Junsuke Akura

Effect of round-edged acrylic intraocular lenses on preventing posterior capsule opacification

Purpose: To clarify the extent to which the adhesiveness of an acrylic material influences the formation of posterior capsule opacification (PCO). Setting: Jinshikai Medical Foundation, Nishi Eye Hospital, Osaka, Japan. Methods: Two types of AcrySof® intraocular lenses (IOLs) were prepared: round edged and tumbled. The AcrySof with round edges was implanted in 1 eye in a group of 4 rabbits and the tumbled IOL, in 1 eye in a group of 5 rabbits. In both groups, the contralateral eye received a conventional AcrySof with sharp optic edges. A histopathological examination was performed 3 weeks after surgery. Results: With the round‐edged AcrySof IOL, no capsular bend formed at the optic edge and abundant lens epithelial cells (LECs) migrated posteriorly. With the sharp‐edged AcrySof lens, a sharp capsular bend formed and LEC migration was significantly inhibited. In eyes with a tumbled IOL, a capsular bend was created, but it was less marked than that created by the sharp‐edged lens and there was slightly more LEC migration posteriorly. Conclusions: The AcrySof IOL lost its preventive effect on PCO when the optic was rounded. The effect of the AcrySof lens in preventing PCO is mainly a result of its rectangular, sharp‐edged optic design. The acrylic material may play a complementary role by helping create a sharp capsular bend. Capsular bend formation is the key to the PCO preventive effect of an IOL.

Treatment of retinal detachment resulting from myopic macular hole with internal limiting membrane removal

PURPOSE To examine the efficacy of vitrectomy with internal limiting membrane removal for retinal detachment resulting from a macular hole in highly myopic eyes. METHODS Eleven consecutive highly myopic eyes (11 patients) with retinal detachment resulting from a macular hole were treated by vitrectomy with removal of the internal limiting membrane, which was stained with indocyanine green and sulfur hexafluoride gas injection. Postoperatively, the patients were instructed to remain prone for 2 weeks. The excised specimens were evaluated with transmission electron microscopy. RESULTS The mean postoperative follow-up was 9.2 +/- 2.3 months (range, 7 to 13 months). In 10 of the 11 eyes (91%) the retina was reattached during the initial surgery. Redetachment occurred in one eye, which was successfully treated during the second surgery. Best-corrected visual acuity improved in all eyes and ranged from 20/400 to 20/50. Pathologic examination showed that the internal limiting membrane and epiretinal tissues were present in all specimens. CONCLUSIONS The use of indocyanine green staining can facilitate removal of a macular internal limiting membrane and overlying epiretinal membrane, resulting in complete relief of the macular traction. Primary removal of the internal limiting membrane may contribute to a high initial success rate for retinal reattachment and be an important adjuvant to the treatment of retinal detachment resulting from a macular hole in highly myopic eyes.

Speed of capsular bend formation at the optic edge of acrylic, silicone, and poly(methyl methacrylate) lenses

Purpose: To evaluate how and how fast a capsular bend is created clinically at the optic edge of an intraocular lens (IOL) after cataract surgery. Setting: Jinshikai Medical Foundation, Nishi Eye Hospital, Osaka, Japan. Methods: Capsular bend formation was observed by slitlamp after maximum pupil dilation in 45 eyes of 45 patients with senile cataract. Fifteen eyes each received an AcrySof® MA60BM acrylic (Alcon), PhacoFlex II® SI‐40NB silicone (Allergan), or UV26T poly(methyl methacrylate) (PMMA) (Menicon) IOL. Patients were evaluated prospectively at 1 day and 1, 2, and 4 weeks and retrospectively (15 eyes per IOL) 1 year after cataract surgery. A capsular bend index was developed to document and categorize the capsular bend formation process at the IOL optic edge. Results: The anterior and posterior capsules adhered, with the latter attracted to the former. The adhesion always progressed from the periphery to the optic edge so that the posterior capsule eventually wrapped around the posterior optic edge, although not fully circumferentially in all cases. The process took place in 4 stages. Capsular bend formation was complete 1 month after surgery with the foldable IOLs (AcrySof, PhacoFlex II) but was significantly delayed with the PMMA IOL. After 1 year, the capsular wrapping was firm and fully circumferential at the optic edge with all IOL types in all cases. Conclusions: Capsular bend formation progressed in the same fashion but at significantly different speeds among the IOLs, suggesting that the process depends on IOL material and design. Fast, early capsular bend formation may be 1 reason AcrySof and PhacoFlex II IOLs prevent PCO statistically better than PMMA IOLs. The results indicate that PCO is prevented by the sharp capsular bend created by sharp optic edges and by quick bend formation.

Capsular bending ring to prevent posterior capsule opacification: 2 year follow-up

Purpose: To evaluate the preventive effect of a capsular bending ring on anterior and posterior capsule (PCO) opacification in a 2 year clinical study. Setting: Jinshikai Medical Foundation, Nishi Eye Hospital, Osaka, Japan. Methods: This study comprised 60 patients with senile cataract (35 women, 25 men) with a mean age of 69 years. An open poly(methyl methacrylate) capsular bending ring with a truncated edge profile designed to create a sharp bend in the equatorial capsule was implanted in 1 eye of patients with a hydroxyethyl methacrylate intraocular lens (IOL). The contralateral eye, which acted as a control, received an IOL but no ring. Patients were examined 6 months (n = 52), 1 year (n = 48), and 2 years (n = 42) postoperatively. Anterior capsule opacification was determined by slitlamp evaluation. Anterior capsule shrinkage (area within the capsulorhexis) and PCO were evaluated and scored using a computer software package for image analysis. Posterior capsule opacification was also measured by the rate of neodymium:YAG (Nd:YAG) capsulotomies. Results: Anterior capsule opacification and shrinkage were significantly less in eyes with the ring. The mean PCO score was 0.235 ± 0.215 (SD), 0.287 ± 0.200, and 0.398 ± 0.248 with the ring and 0.530 ± 0.190, 0.670 ± 0.225, and 1.111 ± 0.298 without the ring at 6 months, 1 year, and 2 years, respectively (P < .01 at each follow‐up). An Nd:YAG laser capsulotomy was performed in 4 eyes with and 17 eyes without the ring after 2 years (P < .01). Conclusions: The capsular bending ring significantly reduced anterior capsule fibrosis and shrinkage as well as PCO. The ring may be useful in patients who are at high risk of developing eye complications from capsule opacification that require Nd:YAG laser capsulotomy, in those expected to have vitreoretinal surgery and photocoagulation, and in cases of pediatric cataract.

Adjusting intraocular lens power for sulcus fixation

Purpose: To determine the appropriate correction of predicted intraocular lens (IOL) power for sulcus fixation and to prospectively assess the validity of the obtained correction value in patients having sulcus fixation. Setting: Department of Ophthalmology, Saiseikai Kurihashi Hospital, Saitama, Japan. Methods: The postoperative refraction, virtual in‐the‐bag IOL power for the same postoperative refraction, predicted refraction with an increase in in‐the‐bag IOL power by 0.50 to 2.00 diopters (D), and effective lens position (ELP) in 30 eyes with a normal axial length after sulcus fixation were retrospectively evaluated. The results were confirmed prospectively in 16 other eyes requiring sulcus fixation. Results: A significant myopic shift (mean 0.78 D ± 0.47 [SD]) from the predicted refraction occurred after sulcus fixation (P<.0001). The mean virtual IOL power was 1.11 ± 0.67 D higher than that of the actual sulcus‐fixated IOL. The difference between the predicted refraction and the refraction after sulcus fixation was less when the difference in IOL power was 1.00 D. The ELP of the IOLs was 0.75 mm shorter using A‐mode measurement and 0.62 mm shorter using back calculation from the theoretical formula with sulcus fixation than with in‐the‐bag fixation. In the prospective study, there was a small refractive error (mean −0.06 ± 0.19 D) when the planned IOL power was reduced by 1.00 D for sulcus fixation. Conclusion: For sulcus fixation in eyes with a normal axial length, the IOL power should be 1.00 D less than the power for in‐the‐bag fixation.

Efficacy and safety of prophylactic intracameral moxifloxacin injection in Japan

Purpose To report endophthalmitis rates after cataract surgery and the incidence of complications after intracameral moxifloxacin injection. Setting Nineteen clinics in Japanese institutions. Design Retrospective survey cohort study. Methods The number of surgeries and endophthalmitis cases in the past 4 years before and after the introduction of intracameral moxifloxacin was evaluated. The survey was performed by mail or interview in February 2013. Results All institutions used total‐replacement administration rather than small‐volume injection. At 3 institutions, 50 to 100 &mgr;g/mL moxifloxacin; at 9 institutions, 100 to 300 &mgr;g/mL moxifloxacin; and at 7 institutions, 500 &mgr;g/mL moxifloxacin was administered. The highest concentration (500 &mgr;g/mL) was administered in 14 124 cases. Endophthalmitis cases occurred 1 month or sooner postoperatively in 8 of 15 958 cases (ie, 1 in 1955) without intracameral moxifloxacin administration and in 3 of 18 794 cases (ie, 1 in 6265) with intracameral moxifloxacin administration. Conclusions Intracameral moxifloxacin (50 to 500 &mgr;g/mL) administration decreased the risk for endophthalmitis by 3‐fold. In more than 18 000 cases, moxifloxacin administration of 500 &mgr;g/mL or less did not result in severe complications, such as toxic anterior segment syndrome or corneal endothelial cell loss. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Analysis of liquid accumulated in the distended capsular bag in early postoperative capsular block syndrome

PURPOSE To analyze the transparent liquid between the posterior lens capsule and the posterior chamber intraocular lens (PC IOL) in early postoperative capsular block syndrome and discuss the mechanism of posterior capsule distention. SETTING Department of Ophthalmology, Tokyo University School of Medicine, and Tokyo Research Institute, Seikagaku Corporation, Tokyo, Japan. METHODS This study evaluated 3 cases of capsular block syndrome presenting with transparent liquid in the distended capsular bag 1 day after cataract surgery. The transparent liquid material between the posterior capsule and PC IOL was aspirated and analyzed using high-performance liquid chromatography (HPLC). Also, sodium hyaluronate was diluted using a dialyzer to determine whether the aqueous humor was drawn into the capsular bag by an osmotic gradient across the capsule. RESULTS The elution time of the samples was almost the same as that of sodium hyaluronate 1.0% (Healon) The concentration of the samples ranged from 3.29 to 9. 01 mg/mL by HPLC analysis. The sodium hyaluronate absorbed the physiological salt solutions through the dialyzer and expanded to 1. 9 times its original volume. CONCLUSIONS These results indicate that the main ingredient of the transparent liquid in capsular bags is sodium hyaluronate and that the distention is caused by aqueous humor being drawn into the capsular bag by an osmotic gradient across the capsule when the capsulorhexis diameter is smaller than that of the PC IOL and by viscoelastic material retained and trapped in the bag intraoperatively.

Iris neovascularization after vitrectomy combined with phacoemulsification and intraocular lens implantation for proliferative diabetic retinopathy.

PURPOSE To analyze the incidence of iris neovascularization after vitrectomy combined with phacoemulsification and intraocular lens (IOL) implantation using a small incision in the treatment of proliferative diabetic retinopathy (PDR). PATIENTS AND METHODS We studied a consecutive series of 46 eyes in which vitrectomy combined with phacoemulsification and IOL implantation had been performed, and compared the surgical results with a prior series of 40 eyes in which vitrectomy alone had been performed. RESULTS Postoperative iris and angle neovascularization was found in 6 eyes (15%) treated by vitrectomy alone, but in only 1 eye (2%) treated by combined vitrectomy (P<0.05). Final visual acuity improved by two or more lines in 23 eyes (57%) in the vitrectomy alone group, and in 35 eyes (76%) in the combined vitrectomy group. CONCLUSIONS The incidence of postoperative rubeosis iridis was significantly lower, and the visual results were satisfactory with vitrectomy combined with phacoemulsification and IOL implantation for PDR. These findings suggest that combined vitrectomy for PDR is a useful surgical procedure.

Measures for preventing recurrence after pterygium surgery.

Purpose. To introduce an improved technique of pterygium surgery and to compare postoperative results between this technique and previous techniques. Methods. In a retrospective survey, the records of 216 consecutive eyes with primary pterygium that underwent surgery by three different techniques were reviewed. The new technique (mini-flap technique) involves making a small excision of the pterygium body, removing the pterygium head by scraping with forceps, applying mitomycin C (MMC), and performing a small conjunctival transposition flap. The previous technique (large-flap technique II) involved making a large excision in the pterygium body, removing the pterygium head with a knife, applying MMC, and performing a large transposition flap. Large-flap technique I is the same as large-flap technique II except for the use of intraoperative MMC. The recurrence rate of each technique was estimated by the Kaplan–Meier life table analysis. Results. The recurrence rates estimated at 1 year after surgery were 15.5% in large-flap technique I, 4.2% in large-flap technique II, and 0% in the mini-flap technique. Large-flap technique II or the mini-flap technique had significantly lower recurrence rates compared with large-flap technique I (p = 0.02 and p < 0.01, respectively). The mini-flap technique had a significantly lower incidence of conjunctival scarring or granuloma compared with large-flap technique I and large-flap technique II (p = 0.05 and p = 0.03, respectively.) Conclusions. The mini-flap technique was useful for preventing recurrence and was technically easier and induced fewer postoperative complications than large-flap techniques I and II.

Management of posterior capsule rupture during phacoemulsification using the dry technique

&NA; To manage posterior capsule rupture during phacoemulsification, we use a dry technique in which all procedures are performed without an irrigation/aspiration system. The dry technique is characterized by (1) continuous viscoelastic injection instead of fluid irrigation to maintain anterior chamber depth with the posterior capsule and vitreous located posteriorly and (2) static removal of most residual lens material by viscoexpression and/or manual small incision extracapsular cataract extraction without aspiration and dynamic water flow. In 16 cases of posterior capsule rupture managed using the dry technique, the residual nucleus and cortex were readily removed with minimum extension of the ruptured area and new vitreous loss. Although large amounts of viscoelastic material (mean 5.8 mL) were required, rapid and stable visual recovery was comparable to that in patients having uneventful surgery. The dry system is a safe and reliable technique for managing posterior capsule rupture during phacoemulsification.