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Complications of late capsulotomy
Complications of late caps ulotomy Richard Livernois, M.D. Robert M. Sinskey, M.D. Santa Monica, California
ABSTRACT One hundred forty-two aphakic and pseudophakic eyes underwent capsulotomy six or more months after cataract extraction. The incidence of cystoid macular edema was 3.5%. The presence of an intraocular lens did not seem to alter the incidence or severity of cystoid macular edema. There is an increased risk ofinflammation after a second intraocular procedure such as a posterior capsulotomy. Key words: posterior capsule opacification, secondary capsulotomy, phacoemulsification, intraocular lens implantation, cystoid macular edema Recent reports suggest that the presence of an intact posterior capsule after extracapsular cataract surgery reduces the incidence and duration of aphakic cystoid macular edema (CME). 1,2 Performing posterior capsulotomy months after the original surgery may also reduce the incidence of CME.:3 We conducted a retrospective study to analyze clinical results of late capsulotomy on patients who had undergone previous phacoemulsification with or without intraocular lens (IOL) implantation.
SUBJECTS AND METHODS The records of all phacoemulsification patients who underwent secondary posterior capsulotomy between 1976 and 1980 were reviewed. All surgery had been performed by one surgeon (RMS). Eliminated from the study were 20 patients whose cataract surgery had been performed elsewhere, who had diagnosed retinal disease, or who had undergone another intraocular procedure before phacoemulsification or before capsulotomy. The 142 eyes left in the study had undergone posterior chamber phacoemulsification with posterior capsule polishing. 4 In 101 cases cataract extraction was followed by implantation of a 2-100p IOL, inserted under an air bubble with a lens guide. The wound was closed with 1O~0 nylon suture material; subconjunctival steroids and antibiotics were injected at the termination of the operation. Postoperative management consisted of a prednisolone and sulfacetamide topical suspension for three to five days, followed by topical prednisolone drops, In cases of prolonged or increased inflammatory reaction, oral prednisone was used in a rapidly tapering dose. Measurement ofvisual acuity and slitlamp biomicroscopy were performed on all patients three to five days after cataract surgery, and at least monthly for three months postoperatively.
Observation of the intact posterior capsules revealed a large variation in the time of onset of fibrosis or Elschnig pearl formation, When opacification of the capsule reduced vision, a caps ulotomy was performed under topical anesthesia as an outpatient procedure, using an operating microscope. The anesthetized eye was fixed with forceps and a limbal stab incision made with a Haab or Ziegler knife. The knife was directed behind the lens optic (when an IOL was present) and a central incision was made in the posterior capsule with a sweeping inferior motion. The knife was then removed atraumatically. Patients used a steroid and antibiotic eye drop for two days and were seen again in one or two days. There were no wound leaks. All patients with clinically suspected macular lesions and decreased vision underwent fluorescein angiography.
RESULTS Of 142 eyes included in this study, 125 (88%) achieved visions of 20/40 or better three months after cataract surgery. However, only 49(34%) had acuities of 20/40 or better prior to capsulotomy. The time interval between cataract surgery and caps ulotomy ranged from six to 38 months, with an average of 22 months. After posterior capsulotomy, 125 (88%) eyes had visions of 20/40 or better (Table 1). The follow-up period after posterior capsulotomy ranged from six to 60 months, with an average of 26 months. Only six (15%) of the 41 aphakic eyes had less than 20/40 vision after capsulotomy. Two patients had 20/30 vision at six months but developed central visual field changes secondary to open angle glaucoma: resulting visions were 20/50 and 20/80. The other four patients all underwent fluorescein angiography. One had corneal opacification secondary to an interstitial keratitis,
Presented at the Fourth U,S. Intraocular Lens Symposium, Los Angeles, California, March 27, 1981. Reprint requests to Dr, Livernois, 2232 Santa Monica Blvd., Santa Monica, CA 90404. 242
AM INTRA-OCULAR IMPLANT SOC J-VOL. 7, SUMMER 1981
and another developed a branch vein occlusion with he morrhage in the macula. Two patients had final acuities of 20/200. One of these eyes had Doyne's honeycomb maculopathy or giant Drusen, which was not visualized prior to cataract extraction and thus not excluded from this study. The second 20/200 eye had angiographically proven cystoid macular edema which did not respond to treatment with anti-inflammatory agents. Of the 101 pseudophakic eyes, 11 (11 %) had final visions less than 20/40. One of these eyes (20/50) developed a late vitritis with no evidence of vitreous to th e wound; the vitritis cleared and angiography failed to reveal any macular pathology. Another eye developed fibrin behind the IOL which did not clear; vision was 20/50 after treatment. Diabetic retinopathy was the cause of 20/50 vision in a third eye. Four eyes had macular disease associated with senile macular choroidal degeneration , angioid streaks or asteroid hyalosis with macular involve ment. None had CME on fluorescein angiograph y. Four other eyes developed angiographically proven CME with acuities of 20/60, 20/60, 20/100, and 20/200. After oral steroid treatme nt the 20/200 eye improved to 20/60 by 33 months postoperative ly . The other three cases showed no improvement in visual acuity with steroid treatment (follow-up was over 18 months in each case).
Table 1. Visual acuities after secondary posterior capsulotomy. Visual Acuity
No. of Eyes
20/20 20/25 - 20/30 20/40 < 20/40
39 62 24 17 . 142
(27%) (44%) (17%) (12%) (100%)
DISCUSSION Theoretically an intact posterior capsule reduces the incidence of cystoid macular edema to less than 1 %, markedly reduces the incidence of retinal detachment and vitreous to the wound, and avoids th e vitreous wick syndrom e . Late capsulotomy has been claimed to eliminate retinal complications such as CME or retinal detachment. 3 In our study, five ( 3.5%) of the 142 patients who underwent secondary caps ulotomy six to 24 months after cataract surgery developed angiographically proven cystoid macular edema. In only one of these cases did vision improve; this was a patient in the pseudophakic group. The severity and incidence of CME did not seem to differ from that we have observed in eyes undergoing primary capsulotomy. Although cystoid macular edema developed in four (4%) of 101 pseudophakic eyes and one ( 2%) of 41 aphakic eyes, we do not believe the prese nce of an IOL influences th e course or incidence of CME. However, our study is too small to allow statistical verification. The complication s observed in this study and by others lead us to believe that a late caps ulotomy increases the risk to the eye, since it is a second intraocular procedure. However, some causes for decreased postoperative vision Were only apparent after capsulotomy and were not related to the intraocular surgery itself.
REFERENCES 1. Binkhorst CD: Five hundred planned extracapsular extractions
with irido-capsular oval clip lens implantation in senile cataract. Ophthalmic Surg 8:37, 1977 2. The .\1iami Study Croup: Cystoid macular edema in aphakic and pseudophakic eyes . Am] Ophthalmol 88:45, 1979 3. Lindstrom RL, Harris WS: .\1anagement of the posterior capsule followin g posterior chamber lens implantation. Am IntraOcular Implant Soc] 6:255, 1980 4 . Sinskey R.\1 , Cain W Jr : The posterior caps ul e and phacocmulsification . Am Intra-Ocular Implant Soc] 4:206, 1978
AM INTRA-OCULAR IMPLANT SOC J-VOL. 7, SUMMER 1981
243
ABSTRACT One hundred forty-two aphakic and pseudophakic eyes underwent capsulotomy six or more months after cataract extraction. The incidence of cystoid macular edema was 3.5%. The presence of an intraocular lens did not seem to alter the incidence or severity of cystoid macular edema. There is an increased risk ofinflammation after a second intraocular procedure such as a posterior capsulotomy. Key words: posterior capsule opacification, secondary capsulotomy, phacoemulsification, intraocular lens implantation, cystoid macular edema Recent reports suggest that the presence of an intact posterior capsule after extracapsular cataract surgery reduces the incidence and duration of aphakic cystoid macular edema (CME). 1,2 Performing posterior capsulotomy months after the original surgery may also reduce the incidence of CME.:3 We conducted a retrospective study to analyze clinical results of late capsulotomy on patients who had undergone previous phacoemulsification with or without intraocular lens (IOL) implantation.
SUBJECTS AND METHODS The records of all phacoemulsification patients who underwent secondary posterior capsulotomy between 1976 and 1980 were reviewed. All surgery had been performed by one surgeon (RMS). Eliminated from the study were 20 patients whose cataract surgery had been performed elsewhere, who had diagnosed retinal disease, or who had undergone another intraocular procedure before phacoemulsification or before capsulotomy. The 142 eyes left in the study had undergone posterior chamber phacoemulsification with posterior capsule polishing. 4 In 101 cases cataract extraction was followed by implantation of a 2-100p IOL, inserted under an air bubble with a lens guide. The wound was closed with 1O~0 nylon suture material; subconjunctival steroids and antibiotics were injected at the termination of the operation. Postoperative management consisted of a prednisolone and sulfacetamide topical suspension for three to five days, followed by topical prednisolone drops, In cases of prolonged or increased inflammatory reaction, oral prednisone was used in a rapidly tapering dose. Measurement ofvisual acuity and slitlamp biomicroscopy were performed on all patients three to five days after cataract surgery, and at least monthly for three months postoperatively.
Observation of the intact posterior capsules revealed a large variation in the time of onset of fibrosis or Elschnig pearl formation, When opacification of the capsule reduced vision, a caps ulotomy was performed under topical anesthesia as an outpatient procedure, using an operating microscope. The anesthetized eye was fixed with forceps and a limbal stab incision made with a Haab or Ziegler knife. The knife was directed behind the lens optic (when an IOL was present) and a central incision was made in the posterior capsule with a sweeping inferior motion. The knife was then removed atraumatically. Patients used a steroid and antibiotic eye drop for two days and were seen again in one or two days. There were no wound leaks. All patients with clinically suspected macular lesions and decreased vision underwent fluorescein angiography.
RESULTS Of 142 eyes included in this study, 125 (88%) achieved visions of 20/40 or better three months after cataract surgery. However, only 49(34%) had acuities of 20/40 or better prior to capsulotomy. The time interval between cataract surgery and caps ulotomy ranged from six to 38 months, with an average of 22 months. After posterior capsulotomy, 125 (88%) eyes had visions of 20/40 or better (Table 1). The follow-up period after posterior capsulotomy ranged from six to 60 months, with an average of 26 months. Only six (15%) of the 41 aphakic eyes had less than 20/40 vision after capsulotomy. Two patients had 20/30 vision at six months but developed central visual field changes secondary to open angle glaucoma: resulting visions were 20/50 and 20/80. The other four patients all underwent fluorescein angiography. One had corneal opacification secondary to an interstitial keratitis,
Presented at the Fourth U,S. Intraocular Lens Symposium, Los Angeles, California, March 27, 1981. Reprint requests to Dr, Livernois, 2232 Santa Monica Blvd., Santa Monica, CA 90404. 242
AM INTRA-OCULAR IMPLANT SOC J-VOL. 7, SUMMER 1981
and another developed a branch vein occlusion with he morrhage in the macula. Two patients had final acuities of 20/200. One of these eyes had Doyne's honeycomb maculopathy or giant Drusen, which was not visualized prior to cataract extraction and thus not excluded from this study. The second 20/200 eye had angiographically proven cystoid macular edema which did not respond to treatment with anti-inflammatory agents. Of the 101 pseudophakic eyes, 11 (11 %) had final visions less than 20/40. One of these eyes (20/50) developed a late vitritis with no evidence of vitreous to th e wound; the vitritis cleared and angiography failed to reveal any macular pathology. Another eye developed fibrin behind the IOL which did not clear; vision was 20/50 after treatment. Diabetic retinopathy was the cause of 20/50 vision in a third eye. Four eyes had macular disease associated with senile macular choroidal degeneration , angioid streaks or asteroid hyalosis with macular involve ment. None had CME on fluorescein angiograph y. Four other eyes developed angiographically proven CME with acuities of 20/60, 20/60, 20/100, and 20/200. After oral steroid treatme nt the 20/200 eye improved to 20/60 by 33 months postoperative ly . The other three cases showed no improvement in visual acuity with steroid treatment (follow-up was over 18 months in each case).
Table 1. Visual acuities after secondary posterior capsulotomy. Visual Acuity
No. of Eyes
20/20 20/25 - 20/30 20/40 < 20/40
39 62 24 17 . 142
(27%) (44%) (17%) (12%) (100%)
DISCUSSION Theoretically an intact posterior capsule reduces the incidence of cystoid macular edema to less than 1 %, markedly reduces the incidence of retinal detachment and vitreous to the wound, and avoids th e vitreous wick syndrom e . Late capsulotomy has been claimed to eliminate retinal complications such as CME or retinal detachment. 3 In our study, five ( 3.5%) of the 142 patients who underwent secondary caps ulotomy six to 24 months after cataract surgery developed angiographically proven cystoid macular edema. In only one of these cases did vision improve; this was a patient in the pseudophakic group. The severity and incidence of CME did not seem to differ from that we have observed in eyes undergoing primary capsulotomy. Although cystoid macular edema developed in four (4%) of 101 pseudophakic eyes and one ( 2%) of 41 aphakic eyes, we do not believe the prese nce of an IOL influences th e course or incidence of CME. However, our study is too small to allow statistical verification. The complication s observed in this study and by others lead us to believe that a late caps ulotomy increases the risk to the eye, since it is a second intraocular procedure. However, some causes for decreased postoperative vision Were only apparent after capsulotomy and were not related to the intraocular surgery itself.
REFERENCES 1. Binkhorst CD: Five hundred planned extracapsular extractions
with irido-capsular oval clip lens implantation in senile cataract. Ophthalmic Surg 8:37, 1977 2. The .\1iami Study Croup: Cystoid macular edema in aphakic and pseudophakic eyes . Am] Ophthalmol 88:45, 1979 3. Lindstrom RL, Harris WS: .\1anagement of the posterior capsule followin g posterior chamber lens implantation. Am IntraOcular Implant Soc] 6:255, 1980 4 . Sinskey R.\1 , Cain W Jr : The posterior caps ul e and phacocmulsification . Am Intra-Ocular Implant Soc] 4:206, 1978
AM INTRA-OCULAR IMPLANT SOC J-VOL. 7, SUMMER 1981
243