Jan Van Looveren

Posterior capsule management in congenital cataract surgery.

&NA; Management of the posterior capsule significantly affects the outcome of pediatric cataract surgery. Posterior capsule opacification (PCO) is rapid and virtually inevitable in very young children when adult‐style cataract surgery is performed and the posterior capsule is left intact. In eyes with pediatric cataract, primary posterior capsulotomy and vitrectomy are considered routine surgical steps, especially in younger children. The site of intraocular lens (IOL) fixation and the surgical technique used also affect the prevalence of PCO. The present systematic review evaluates the options available to prevent PCO or ensure a clear central visual axis after pediatric cataract surgery. Newer approaches to posterior capsule management such as pars plicata posterior capsulorhexis, sutureless vitrectomy, sealed‐capsule irrigation, and bag‐in‐the‐lens IOL are discussed. Management of the posterior capsule in the presence of a preexisting posterior capsule defect and posterior capsule plaque and options to treat PCO are also reviewed. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Clinical outcomes of cataract surgery after bag-in-the-lens intraocular lens implantation following ISO standard 11979-7:2006

PURPOSE: To assess the clinical outcomes of bag‐in‐the‐lens intraocular lens (BIL IOL) implantation following the International Organization for Standardization (ISO) 11979‐7:2006 in pediatric eyes and eyes with ocular comorbidities. SETTING: Antwerp University Hospital, Department of Ophthalmology, Antwerp, Belgium. DESIGN: Cohort study. METHODS: This cohort included the first series of patients having IOL implantation using the bag‐in‐the‐lens technique. Surgeries were performed between December 1999 and September 2006. In addition to IOL implantation, the technique comprised creation of a primary posterior continuous curvilinear capsulorhexis (PCCC) equal in size to the anterior capsulorhexis. RESULTS: The study enrolled 807 eyes of 547 patients; 326 of the eyes (40.40%) had ocular comorbidity. In the 481 eyes without ocular comorbidity, the mean decimal corrected distance visual acuity was 0.52 ± 0.24 (SD) (0.276 ± 0.206 logMAR) preoperatively and 0.94 ± 0.18 (−0.012 ± 0.053 logMAR) postoperatively. The mean postoperative achieved spherical equivalent was 0.48 ± 0.83 diopter (D) and the mean targeted refraction, −0.24 ± 0.71 D. The A‐constant was modified from 118.4 to 118.04. Posterior capsule opacification (PCO) did not occur in any adult eye during the follow‐up. Retinal detachment after IOL implantation occurred in 10 eyes (1.24%). In 19 eyes, the iris was captured by the IOL haptics postoperatively. Hypopyon occurred in 3 patients and toxic anterior segment syndrome in 1 patient. CONCLUSION: The BIL IOL met the ISO criteria; that is, primary PCCC was safe in healthy eyes and in eyes with ocular comorbidities and no eye developed PCO over a mean follow‐up of 26.1 ± 21.3 months. Financial Disclosure: Drs. Gobin, Mathysen, Van Looveren, and De Groot have no financial or proprietary interest in any material or method mentioned. Additional disclosure is found in the footnotes.

Influence of cataract morphology on straylight and contrast sensitivity and its relevance to fitness to drive.

Aims: To evaluate straylight and contrast sensitivity in cataractous eyes of different morphologies, and to determine which type of cataract presents higher impairment of visual function, specifically compared to studies proposing new norms for European drivers. Methods: Best-corrected visual acuity (BCVA), contrast sensitivity and straylight were measured in 97 cataractous eyes using respectively a Snellen chart, a Pelli-Robson chart and the compensation comparison method (C-Quant Straylight Meter). Cataracts were graded using the Lens Opacities Classification System III (LOCS III) and divided into 4 groups: nuclear, cortical, nuclear-cortical and posterior subcapsular cataract. These results were compared to data from 38 cataract-free control subjects. Results: Contrast sensitivity was reduced and straylight increased in all cataract patients, most notably in posterior subcapsular and nuclear-cortical cataract. Contrast sensitivity and BCVA were correlated (r = 0.44), whereas straylight and BCVA were not. Applying cut-off values as proposed by European drivers studies of 1.25 log contrast sensitivity and 1.4 log straylight as safe margins for driving, 31% would be considered unfit to drive on the basis of contrast sensitivity and 78% on the basis of straylight, although their visual acuity was still above the current European visual acuity requirement for driving. Conclusions: Straylight and, to a lesser extent, contrast sensitivity are complementary to BCVA and should be taken into account when considering surgery or driving legality.

Pediatric bag-in-the-lens intraocular lens implantation: Long-term follow-up

Purpose To evaluate long‐term follow‐up results of pediatric cataract surgery using the bag‐in‐the‐lens (BIL) intraocular lens (IOL) implantation technique. Setting Antwerp University Hospital, Edegem, Antwerp, Belgium. Design Prospective case series. Methods All pediatric cataract surgeries with BIL IOL implantation performed at the Antwerp University Hospital were evaluated. Only cases that completed a follow‐up of 5 years at the hospital’s Department of Ophthalmology were included in this study. Results Forty‐six eyes of 31 children had a complete follow‐up of 5 years or more after BIL IOL implantation. Sixteen cases were unilateral and 15 were bilateral. Patient age at time of surgery ranged from 2 months to 14 years. The mean refraction at the end of follow‐up was −1.99 diopters (D) ± 3.70 (SD). In bilateral cases, a corrected distance visual acuity (CDVA) of better than 0.5 was attained in 86.7% and a CDVA of 1.0 was achieved in 56.7%. In unilateral cases, 31.2% achieved a CDVA of better than 0.5 but none obtained a CDVA of 1.0. A clear visual axis was maintained in 91.3% of cases during follow‐up. Visual axis reopacification was detected in 4 eyes of 3 cases, all due to inadequate BIL IOL positioning. None of these eyes needed more than 1 intervention to maintain visual axis clarity. Other than 1 case of glaucoma, no severe complications were detected. Conclusion Long‐term follow‐up results show that BIL IOL implantation is a safe, well‐tolerated approach for treating pediatric cataract with a very low rate of visual axis reopacification and a low rate of secondary interventions for other postoperative complications. Financial Disclosure Dr. Tassignon has intellectual property rights to the bag‐in‐the‐lens intraocular lens (U.S. patent 6 027 531; EU patent 009406794.PCT/120268), which is licensed to Morcher GmbH, Stuttgart, Germany. No other author has a financial or proprietary interest in any material or method mentioned.

Clinical results after spherotoric intraocular lens implantation using the bag-in-the-lens technique

PURPOSE: To evaluate the clinical results after implantation of a spherotoric intraocular lens (IOL) using the bag‐in‐the‐lens (BIL) technique. SETTING: Antwerp University Hospital, Department of Ophthalmology, Antwerp, Belgium. DESIGN: Evidence‐based manuscript. METHODS: Consecutive eyes with cataract and corneal astigmatism had implantation of a spherotoric BIL intraocular lens (IOL). The IOL was centered based on the patient’s pupillary entrance using Purkinje reflexes of the surgical microscope light. RESULTS: The study enrolled 52 eyes of 35 patients (23 women) with corneal astigmatism ranging from 0.90 to 6.19 diopters (D). The toric power was between 1.00 D and 8.00 D. One‐third of eyes had an additional ocular comorbidity (including amblyopia) that could influence the clinical outcomes; 5.2% had an irregular astigmatism up to 15 degrees. Twelve eyes had high myopia (axial length [AL] >26 mm) and 5 eyes, high hyperopia (AL <21 mm). The mean preoperative corrected distance visual acuity was 0.58 ± 0.25 (SD). Postoperatively, the uncorrected distance visual acuity (UDVA) was 0.5 or better in 92% of eyes, the mean UDVA was 0.85 ± 0.21 D, the mean magnitude of error was 0.05 ± 0.49 D, and the mean angle of error was 0.29 ± 0.89 degree. Astigmatism correction was successful in 82% of eyes. CONCLUSION: Spherotoric BIL IOL implantation yielded outcomes similar to those with other spherotoric IOLs, even in eyes with ocular comorbidity or irregular astigmatism up to 15 degrees. Financial Disclosure: Drs. Gobin and Van Looveren and Mr. Mathysen have no financial or proprietary interest in any material or method mentioned. Additional disclosure is found in the footnotes.

Incidence of rhegmatogenous retinal detachment after bag-in-the-lens intraocular lens implantation.

Purpose To determine the incidence of rhegmatogenous retinal detachment (RRD) and associated risk factors after phacoemulsification and bag‐in‐the‐lens intraocular lens (IOL) implantation. Setting Antwerp University Hospital, Department of Ophthalmology, Antwerp, Belgium. Design Prospective cohort study. Methods All consecutive bag‐in‐the‐lens IOL implantations performed between January 2001 and December 2007 were included, with the exception of combined procedures and IOL exchanges. The retinal detachment (RD) incidence was studied in the total cohort, in a subgroup of patients with 1 to 5 years of follow‐up, and finally in the group remaining after exclusion of all risk factors except gender. Results RD after bag‐in‐the‐lens IOL implantation in 1323 eyes with an average follow‐up of 44.75 months (range 0 to 152 months) was found in 19 eyes (1.44%). The 1‐year RD incidence was 0.49% (5 RD cases in 1024 eyes) (0.00% in patients without risk factors). The 2‐year cumulative RD incidence was 0.84% (9 RD cases in 931 eyes; 0.15% without risk factors). Four clinically significant risk factors were confirmed: male gender, young age at time of surgery (<60 years), axial myopia (axial length ≥25 mm), and history of contralateral RD in the total cohort. Conclusion The RRD incidence following bag‐in‐the‐lens IOL implantation was comparable to that seen after lens‐in‐the‐bag (LIB) implantation. The wide variation in study design in the literature precludes direct comparison, so there is a need for standardization in evaluating RRD incidence after cataract surgery. Future prospective studies should consider patients with and without risk factors (except gender) separately. Financial Disclosure Prof. dr. M.J. Tassignon has intellectual property rights to the bag‐in‐the‐lens intraocular lens (U.S. patent 6 027 531; EU patent 009406794; PCT/120268), which is licensed to Morcher GmbH, Stuttgart, Germany.

Immunohistochemical characteristics of the vitreolenticular interface in congenital unilateral posterior cataract.

Purpose To gain insight into the histology of the vitreolenticular interface in congenital unilateral posterior cataract. Setting Antwerp University Hospital, Department of Ophthalmology, Edegem, and the University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium. Design Prospective case study. Methods Samples of the posterior lens capsule of patients with congenital posterior cataract (including opaque plaque on the anterior and adhesion to the vitreous on the posterior surface) were collected during the posterior capsulorhexis procedure. Staining for collagen types II and IV was performed using indirect immunohistochemistry. Results were compared with those of control posterior lens capsules of 3 children and 3 adults. Results Samples were collected from 3 patients. All posterior lens capsules contained collagen type IV. Samples from congenital posterior cataract patients all showed a narrow band of collagen type II on the outer surface, indicating strong adherence of the anterior hyaloid membrane to the center of the posterior lens capsule. Surprisingly, collagen type II was also found in the posterior capsule plaques. Collagen type II was not found in any control posterior lens capsule. Conclusion The adherence of collagen type II to the center of the posterior lens capsule histologically supports the hypothesis that this subgroup of congenital cataract hints at an abnormality at the vitreolenticular interface. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

Influence of the vitreolenticular interface in pediatric cataract surgery

PURPOSE To report the status of Berger space in pediatric cataract cases and the influence of anterior vitreolenticular interface dysgenesis during primary posterior continuous curvilinear capsulorhexis (PCCC). SETTING Department of Ophthalmology, Antwerp University Hospital, Edegem, Belgium. DESIGN Prospective case series. METHODS The study comprised consecutive pediatric cataract cases planned for bag-in-the-lens intraocular lens (BIL IOL) implantation. A video-based analysis of the surgical interventions included the type of crystalline lens opacification, presence of a posterior capsule plaque (PCP), presence of anterior vitreolenticular interface dysgenesis, complications during primary PCCC, integrity of the anterior hyaloid membrane, need for anterior vitrectomy, and feasibility of BIL IOL implantation. RESULTS Abnormalities in Berger space were observed in 35 of the 64 pediatric cataract cases. Anterior vitreolenticular interface dysgenesis was most often found in cases with persistent fetal vasculature (PFV) and those with posterior cataract. Anterior vitreolenticular interface dysgenesis was diagnosed significantly more often in eyes with unilateral cataract and those with PCP. In pediatric cataract cases presenting with PCP and anterior vitreolenticular interface dysgenesis, the primary PCCC procedure was surgically more demanding, often resulting in detectable breaks in the anterior hyaloid membrane (58.6%) and sometimes necessitating an unplanned anterior vitrectomy (13.8%). Bag-in-the-lens IOL implantation was feasible in all except 1 eye with PFV, which was left aphakic. CONCLUSIONS Primary vitreolenticular interface abnormalities are often encountered during pediatric cataract surgeries, especially when confronted with PCP in a unilateral cataract. The presence of anterior vitreolenticular interface dysgenesis may complicate a primary PCCC procedure, resulting in an unplanned anterior vitrectomy in some cases.

Proteomic analysis of posterior capsular plaques in congenital unilateral cataract

To obtain insights on the protein composition of posterior capsular plaques (PCP) in congenital unilateral cataract with anterior vitreolenticular interface dysgenesis (AVLID).