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Intercapsular cataract surgery with lens epithelial cell removal Part I: Without capsulorhexis
Intercapsular cataract surgery with lens epithelial cell removal Part I: Without capsulorhexis Okihiro Nishi, M.D.
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The anterior capsule is usually removed after posterior chamber lens implantation in intercapsular cataract surgeryl to avoid anterior capsule opacification, which has been reported to occur in 88% to 92% of cases. 2 There are some advantages to the absence of capsular excision , such as better encapsulation of posterior chamber lenses and taut capsules (J.D. Hunkeler, M.D., "Management of the Anterior Capsule ," Symposium on Cataract, IOL and Refractive Surgery, Los Angeles, April 1986). However, an increase in complications such as capsular opacification and IOL dislocation caused by the fibrous proliferation of lens epithelial cells may result . To avoid these complications, the lens epithelial cells must be sufficiently removed. I report the clinical results of intercapsular cataract extraction with lens epithelial cell removal using an ultrasound method in which the anterior capsule is not
removed after posterior chamber intraocular lens (IOL) insertion. MATERIALS AND METHODS Thirty eyes from 30 patients between 22 and 89 years of age (mean 64 ± 14 years) had endocapsular phacoemulsification 2 (four cases) or intercapsular cataract extraction. After a curvilinear incision , nucleus delivery and cortex removal, the lens epithelial cells were removed using ultrasound and aspiration. 3 The anterior capsule was left in place after insertion of a modified C-Ioop posterior chamber IOL (Figure 1). The follow-up period was from 10 to 22 months (mean 16.4 ± 2.8 months). RESULTS Anterior capsule opacification (Figure 2) was seen in six eyes (20%). In all cases, it was very thin and
Reprint requests to Okihiro Nishi, M.D., Nishi Eye Hospital, Higashinari-ku , Nakamichi, 4-14-26, 537 Osaka , Japan .
J CATARACT REFRACT SURG-VOL 15, MAY 1989
297
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Fig. 1.
Fig. 2.
298
(Nishi) Intercapsular cataract surgery with epithelial cell removal: After a curvilinear incision is made, the nucleus and cortex are removed (a); an irrigation/aspiration tip with a 0.2 mm side port is connected to the handle of a phacoemulsification device and inserted beneath the anterior capsule. The lens epithelial cells are destroyed and detached from the capsule by ultrasound vibration and aspiration (b,c); the anterior capsule is not removed after posterior chamber IOL implantation (d).
(Nishi) Thin opacification is seen beneath the undulated anterior capsule.
J CATARACT REFRACT
appeared within three months. Neodymium:YAG laser caps ulotomy was performed in three of these cases. In the other three cases, there was no disturbance of visual acuity. Shrinkage of the anterior capsule with or without opacification (Figure 3), i.e., "pea podding," a condition in which the anterior capsule edge is pulled below the posterior chamber lens center, was seen in 11 eyes (37%). Because the posterior chamber IOL optics were not covered by the anterior capsule, there was no decrease in visual acuity. Two cases showed partial opacification, which would have affected visual acuity if the shrinkage had not occurred. Shrinkage of the anterior capsule was seen only in the eyes that had intercapsular surgery. Posterior synechias were seen in six eyes (20%) (Figure 4). These occurred mainly at the edges of the anterior capsule which were lifted from the posterior chamber lens. Twenty eyes (67%) had at least one of the following conditions: anterior capsule opacification, shrinkage, posterior synechias. In the remaining ten eyes, the SURG-VOL 15, MAY 1989
Fig. 3.
(Nishi) The anterior capsule margin is pulled down by the lens epithelial cells. No visual impairment is present.
posterior chamber IOLs were well encapsulated and centered and the anterior capsules were clear (Figure 5). No fibrinous reaction or posterior capsule opacification has occurred in any eye. The results in all 30 eyes are summarized in Table 1. DISCUSSION The results suggest that posterior chamnber IOL implantation can be performed without removing the anterior capsule because Nd:YAG laser capsulotomy for anterior capsule opacification was necessary in only three cases. However, anterior capsule shrinkage was seen in 11 cases. This was probably caused by the large anterior capsule opening and the fibrous proliferation of the lens epithelial cells, which apparently remained despite attempts at thorough removal.
Fig. 4.
(Nishi) Posterior synechia.
These results also suggest that thorough removal of lens epithelial cells is extremely difficult, even if the ultrasound removal technique is histologically confirmed as very effective.·3 Therefore, sweeping the undersurface of the anterior capsule must be performed more carefully and thoroughly. The posterior synechias seen in six eyes also caused pupil distortion. This condition may be promoted by the large anterior capsule opening required for the intercapsular technique. In the present study, complications were observed in 20 eyes (67%). Although these conditions did not cause significant impairment of visual acuity, at this time I prefer to remove at least the central part of the anterior capsule after posterior chamber lens implantation in intercapsular cataract extraction even when it is possible to remove lens epithelial cells effectively. The other postoperative complications caused by lens epithelial cells, such as posterior capsule opacification, IOL dislocation, and fibrinous reaction,4 can be Table 1. Complications of intercapsular surgery with lens epithelial cell removal without capsulorhexis (capsule in place) in 30 eyes. Complication Anterior capsule opacification (Nd:YAG capsulotomy) Anterior capsule shrinkage Posterior synechia
Fig ..5.
(l\ishi) The \\'ell-encapsulated posterior chamber IOL \\'ith the dear anterior capsule. Anterior capsule margin ShO\\'I1 hy arro\\'.
J CATARACT
Number of Eyes (0/0) 6 (20) 3 (10) 11 (37)
6 (20)
Anterior capsule opacification and posterior synechia
12 (40)
Anterior capsule opacification. anterior capsule shrinkage. posterior synechia
20 (67)
REFRACT SeRG-VOL 15. MAY 1989
299
prevented. I recently removed the anterior capsule after posterior chamber lens implantation but removed the lens epithelial cells prior to lens insertion. The results are reported in Part II. REFERENCES 1. Galand A. Delmelle M: Preliminary report on the rigid disc lens. ] Cataract Refract Surg 12:394-397. 1986
300
2. Ham T, Hara T: Clinical re sults of endocapsular phacoem ulsification and complete in-the-hag intraocular lens fi"i\tion. ] Cataract Refract Surg 13::279-286. 1987 3. Nishi 0: Removal of lens epith elial cells bv ultrasound in e ndocapsular cataract surgery. Ophthalmic Surg 18 :577-580. 1987 4. Nishi 0: Fibrinous membrane formation on the posterior chamber lens during the early postoperative period. ] Cataract Refract Surg 14:73-77,1988
J CATARACT REFRACT SURG-VOL
15, MAY 1989
B TR
r m v po l ri ti n. Kc
W rd :
The anterior capsule is usually removed after posterior chamber lens implantation in intercapsular cataract surgeryl to avoid anterior capsule opacification, which has been reported to occur in 88% to 92% of cases. 2 There are some advantages to the absence of capsular excision , such as better encapsulation of posterior chamber lenses and taut capsules (J.D. Hunkeler, M.D., "Management of the Anterior Capsule ," Symposium on Cataract, IOL and Refractive Surgery, Los Angeles, April 1986). However, an increase in complications such as capsular opacification and IOL dislocation caused by the fibrous proliferation of lens epithelial cells may result . To avoid these complications, the lens epithelial cells must be sufficiently removed. I report the clinical results of intercapsular cataract extraction with lens epithelial cell removal using an ultrasound method in which the anterior capsule is not
removed after posterior chamber intraocular lens (IOL) insertion. MATERIALS AND METHODS Thirty eyes from 30 patients between 22 and 89 years of age (mean 64 ± 14 years) had endocapsular phacoemulsification 2 (four cases) or intercapsular cataract extraction. After a curvilinear incision , nucleus delivery and cortex removal, the lens epithelial cells were removed using ultrasound and aspiration. 3 The anterior capsule was left in place after insertion of a modified C-Ioop posterior chamber IOL (Figure 1). The follow-up period was from 10 to 22 months (mean 16.4 ± 2.8 months). RESULTS Anterior capsule opacification (Figure 2) was seen in six eyes (20%). In all cases, it was very thin and
Reprint requests to Okihiro Nishi, M.D., Nishi Eye Hospital, Higashinari-ku , Nakamichi, 4-14-26, 537 Osaka , Japan .
J CATARACT REFRACT SURG-VOL 15, MAY 1989
297
~(..
.,. .,. :r~~
7i . ~'.
:
a
,
"-.\.
"\
.
,
",
b
c d
Fig. 1.
Fig. 2.
298
(Nishi) Intercapsular cataract surgery with epithelial cell removal: After a curvilinear incision is made, the nucleus and cortex are removed (a); an irrigation/aspiration tip with a 0.2 mm side port is connected to the handle of a phacoemulsification device and inserted beneath the anterior capsule. The lens epithelial cells are destroyed and detached from the capsule by ultrasound vibration and aspiration (b,c); the anterior capsule is not removed after posterior chamber IOL implantation (d).
(Nishi) Thin opacification is seen beneath the undulated anterior capsule.
J CATARACT REFRACT
appeared within three months. Neodymium:YAG laser caps ulotomy was performed in three of these cases. In the other three cases, there was no disturbance of visual acuity. Shrinkage of the anterior capsule with or without opacification (Figure 3), i.e., "pea podding," a condition in which the anterior capsule edge is pulled below the posterior chamber lens center, was seen in 11 eyes (37%). Because the posterior chamber IOL optics were not covered by the anterior capsule, there was no decrease in visual acuity. Two cases showed partial opacification, which would have affected visual acuity if the shrinkage had not occurred. Shrinkage of the anterior capsule was seen only in the eyes that had intercapsular surgery. Posterior synechias were seen in six eyes (20%) (Figure 4). These occurred mainly at the edges of the anterior capsule which were lifted from the posterior chamber lens. Twenty eyes (67%) had at least one of the following conditions: anterior capsule opacification, shrinkage, posterior synechias. In the remaining ten eyes, the SURG-VOL 15, MAY 1989
Fig. 3.
(Nishi) The anterior capsule margin is pulled down by the lens epithelial cells. No visual impairment is present.
posterior chamber IOLs were well encapsulated and centered and the anterior capsules were clear (Figure 5). No fibrinous reaction or posterior capsule opacification has occurred in any eye. The results in all 30 eyes are summarized in Table 1. DISCUSSION The results suggest that posterior chamnber IOL implantation can be performed without removing the anterior capsule because Nd:YAG laser capsulotomy for anterior capsule opacification was necessary in only three cases. However, anterior capsule shrinkage was seen in 11 cases. This was probably caused by the large anterior capsule opening and the fibrous proliferation of the lens epithelial cells, which apparently remained despite attempts at thorough removal.
Fig. 4.
(Nishi) Posterior synechia.
These results also suggest that thorough removal of lens epithelial cells is extremely difficult, even if the ultrasound removal technique is histologically confirmed as very effective.·3 Therefore, sweeping the undersurface of the anterior capsule must be performed more carefully and thoroughly. The posterior synechias seen in six eyes also caused pupil distortion. This condition may be promoted by the large anterior capsule opening required for the intercapsular technique. In the present study, complications were observed in 20 eyes (67%). Although these conditions did not cause significant impairment of visual acuity, at this time I prefer to remove at least the central part of the anterior capsule after posterior chamber lens implantation in intercapsular cataract extraction even when it is possible to remove lens epithelial cells effectively. The other postoperative complications caused by lens epithelial cells, such as posterior capsule opacification, IOL dislocation, and fibrinous reaction,4 can be Table 1. Complications of intercapsular surgery with lens epithelial cell removal without capsulorhexis (capsule in place) in 30 eyes. Complication Anterior capsule opacification (Nd:YAG capsulotomy) Anterior capsule shrinkage Posterior synechia
Fig ..5.
(l\ishi) The \\'ell-encapsulated posterior chamber IOL \\'ith the dear anterior capsule. Anterior capsule margin ShO\\'I1 hy arro\\'.
J CATARACT
Number of Eyes (0/0) 6 (20) 3 (10) 11 (37)
6 (20)
Anterior capsule opacification and posterior synechia
12 (40)
Anterior capsule opacification. anterior capsule shrinkage. posterior synechia
20 (67)
REFRACT SeRG-VOL 15. MAY 1989
299
prevented. I recently removed the anterior capsule after posterior chamber lens implantation but removed the lens epithelial cells prior to lens insertion. The results are reported in Part II. REFERENCES 1. Galand A. Delmelle M: Preliminary report on the rigid disc lens. ] Cataract Refract Surg 12:394-397. 1986
300
2. Ham T, Hara T: Clinical re sults of endocapsular phacoem ulsification and complete in-the-hag intraocular lens fi"i\tion. ] Cataract Refract Surg 13::279-286. 1987 3. Nishi 0: Removal of lens epith elial cells bv ultrasound in e ndocapsular cataract surgery. Ophthalmic Surg 18 :577-580. 1987 4. Nishi 0: Fibrinous membrane formation on the posterior chamber lens during the early postoperative period. ] Cataract Refract Surg 14:73-77,1988
J CATARACT REFRACT SURG-VOL
15, MAY 1989