Abhay R. Vasavada

Primary posterior capsulorhexis with and without anterior vitrectomy in congenital cataracts

Purpose: To determine whether anterior vitrectomy is necessary along with primary posterior capsulorhexis in children less than 5 years of age with congenital cataracts. Setting: Iladevi Cataract & IOL Research Centre, Ahmedabad, India. Method: This prospective study comprised 18 eyes of 16 children whose mean age was 2.3 years (range 3 months to 5 years). Primary posterior continuous curvilinear capsulorhexis (PCCC) and posterior chamber intraocular lens (IOL) implantation were performed in all eyes. No vitrectomy was done in 8 eyes (Group 1); an anterior vitrectomy was performed in 10 eyes (Group 2). Optic capture through the posterior capsule was achieved in 3 eyes in Group 1 and in 5 eyes in Group 2. Average follow‐up was 13.3 months. Results: Five eyes (62.5%) in Group 1 needed secondary pars plana vitrectomy because the visual axis was obscured; no eye in Group 2 needed a secondary procedure. Four Group 1 eyes developed significant complications (updrawn pupil, decentration, occlusio pupillae, transient glaucoma). While no Group 2 eye developed a serious complication, some degree of pigment dispersion was noted in all the eyes. Conclusion: The results suggest that anterior vitrectomy is desirable along with primary PCCC in children younger than 5 years with congenital cataracts.

Intraocular lens implantation in infants with congenital cataracts

Abstract We evaluated 21 eyes of 13 infants between two and eight months old who had primary posterior chamber intraocular lens (IOL) implantation for congenital cataracts between 1988 and 1993. Twelve eyes had a posterior capsulorhexis or plaque peeling at the time of implantation and one eye had a vitrectomy. Eight eyes had no posterior capsule procedure during the initial surgery. Follow‐up ranged from six months to five years. All eyes developed one or multiple posterior synechias and all, except one, required secondary capsulectomy and vitrectomy between one month and one year. Twenty eyes attained stable IOL fixation and a clear visual axis. In one eye, the IOL decentered downward. Patients with bilateral cataracts had greater visual improvement than those with a cataract in one eye only. No patient could manage spectacles postoperatively. Our findings show the benefits of posterior capsulectomy and anterior vitrectomy done in the early postoperative period and that IOL implantation in infants is a reasonable treatment in some parts of the world.

Contrast sensitivity and glare disability after implantation of AcrySof IQ Natural aspherical intraocular lens: Prospective randomized masked clinical trial

PURPOSE: To evaluate contrast sensitivity and glare disability after implantation of an AcrySof IQ Natural SN60WF aspherical intraocular lens (IOL) (Alcon Laboratories). SETTING: Iladevi Cataract & IOL Research Centre, Ahmedabad, India. METHODS: One hundred twenty consecutive patients who had phacoemulsification in a prospective triple‐masked trial were randomized to receive an AcrySof SA60AT IOL (40 eyes), AcrySof Natural SN60AT IOL (40 eyes), or AcrySof IQ SN60WF IOL (40 eyes). At 3 months, contrast sensitivity was measured using the CSV‐1000E contrast sensitivity chart test face (Vector Vision) at 3, 6, 12, and 18 cycles per degrees (cpd) under photopic conditions (85 cd/m2) and mesopic conditions (2.7 cd/m2) with 4.0 mm and 6.0 mm fixed central apertures, with and without glare. The Kruskal‐Wallis test was used and a pair‐wise comparison performed. The main outcome measure was the difference in contrast sensitivity between IOLs at each spatial frequency. RESULTS: The best corrected visual acuity was similar between the 3 IOL groups (P = .6). The AcrySof IQ group had significantly higher contrast sensitivity at 18 cpd under photopic conditions (P = .008); at 3, 6, 12, and 18 cpd during mesopic testing with a 4.0 mm aperture without glare (P = .018, P = .011, P = .007, and P = .0001, respectively) and with glare (P = .003, P = .006, P = .005, and P = .004, respectively); and at all spatial frequencies during mesopic testing with a 6.0 mm aperture without glare (P = .018, P = .006, P = .009, and P = .0001, respectively) and with glare (P = .019, P = .002, P = .01, and P = .017, respectively). CONCLUSION: Eyes with the AcrySof IQ SN60WF IOL had significantly higher contrast sensitivity than eyes with an AcrySof SA60AT or AcrySof Natural SN60AT IOL at all spatial frequencies during mesopic testing (with and without glare) with 4.0 and 6.0 mm artificial pupil.

Phacoemulsification in eyeswith posterior polar cataract

PURPOSE To evaluate the results of phacoemulsification in eyes with posterior polar developmental cataract and to appraise the strategy for surgical management. SETTING Iladevi Cataract & IOL Research Centre, Raghudeep Eye Clinic, Ahmedabad, India. METHOD This prospective study comprised 25 consecutive patients. All surgeries were performed by 1 surgeon. Endophacoemulsification was carried out after hydrodelineation. Hydrodissection or rotation was not attempted. A 2-port vitrectomy was performed when necessary. RESULTS Mean follow-up was 13.72 months (range 7 to 22 months). Nine patients (36%) developed posterior capsule rupture and 8 (32%) revealed plaques. An intraocular lens (IOL) was implanted in all 25 eyes. In 8 of 9 cases with rupture, the haptics were placed in the sulcus; in 1 case, the IOL was placed in the bag. One patient in the capsular rupture group developed macular edema 3 weeks postoperatively that responded to conservative treatment. Among 25 patients, 18 had a visual acuity of 20/20 to 20/30 and 6, 20/80 to 20/120. These 6 patients had residual posterior capsule plaque. All except 2 patients with plaque required a neodymium:YAG capsulotomy. In these patients, visual acuity improved to 20/30. In 1 patient, with microcornea, acuity did not improve to beyond 20/120. CONCLUSION This study confirms the predisposition to posterior capsule rupture in eyes with posterior polar cataracts. Careful surgical planning produces satisfactory technical and visual outcomes.

Necessity of vitrectomy when optic capture is performed in children older than 5 years.

Purpose: To determine whether anterior vitrectomy is necessary when optic capture is performed in children between 5 and 12 years old with congenital cataract. Setting: Iladevi Cataract and IOL Research Center, Ahmedabad, India. Methods: This prospective randomized controlled study comprised 41 eyes of 25 children whose mean age was 83.57 months (range 60 to 144 months). Intraocular lens (IOL) implantation with optic capture through a primary posterior continuous curvilinear capsulorhexis was performed in all the eyes. The IOL haptics were bag fixated. Patients were randomly assigned to 1 of 2 groups. Vitrectomy was performed in 1 group (n = 21 eyes) and not performed in the other group (n = 20 eyes). The mean follow‐up was 21.04 months. A Student t test and chi‐square test were used for statistical analysis. Results: All eyes in the vitrectomy group and 30% in the no‐vitrectomy group had a clear visual axis at the last follow‐up (P < .001) The visual axis was obscured as a result of anterior vitreous fibrosis in 70% of eyes in the no‐vitrectomy group. High‐contrast visual acuity was not significantly different between groups (P = .28). Low‐contrast sensitivity was significantly better in the vitrectomy group (P = .02). Eighteen eyes (85.7%) in the vitrectomy group and 16 eyes (80%) in the no‐vitrectomy group developed deposits on the IOL (P = .62). The deposits were present at the last follow‐up in 4 eyes (19.0%) in the vitrectomy group and in 6 eyes (30.0%) in the no‐vitrectomy group (P = .85). Three eyes (14.3%) in the vitrectomy group and 8 eyes (40.0%) in the no‐vitrectomy group developed synechias (P = .06). Conclusion: The results suggest that anterior vitrectomy is necessary with optic capture in children with congenital cataract who are between 5 and 12 years old.

Step-by-step chop in situ and separation of very dense cataracts

Abstract A technique is described that combines the principles of chop in situ and cracking for division of leathery, hard cataracts. After a space (trench or crater) is created in the center, the phaco probe is buried at 6 o’clock to produce a vacuum seal, resulting in an effective hold on the nucleus. The chopper is placed close to the phaco probe, which remains steady throughout. The vertical element of the chopper is depressed posteriorly to produce an initial crack. The chopper is repositioned in the depths of the crack and pushed laterally for complete separation. The complete division of the bottom plate is accomplished in step‐by‐step fashion by repeated lateral movements of the chopper at different sites along the length of the trench/crater, while the phaco probe continues to hold the nucleus at 6 o’clock. This stepwise division eliminates stress on the capsular bag. Similar maneuvers are repeated to create multiple small lens fragments.

Antibiotic prophylaxis of postoperative endophthalmitis after cataract surgery: Results of the 2014 ASCRS member survey

&NA; A 2014 online survey of the American Society of Cataract and Refractive Surgery members indicated increasing use of intracameral antibiotic injection prophylaxis compared with a comparable survey from 2007. Forty‐seven percent of respondents already used or planned to adopt this measure. One half of all surgeons not using intracameral prophylaxis expressed concern about the risks of noncommercially prepared antibiotic preparations. Overall, the large majority (75%) said they believe it is important to have a commercially available antibiotic approved for intracameral injection. Assuming reasonable cost, the survey indicates that commercial availability of Aprokam (cefuroxime) would increase the overall percentage of surgeons using intracameral antibiotic injection prophylaxis to nearly 84%. Although the majority used topical perioperative antibiotic prophylaxis, and gatifloxacin and moxifloxacin were still the most popular agents, there was a trend toward declining use of fourth‐generation fluoroquinolones (60%, down from 81% in 2007) and greater use of topical ofloxacin and ciprofloxacin (21%, up from 9% in 2007).

Rotational stability of a toric intraocular lens: influence of axial length and alignment in the capsular bag.

PURPOSE: To evaluate the rotational stability of a toric intraocular lens (IOL) using purpose‐designed software and to determine the influence of axial length (AL) and in‐the‐bag IOL alignment on IOL rotation. SETTING: Iladevi Cataract & IOL Research Centre, Ahmedabad, India. DESIGN: Prospective observational case series. METHODS: This study enrolled eyes that had AcrySof toric IOL implantation. The AL was measured using optical coherence biometry or immersion A‐scan biometry. Corneal astigmatism was determined by manual keratometry and topography. The IOL alignment was vertical, horizontal, or oblique. Rotational stability was measured using the purpose‐designed software, and the mean absolute difference was determined. The effect of AL and IOL alignment on rotational stability was determined 6 months postoperatively. RESULTS: The study evaluated 168 eyes (168 patients). The mean AL was 23.86 mm ± 1.63 (SD), (range 19.50 to 29.03 mm). The median IOL rotation was 0.3 degree from baseline to 1 week, 1.0 degree from 1 week to 1 month, 0.2 degree from 1 to 3 months, and 0.1 degree from 3 to 6 months. The maximum rotation occurred between 1 week and 1 month. There was a strong correlation between AL and IOL rotation at 6 months (r = 0.93, P<.001). The mean absolute difference at 6 months was not significantly different between the 3 axis placement categories when correlated with the rotation (P=.102, analysis of variance). CONCLUSIONS: Toric IOL rotation was greater in eyes with a longer AL. Alignment of the IOL in the capsular bag had no influence on rotation. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Visual axis opacification after AcrySof intraocular lens implantation in children

Purpose: To evaluate visual axis opacification after AcrySof® intraocular lens (IOL) (Alcon) implantation in pediatric eyes. Setting: Iladevi Cataract and IOL Research Centre, Ahmedabad, India. Methods: This prospective study evaluated 103 consecutive eyes of 72 children with congenital cataract. Two groups were formed based on age at surgery: Group 1, younger than 2 years, and Group 2, older than 2 years. All eyes in Group 1 (n = 37) had primary posterior continuous curvilinear capsulorhexis (PCCC) with anterior vitrectomy. In Group 2 (n = 66), management of the posterior capsule was assigned randomly to no PCCC (Group 2A, n = 37) or PCCC (Group 2B, n = 29). The PCCC group was further randomized into 2 subgroups: no vitrectomy (Group 2BN, n = 14) or vitrectomy (Group 2BV, n = 15). The primary outcome measures were visual axis opacification and the resulting need for a secondary procedure. Statistical analysis was performed using SPSS for Windows (version 11.0.1). Results: The mean age of the patients was 5.2 years ± 5.0 (SD) (range 0.2 to 16.0 years) and the mean follow‐up, 2.3 ± 0.9 years (range 1.0 to 4.0 years). Overall, 41 eyes (39.8%) developed visual axis opacification and 14 (13.6%) required secondary intervention. In Group 1, 4 eyes (10.8%) developed visual axis opacification and 3 (8.1%) had a secondary pars plana vitrectomy. In Group 2A, 31 eyes (83.8%) developed posterior capsule opacification (PCO) and 10 eyes (27.7%) had secondary intervention. Children 8 years or younger at the time of surgery developed significantly greater PCO than older children (P = .01). Five eyes (37.5%) in Group 2BN had opacification of the anterior vitreous face, 1 of which required a secondary procedure. One eye (6.7%) in Group 2BV had visual axis opacification that did not require a secondary procedure. Conclusions: AcrySof IOL implantation with appropriate management of the posterior capsule maintained a clear visual axis in 60.2% of eyes. Of the 39.8% of eyes with visual axis opacification, 13.6% had visually significant opacification and required a secondary procedure.

Role of optic capture in congenital cataract and intraocular lens surgery in children

Purpose: To evaluate the role of optic capture in eyes having cataract extraction, anterior vitrectomy, and intraocular lens (IOL) implantation for congenital cataract. Setting: Iladevi Cataract & IOL Research Centre, Ahmedabad, India. Methods: This prospective study comprised 40 eyes of 28 children, whose mean age was 26.08 months (range 4 to 55 months). Primary posterior continuous curvilinear capsulorhexis, anterior vitrectomy, and IOL implantation were performed in all eyes. Eyes were randomly assigned to 1 of 2 groups of 20 each: in 1 group, optic capture would be used and in the other, the noncapture technique. Permanent optic capture was achieved in 14 eyes, and 26 eyes had no optic capture. Mean follow‐up was 16.53 months (range 5 to 24 months). A Student t test and chi‐square test were used for statistical analyses. Results: All eyes in both groups maintained a clear visual axis. One eye in the optic‐capture group developed a membrane in front of the IOL that required a secondary procedure. Posterior synechia formation was significantly greater in the optic‐capture group (P = .04), as were deposits on the IOL optic (P = .0086). Although all eyes in both groups maintained a clinically centered IOL, geometric decentration was more common in the no‐capture group (P = .0000). Conclusion: Optic capture resulted in better IOL centration but predisposed the eye to an increased uveal inflammatory response.