technique using 2 OVDs is advantageous over the use of only 1 OVD because it leaves the tension of the lens capsule unaffected. Further studies of a larger group of eyes would be beneficial to confirm these findings. Our results can serve as a basis for future studies using a femtosecond laser in cataract surgery involving intumescent white cataracts. WHAT WAS KNOWN Cataract surgery in intumescent white cataracts has a higher complication rate in regard to the creation of a CCC compared to standard situations. WHAT THIS PAPER ADDS The use of 2 OVDs with different viscosities created a central indentation of the anterior lens capsule before a CCC. This technique, in combination with anterior capsule staining, enabled the surgeon to perform a safe approach while minimizing capsular bag complications and increasing the precision of the attempted capsulorhexis in size and shape.
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COMPARISON OF TWO OVDS IN INTUMESCENT CATARACT SURGERY
REFERENCES 1. Brazitikos PD, Tsinopoulos IT, Papadopoulos NT, Fotiadis K, Stangos NT. Ultrasonographic classification and phacoemulsification of white senile cataracts. Ophthalmology 1999; 106:2178–2183 2. Vasavada A, Singh R, Desai J. Phacoemulsification of white mature cataracts. J Cataract Refract Surg 1998; 24:270–277 ^ra ^us C, Gusho E, Kantor E. [Phacoemulsifi3. Gavris M, Popa D, Ca cation in white cataract]. [Romanian] Oftalmologia 2004; 48:81–87 4. Figueiredo CG, Figueiredo J, Figueiredo GB. Brazilian technique for prevention of the Argentinean flag sign in white cataract. J Cataract Refract Surg 2012; 38:1531–1536 5. Gimbel HV, Willerscheidt AB. What to do with limited view: the intumescent cataract. J Cataract Refract Surg 1993; 19:657–661 6. Findl O, Amon M. Anterior capsulotomy created by radiofrequence endodiathermy and continuous curvilinear posterior capsulorhexis in a patient with intumescent cataract and primary capsular fibrosis. J Cataract Refract Surg 1998; 24:870–871 €ffnung bei intu7. Pham DT, Liekfeld A, Hartmann C. Kapselo meszenter Katarakt mit dem Hochfrequenz-Diathermie-Kapsulotom[Capsulotomy in intumescent cataract with the high frequency diathermy capsulotomy]. Klin Monatsbl Augenheilkd 1998; 212:29–31 8. Luck J. Capsular endodiathermy and intumescent cataract [letter]. J Cataract Refract Surg 1994; 20:365; reply by HV Gimbel, 365–366 9. Hausmann N, Richard G. Investigations on diathermy for anterior capsulotomy. Invest Ophthalmol Vis Sci 1991; 32:2155–2159. Available at: http://www.iovs.org/content/32/7/ 2155.full.pdf. Accessed November 17, 2014 10. Priglinger SG, Palanker D, Alge CS, Kreutzer TC, Haritoglou C, Grueterich M, Kampik A. Pulsed electron avalanche knife: new technology for cataract surgery. Br J Ophthalmol 2007; 91:949–954. Available at: http://bjo.bmj.com/content/91/7/949. full.pdf. Accessed November 17, 2014 11. Dick HB, Aliyeva SE, Hengerer F. Effect of trypan blue on the elasticity of the human anterior lens capsule. J Cataract Refract Surg 2008; 34:1367–1373
12. Chylack LT Jr, Wolfe JK, Singer DM, Leske MC, Bullimore MA, Bailey IL, Friend J, McCarthy D, Wu S-Y; for the Longitudinal Study of Cataract Study Group. The Lens Opacities Classification System III. Arch Ophthalmol 1993; 111:831–836. Available at: http://www.chylac kinc.com/LOCS_III/LOCS_III_Certification_files/LOCS_III_ Reprint_pdf.pdf. Accessed November 17, 2014 13. Melles GRJ, de Waard PWT, Pameyer JH, Beekhuis WH. Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J Cataract Refract Surg 1999; 25:7–9 14. Hawlina M, Stunf S, Hvala A. Ultrastructure of anterior lens capsule of intumescent white cataract. Acta Ophthalmol 2011; 89:367–370. Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.17553768.2010.02102.x/pdf. Accessed November 17, 2014 15. Bhattacharjee K, Bhattacharjee H, Goswami BJ, Sarma P. Capsulorrhexis in intumescent cataract. J Cataract Refract Surg 1999; 25:1045–1047 16. Lee JE, Choi HY, Oum BS, Lee JS. Capsulorhexis assisted by slit illuminator for white cataract without a red reflex. Ophthalmic Surg Lasers Imaging 2007; 38:349–352 17. Richards JC, Harrison DC. Preoperative neodymium:YAG anterior capsulotomy in intumescent cataract: preventing extension of the capsular tear to the lens periphery. J Cataract Refract Surg 2003; 29:1630–1631 18. Coelho RP, Martin LFT, Paula JS, Scott IU. Comparison of preoperative Nd:YAG laser anterior capsulotomy versus two-stage curvilinear capsulorhexis in phacoemulsification of white intumescent cataracts. Ophthalmic Surg Lasers Imaging 2009; 40:582–585
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First author: Fritz H. Hengerer, MD, PhD Department of Ophthalmology, Goethe University, Frankfurt, Germany
Assessment of intraoperative complications in intumescent cataract surgery using 2 ophthalmic viscosurgical devices and trypan blue staining Fritz H. Hengerer, MD, PhD, H. Burkhard Dick, MD, PhD, Thomas Kohnen, MD, PhD, Ina Conrad-Hengerer, MD
PURPOSE: To evaluate intraoperative complications during capsulorhexis and phacoemulsification in intumescent white cataracts using 2 ophthalmic viscosurgical device (OVD) techniques. SETTING: Ruhr University Eye Clinic, Bochum, Germany. DESIGN: Case series. METHODS: Patients with eyes with intumescent white cataract were recruited and placed in 2 groups. After capsule staining using trypan blue, a central indentation of the anterior lens capsule was created in the eyes in Group 1 using a medium-viscosity OVD (Healon 1.0%) and in the eyes in Group 2 using both medium-viscosity (1.0%) and high-viscosity (2.3%) OVDs. Then a continuous curvilinear capsulorhexis (CCC) was performed. The outcomes measured were the horizontal and vertical diameters of the CCC, the deviation from the target diameter, and intraoperative complications. RESULTS: In Group 1 (21 eyes), deviation from the target CCC diameter occurred in 12 eyes (10 oversized, 2 undersized), and in Group 2 (20 eyes) deviation occurred in 6 eyes (4 oversized, 2 undersized). In Group 1, capsule tears appeared in 2 eyes and in 1 eye, the procedure had to be converted to extracapsular cataract extraction with anterior vitrectomy. In Group 2, there were no capsule tears. CONCLUSION: Using 2 different OVDs and placing the high-viscosity OVD centrally led to safe indentation of the anterior lens capsule and reduced the risk for CCC enlargement and capsule tear during surgery. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2015; 41:714–718 Q 2015 ASCRS and ESCRS
In standard cataract surgery, achieving a complete and curvilinear capsulorhexis of a precise size and shape is very important for a successful approach. A safe anterior segment situation must be established intraoperatively by using ophthalmic viscosurgical devices (OVDs) or fluid irrigation to stabilize the anterior chamber. Even a skilled surgeon who is aware of the potential drawbacks in routine and nonroutine cases pays particular attention when performing surgery in eyes with white intumescent cataracts. Such lenses do not permit the red reflex because of the whitening 714
Q 2015 ASCRS and ESCRS Published by Elsevier Inc.
and further liquefaction of the entire parts, leading to a rise in internal pressure. Before surgery, analyzing the lens structure using anterior segment imaging with B-scan ultrasound (US) or optical coherence tomography (OCT) might provide additional information about swelling of the lens and a concomitant rise in pressure. Brazitikos et al.1 developed an ultrasonographybased classification system to grade these lenses into 3 types according to the internal acoustic reflections. Having access to this knowledge could influence a http://dx.doi.org/10.1016/j.jcrs.2014.06.039 0886-3350
COMPARISON OF TWO OVDS IN INTUMESCENT CATARACT SURGERY
715
surgeon to change the initial surgical approach from a standard procedure to 1 that handles these challenging situations in different ways. Several recently published approaches to operating on these cases use different types of OVDs or staining dyes in combination with viscosurgery to enhance the outcome and minimize the risk profile of an uncontrolled opening of the anterior lens capsule.2–5 Other authors describe using different endodiathermy devices to create a continuous curvilinear capsulorhexis (CCC) in such cases.6–10 Dick et al.11 used trypan blue staining to decrease the elasticity of the anterior capsule in regular cases. The present prospective study compared 2 surgical approaches and evaluated their intraoperative complications and their safety and efficacy. In both study groups, trypan blue staining was used before the OVD application. In 1 group a medium-viscosity OVD was used, and in the other group 2 OVDs were used, 1 medium-viscosity and 1 high-viscosity. PATIENTS AND METHODS This case series included only eyes with an intumescent white cataract12 without red reflex and a dilated pupil size of at least 6.0 mm (Figure 1, A). This retrospective trial adhered to the tenets of Declaration of Helsinki. All surgeries were performed by 1 surgeon between November 2010 and July 2011. The exclusion criteria were a history of serious coexisting ocular disease (eg, pseudoexfoliation syndrome, uncontrolled glaucoma, or ocular tumors), poorly dilating pupils (pupil size !6.0 mm), known zonular weakness, ocular trauma, and age younger than 22 years. A physician performed a full ophthalmological examination on each patient using a BQ 900 slitlamp (Haag-Streit AG). Preoperative intraocular lens (IOL) power calculations were performed using noncontact partial coherence interferometry (PCI) (IOLMaster, Carl Zeiss Meditec AG) readings for axial length (AL) and corneal radii. In difficult cases, an additional US A-scan measurement for AL was performed, followed by IOL calculation using the values from PCI that contributed to the corneal radii value. In all eyes, small-incision phacoemulsification was performed using topical anesthesia. The 2-step clear corneal main incision was made at 12 o’clock using a 2.75 mm metal keratome (2.75 mm angled slit knife, Alcon Surgical, Inc.). The single-plane side-port incisions were made at 9 o' clock
Submitted: March 16, 2014. Final revision submitted: May 20, 2014. Accepted: June 8, 2014. From the Department of Ophthalmology (Hengerer, Kohnen), Goethe University, Frankfurt, and the Department of Ophthalmology (Dick, Conrad-Hengerer), Ruhr University, Bochum, Germany. Corresponding author: Fritz H. Hengerer, MD, PhD, Department of Ophthalmology, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany. E-mail: [email protected].
Figure 1. A: Preoperative image of an intumescent white cataract. B: The anterior chamber peripherally filled with medium-viscosity OVD (1.0%) and a central bulk of high-viscosity OVD (2.3%) to achieve a flattened anterior lens capsule.
and 3 o’clock using a 1.2 mm metal keratome (dual bevel, 1.2 mm angled side-port knife, Alcon Surgical, Inc.). In all cases, the anterior lens capsule was stained using trypan blue stain (Visionblue Staining Solution, Dutch Ophthalmic, USA) under air fill, as described previously.13 The target vertical and horizontal diameters of the CCC ranged from 4.5 to 5.5 mm. In the eyes in Group 1, a medium-viscosity OVD (Healon 1.0%) was instilled in the anterior chamber to protect the endothelium; care was taken not to overfill the anterior chamber. The CCC was performed using a bent 19-gauge needle through a side-port incision. The intended size of the capsulorhexis was 5.0 mm. After the capsule was punctured centrally, the leaf of the opened capsule was grasped using a Koch capsulorhexis forceps (Geuder AG) and the capsulorhexis was created circularly. In the eyes in Group 2, the anterior chamber was filled peripherally with the medium-viscosity OVD and then a central bulk of high-viscosity OVD (Healon5) was carefully placed in the anterior chamber to achieve a flattened and, later, centrally indented anterior lens capsule (Figure 1, B). Meticulous care was taken to not overfill the anterior chamber or apply too much pressure on the capsule zonular fibers. The CCC was opened centrally using a bent 19-gauge needle and, in most eyes in this group, the capsulorhexis was performed using only the needle while aiming for a centered, sized result. In 8 eyes (40%), a Koch capsulorhexis forceps was introduced to finish the procedure and extract the capsule leaf (Figure 2).
J CATARACT REFRACT SURG - VOL 41, APRIL 2015
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COMPARISON OF TWO OVDS IN INTUMESCENT CATARACT SURGERY
liquefied cortex and lens material before establishing a central groove, and then to crack the nucleus using a Neuhann chopper (Geuder AG). The phaco-chop technique was followed by removal of the remaining cortex material through the nasal and temporal incisions using bimanual irrigation/aspiration (I/A), and then by polishing the posterior capsule. In all cases, regular vacuum settings were used (600 mm Hg maximum). In uncomplicated cases in both groups, a 3-piece hydrophilic acrylic IOL was implanted in the eye using mediumviscosity OVD to protect the corneal endothelium. After bimanual I/A of the OVD, the paracenteses were hydrated and the eyes covered with a patch. Postoperative medication followed a standard regimen for 4 weeks.
Statistical Analysis Figure 2. Capsulorhexis using a microforceps after staining with trypan blue.
An Engel spatula (Geuder AG) was used to measure the achieved diameter of the capsular bag opening vertically and horizontally in both groups. This device is 0.6 mm in diameter and has a ruler marked with 0.1 mm steps. It was introduced horizontally through the side port and vertically through the main incision and was placed over the middle of the capsulotomy. Then, US phacoemulsification was performed without further hydrodissection or delineation using a Stellaris phacoemulsification system (Bausch & Lomb) in both study groups. A standard microflow needle with an angulation of 30 degrees at the opening was used. The phaco settings were 60% maximum phaco power, 100 cm bottle height, and 600 mm Hg maximum vacuum created by the venturi pump. The preferred technique was to aspirate the
All descriptive statistical analysis was conducted using SPSS software (version 19.0, SPSS, Inc.). A t test was used to compare the mean values. A P value less than 0.05 was considered statistically significant.
RESULTS The initial 44 eyes of patients recruited for analysis were placed in 2 groups of 22 eyes each. In Group 1 the mean patient age was 72.9 years G 11.6 (SD) (range 48 to 89 years) and in Group 2, 69.0 G 12.9 years (range 44 to 86 years). Three eyes were excluded for preoperative capsule rupture, 1 in Group 1 and 2 in Group 2. Treatment was performed in 11 right eyes and 10 left eyes in Group 1 and in 10 right eyes and 10 left eyes in Group 2. Group 1 comprised 9 men and 12 women. Group 2 comprised 10 men and 10 women. Table 1
Table 1. Preoperative, intraoperative, and postoperative data in the 2 study groups. Group 1 (n Z 21)
Group 2 (n Z 20)
Parameter
Mean G SD
Range
Eyes (n)
Mean G SD
Range
Eyes (n)
P Value
Preop lens thickness (mm)* Preop axial length (mm) Capsulorhexis diameter (mm) Horizontal Vertical Capsulorhexis size (n) Over target Under target Within target Capsule tear (n) Dropped nucleus (n) Vitreous loss (n) Posterior capsule rupture (n) Phacoemulsification (n) ECCE (n) IOL implantation (n)
4.2 G 0.66 23.51 G 0.98 d 5.20 G 0.54 5.43 G 0.42
3.0, 5.3 d d 4.0, 6.0 4.6, 6.0
d d d d d
4.1 G 0.58 23.36 G 0.86 d 4.96 G 0.37 5.18 G 0.34
2.7, 5.3 d d 4.5, 5.8 4.7, 5.9
d d d d d
.420 d d .117 .042
d d d d d d d d d d
d d d d d d d d d d
10 2 9 2 0 1 1 20 1 21
d d d d d d d d d d
d d d d d d d d d d
4 2 14 0 0 0 0 20 0 20
d d d d d d d d d d
ECCE Z extracapsular cataract extraction; IOL Z intraocular lens *A-scan
J CATARACT REFRACT SURG - VOL 41, APRIL 2015
COMPARISON OF TWO OVDS IN INTUMESCENT CATARACT SURGERY
shows preoperative, intraoperative, and postoperative data in the 2 study groups. Surgically induced capsule tears occurred in 2 eyes in Group 1 and in no eye in Group 2. One of the eyes with a capsule tear could not be treated using phacoemulsification, and the technique was changed to extracapsular cataract extraction (ECCE). That eye developed a posterior capsule rupture followed by vitreous loss, so an IOL was implanted in the ciliary sulcus. In all other eyes in both groups, an IOL was implanted successfully in the capsular bag. Three months after surgery, there were no postoperative complications such as decentration of the IOL or a rise in intraocular pressure. DISCUSSION This trial compared 2 viscosurgical approaches to creating a CCC in eyes with intumescent white cataracts and evaluated the intraoperative complications and the measured size and centration of the achieved capsulorhexis. Intumescent white cataracts remain a surgical challenge because of the lack of a red reflex; several papers have been published recently that report approaches and results. One reported that ultrastructural analysis of anterior capsules of intumescent white cataracts showed no increase in thickness but that extrusions of basement membrane filaments at the basement membrane–epithelial border could be a structural cause of tensile weakness.14 Some studies used different types of dyes and OVDs in combination to achieve a successful outcome for the surgical approach2–5; others used diathermy or high-frequency diathermy to create an anterior capsulotomy.6–10 Gimbel and Willerscheidt5 described a 2-stage CCC technique that started centrally and later could be enlarged to the required diameter. Bhattacharjee et al.15 first released the intralenticular pressure under OVD protection of the anterior chamber and used high magnification of the operating microscope without further staining of the lens capsule before performing the CCC manually using an endoilluminator and a capsule forceps. Another used an assisted slit illuminator placed near to the operating microscope to enhance visualization of the anterior lens capsule.16 Even neodymium:YAG laser capsulotomy has been reported to reduce the risk for inadvertently enlarging the anterior capsulorhexis in eyes with intumescent cataract.17,18 In the present study, the overall complication rate was higher in Group 1, which used only mediumviscosity OVD, than in Group 2, which received an additional high-viscosity OVD to reduce capsule tension. In all eyes, staining with trypan blue stain helped in visualizing the anterior capsule and in decreasing elasticity. Three eyes showed wrinkles in the anterior
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capsule where a posterior capsule rupture had occurred before surgical intervention. These 3 eyes had the highest complication rate with regard to capsule tear and difficulty handling the remaining parts of the lens capsule. In 1 of them, the surgical technique was changed to ECCE to avoid dropping the nucleus, and the conversion to ECCE led to the complete extraction of the lens parts and an anterior segment vitrectomy because of vitreous prolapsing through the posterior opening of the remaining capsule. In this eye, the IOL was implanted successfully in the sulcus. Using the additional high-viscosity OVD in Group 2 allowed creation of a more precise capsule opening with a diameter closer to the target diameter. Indenting the prestained anterior lens capsule yielded a more controlled procedure and made it easier to circle the capsulorhexis, minimizing the risk for uncontrolled extension to the periphery. Furthermore, it better protected against the egress of liquefied lens material, thus allowing better visualization of the surgery and significantly minimizing the number of capsular bag complications. In all eyes except 1, phacoemulsification was performed safely using a phaco-chop technique. In the exception, conversion was made to ECCE to extract the whole lens material without further support of the posterior capsular bag, as discussed above. In most cases, the IOL was implanted in the capsular bag, but in 3 eyes it was placed in the sulcus because of rupture of the posterior capsule before surgery. In conclusion, the approach of using trypan blue staining and OVD is reliable and safe. The technique using 2 OVDs is advantageous over the use of only 1 OVD because it leaves the tension of the lens capsule unaffected. Further studies of a larger group of eyes would be beneficial to confirm these findings. Our results can serve as a basis for future studies using a femtosecond laser in cataract surgery involving intumescent white cataracts. WHAT WAS KNOWN Cataract surgery in intumescent white cataracts has a higher complication rate in regard to the creation of a CCC compared to standard situations. WHAT THIS PAPER ADDS The use of 2 OVDs with different viscosities created a central indentation of the anterior lens capsule before a CCC. This technique, in combination with anterior capsule staining, enabled the surgeon to perform a safe approach while minimizing capsular bag complications and increasing the precision of the attempted capsulorhexis in size and shape.
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COMPARISON OF TWO OVDS IN INTUMESCENT CATARACT SURGERY
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J CATARACT REFRACT SURG - VOL 41, APRIL 2015
First author: Fritz H. Hengerer, MD, PhD Department of Ophthalmology, Goethe University, Frankfurt, Germany