M. Amon

Intraindividual comparison of surgical trauma after bimanual microincision and conventional small-incision coaxial phacoemulsification

PURPOSE: To compare the surgical trauma after microincision phacoemulsification and small‐incision coaxial phacoemulsification after implantation of conventional, foldable, hydrophobic acrylic intraocular lenses (IOLs). SETTING: Department of Ophthalmology, Medical University of Vienna, Vienna, Austria. METHODS: A prospective investigator‐masked case series comprised patients with bilateral cataract who had cataract surgery on the same day. Thirty‐three patients (66 eyes) were randomized. Microincision cataract surgery (MICS) was performed through 2, 1.4 mm clear corneal incisions (CCIs) using bimanual sleeveless phacoemulsification (cool phaco) in 1 eye. Small‐incision cataract surgery (SICS) was performed on the other eye through a 3.2 mm CCI. In all cases, an AcrySof SA60AT IOL was inserted, in the MICS group after the CCI was enlarged. Laser flare photometry, specular microscopy, corneal endothelial cell density, and pachymetry were evaluated preoperatively and postoperatively. Intraindividual comparison and statistical analyses were performed. RESULTS: There were no relevant clinical differences or perioperative complications in either group. There were no statistically significant differences between preoperative and postoperative anterior chamber flare or endothelial cell loss. On the first postoperative day, the MICS group had statistically significantly increased corneal swelling (P = .008). Postoperatively, the mean endothelial cell density loss was higher in the MICS group (6.2%) than in the SICS group (3.10%); however, the difference between groups was not significant (P = .08) CONCLUSIONS: Microincision cataract surgery was a safe and reproducible technique. The postoperative results in the MICS group were comparable to those in the SICS group.

Uveal and capsular biocompatibility after implantation of sharp-edged hydrophilic acrylic, hydrophobic acrylic, and silicone intraocular lenses in eyes with pseudoexfoliation syndrome

PURPOSE: To evaluate the uveal and capsular biocompatibility of 3 types of sharp‐edged foldable intraocular lenses (IOLs) in eyes with pseudoexfoliation syndrome (PEX). SETTING: Department of Ophthalmology, Medical University of Vienna, Vienna, Austria. METHODS: Eighty‐five eyes with PEX had implantation of 1 of the following sharp‐edged 3‐piece IOLs: hydrophilic acrylic (Injectacryl F3000, OphthalMed), hydrophobic acrylic (AcrySof MA60MB, Alcon), or silicone (CeeOn 911, AMO). Postoperative evaluation (flare, cellular reaction, and capsular reaction) was performed at 1, 3, and 7 days as well as 1, 3, 6, and 12 to 18 months. RESULTS: One year after surgery, flare was comparable between the IOLs. In terms of uveal biocompatibility, whereas the Injectacryl had the highest deposition of debris on the IOL surface (P = .04), the CeeOn 911 had significantly more small round cells in the first 6 months (P<.03). The AcrySof had the highest number of foreign‐body giant cells (P = .01). In terms of capsular biocompatibility, lens epithelial cell outgrowth was highest in the AcrySof group (P<.02). Anterior capsule opacification was comparable between the 3 groups. Posterior capsule opacification was mild in all groups but was significantly greater in the Injectacryl group (P<.05). There were no cases of clinically significant IOL decentration or capsule contraction. CONCLUSIONS: In general, inflammatory cells accumulated more easily on hydrophobic IOLs than on hydrophilic IOLs; the AcrySof IOL had the highest prevalence of foreign‐body giant cells. All 3 IOLs had good biocompatibility, although the AcrySof group had increased inflammatory signs.

New supplementary intraocular lens for refractive enhancement in pseudophakic patients

PURPOSE: To assess the efficacy and safety of implanting a secondary intraocular lens (IOL) in the ciliary sulcus to correct pseudophakic ametropia. SETTING: Department of Ophthalmology, Medical University of Vienna, Vienna, Austria. METHODS: This prospective nonrandomized study included patients who had implantation of a secondary IOL (Sulcoflex 653L) to correct residual refractive error after phacoemulsification with IOL implantation in the capsular bag. After implantation of the secondary IOL in the ciliary sulcus, visual and refractive outcomes were evaluated. Inflammation was measured with a laser flare–cell meter. The position and rotation of the IOLs were documented at all control visits, and Scheimpflug images were taken. Postoperative follow‐up was at 1 week and 1, 6, 12, and 17 months. RESULTS: Twelve eyes of 10 patients were evaluated. The mean spherical equivalent decreased from –1.25 diopters (D) ± 0.25 (SD) (range −2.00 to +4.00 D) preoperatively to −0.25 ± 0.40 D (range −0.50 to +0.25 D) postoperatively. Uncorrected distance visual acuity improved in all cases. There were no significant intraoperative or postoperative complications. CONCLUSIONS: Sulcus implantation of the secondary IOL to correct pseudophakic refractive error was safe and predictable. The IOL was well tolerated in all eyes. Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Biocompatibility of hydrophilic acrylic, hydrophobic acrylic, and silicone intraocular lenses in eyes with uveitis having cataract surgery: Long-term follow-up.

PURPOSE: To evaluate the long‐term uveal and capsular biocompatibility of 5 intraocular lenses (IOLs) in eyes with uveitic cataract. SETTING: Department of Ophthalmology, Medical University of Vienna, Vienna, Austria. DESIGN: Comparative case series. METHODS: Patients with uveitis of various origin were consecutively recruited for cataract surgery (1998–2006) and received 1 of 3 hydrophilic acrylic IOLs (Hydroview, AcrySof MA60BM, or Injectacryl F3000), a silicone IOL (CeeOn 911), or a hydrophilic acrylic IOL with heparin surface modification (BioVue3). A 7‐year follow‐up was performed in the Hydroview, AcrySof, and CeeOn groups. Visual acuity, anterior chamber flare measurements, specular microscopy, biomicroscopy, and fundoscopy were performed postoperatively at 6 months and 1, 2, and 3 years. RESULTS: The study enrolled 136 eyes of 115 patients. There were no significant differences in anterior chamber flare results between the 5 groups. The Hydroview group had the highest grade and the CeeOn IOL and AcrySof groups had the lowest grade of posterior capsule opacification. The BioVue3 and Injectacryl IOLs had good uveal biocompatibility. Patients in all groups had better visual acuity postoperatively. CONCLUSIONS: Overall, patients with uveitis benefited from cataract surgery. The long‐term results indicate that all sharp‐edged hydrophilic and hydrophobic IOLs performed well in eyes with uveitis. Higher uveal biocompatibility was achieved with the modern hydrophilic acrylic IOLs than with the hydrophobic acrylic IOL. Modern hydrophilic acrylic IOLs seem to be a good option in these cases. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Lens epithelial cell ongrowth: comparison of 6 types of hydrophilic intraocular lens models.

PURPOSE: To compare the ongrowth of lens epithelial cells (LECs) on the anterior surface of 6 different hydrophilic intraocular lenses (IOLs). SETTING: Medical University of Vienna, Department of Ophthalmology and Optometry, Vienna, Austria. METHODS: Six models of hydrophilic IOLs were compared in this prospective study: Visionflex A‐100 (Distra Softcryl), Rayner Centerflex 570H (Rayner), Collamer CC4204BF‐IOL (Staar), Injectacryl F 3000 (Distra), Hydroview H60M (Bausch & Lomb), and MemoryLens (ORC). Postoperative biomicroscopic examinations were performed 1, 3, 7, 30, 90, 180, and 365 days after surgery. Lens epithelial cells in each quadrant of the anterior capsule–free lens surface were graded. The product with the highest density and the number of quadrants with this density were used to measure LEC ongrowth. RESULTS: The Hydroview and Visionflex IOLs showed significantly more LECs than the other IOLs starting on day 7 after surgery (P<.028). There was a statistically significant difference in LEC ongrowth on the Memory IOL compared with all other IOLs from day 30 onward (P<.001). The Rayner, Collamer and Injectacryl IOLs had the fewest LECs on the anterior surface compared with all other IOLs from day 7 until the final examination. CONCLUSIONS: The findings show that LEC ongrowth on the IOL surface is material dependent. The findings suggest that the material of the recently developed hydrophilic IOLs induces less LEC ongrowth than older models.

Evaluation of anterior-segment inflammation and retinal thickness change following cataract surgery

Purpose:u2002 To investigate the physiological retinal response to uneventful cataract surgery using conventional time‐domain (TD‐OCT) and current spectral‐domain optical coherence tomography (SD‐OCT) in combination with an assessment of the anterior chamber inflammatory reaction by laser flare/cell meter (LCFM).

Inzidenz intra- und postoperativer Komplikationen nach Kapsulorhexis und Hochfrequenz-Kapsulotomie

ZusammenfassungIn dieser prospektiv-randomisierten Studie wurden die Unterschiede bezüglich intra- und postoperativer Komplikationen bei Kapsulorhexis bzw. Hochfrequenz-Kapsulotomie (HF-KT) erarbeitet.Intraoperativ kam es bei der Hochfrequenz-Kapsulotomiegruppe zu einer signifikant höheren Inzidenz radiärer Einrisse der vorderen Linsenkapsel (41%) als in der Kapsulorhexisgruppe (0%). Diese Tatsache weist auf die verminderte Stabilität des Randes des vorderen Kapselblattes nach HF-KT hin.Postoperativ zeigten sich nach 3 Monaten keine signifikanten Unterschiede zwischen beiden Gruppen. Allerdings kam es in der HF-KT-Gruppe in 16% der Fälle, als Folge der radiären Einrisse, zu sekundären Fehlpositionierungen der Linse, in der Rhexisgruppe waren alle Linsen im Kapselsack positioniert.Bei spezieller Indikationsstellung stellt die HF-KT eine gute Alternative dar, die verminderte Reißfestigkeit der Kapselöffnung ist allerdings stets zu berücksichtigen.SummaryIn this prospective randomised study we evaluated the difference between the complications after capsulorhexis and high-frequency-capsulotomy during and after cataract-operation. During the operation a significantly difference of radial tears of the anterior edge of the capsul was observed between the used technique: Rhexis (0% tears) and high-frequency-capsulotomy (41% tears).The radial tears may be caused by less stability of the edge of the anterior capsul in compairment to the edge of the capsul after the rhexis.Three month after the operation, there were only few differences between both groups, except the malposition of the intraocular lens after high frequency capsulotomy (16%) which may be caused by the instability of the anterior capsul by the radial tears.High frequency capsulotomy is a good additional surgery method, if there are special indications. Otherwise it should be considered of those complications.

Zelluläre Reaktionen auf der Linsenvorderfläche bei vier unterschiedlichen Faltlinsentypen

ZusammenfassungIn einer prospektiven, randomisierten klinischen Studie an 60 Augen von Patienten im Alter zwischen 40–92 Jahren mit Katarakt und ohne sonstige Grunderkrankungen wurden mit Hilfe der Spiegelmikroskopie die zellulären Reaktionen auf der Linsenvorderfläche von vier unterschiedlichen Faltlinsentypen beobachtet und dokumentiert.Implantiert wurden folgende Faltlinsen: STORZ HYDROVIEW, eine hydrophile Acryllinse; ACRYSOF, eine hydrophobe Acryllinse; MEMORY, eine hydrophile Acryllinse; PHARMACIA 920, eine hydrophobe Silikonlinse.Bei den postoperativen Nachkontrollen (1, 3, 7, 30, 90 und 180 Tage) wurde die Linsenvorderfläche in 25facher Vergrößerung begutachtet.Beobachtet wurden zwei unterschiedliche Zellmuster: 1.) Als Ausdruck einer unspezifischen Fremdkörperreaktion das Auftreten von kleinen Rundzellen und fibroblastenartigen Zellen, die später zu Epitheloid- und mehrkernigen Fremdkörperriesenzellen fusionieren können und 2.) eine Linsenepithelzellreaktion. Linsenepithelzellen (LEC) reflektieren die Interaktionen zwischen der IOL und dem vorderen Kapselblatt und spielen eine wichtige Rolle in der Pathogenese von Kapseltrübungen.Die höchste Inzidenz der LEC fand sich bei der STORZ-Linse. Zum letzten Nachkontrollzeitpunkt fanden sich noch bei 86,7% aller STORZ-Linsen LEC in höchster Zelldichte. Die fibroblastenartigen Zellen zeigten bei allen vier Faltlinsen die höchste Zelldichte und Inzidenz in der ersten post-operativen Woche, dann war der zeitliche Verlauf bei den einzelnen Typen unterschiedlich, wobei die Zellreaktion bei der STORZ-Linse und der PHARMACIA-920-Linse am geringsten war. Epitheloid- und Fremdkörperriesenzellen wurden insgesamt sehr selten und erst zu einem späteren postoperativen Zeitpunkt beobachtet. Am häufigsten traten sie bei der ACRYSOF-Linse und MEMORY-Linse auf. Die klinischen Ergebnisse waren bei allen Linsentypen sehr zufriedenstellend.SummarySixty eyes scheduled for cataract surgery were randomized prospectively into four groups of fifteen eyes each using random number tabels. Group 1 received a STORZ HYDROVIEW-lens, group 2 received an ACRY-SOF-lens, group 3 received a MEMORY-lens and group 4 a PHARMACIA 920-lens. Regarding patient selection, surgical technique and postoperative pharmaceutical therapy, every attempt was made to control or eliminate factors that could contribute to the degree of cellular reaction.Patient were examined at 1, 3, 7, 30, 90, and 180 days postoperatively. Postoperative biomicroscopic examinations were done with a slitlamp with specular technique to identify the presence of cellular deposits and the areas with the highest density of cells. The local tissue response consisted of two cellular patterns: a nonspecific foreign-body reaction to the IOL and a lens epithelial cell reaction (LEC).The highest incidence of LEC was observed on the STORZ-lens. After 180 days postoperatively we could found LEC on 86.7% of the STORZ-lenses with the highest cell density. During the first postoperative days, small round and spindle-shaped cells were found on all IOLs. After the 7th day postoperatively the development was different, the incidence and cell density of these cells was less severe on the STORZ-lens and on the PHARMACIA 920-lens. After several days, epitheloid cells and foreign-body giant cells were seen on some IOLs. These cells appeared more often on the ACRYSOF-lens and MEMORY-lens. Clinically results were satisfactory in all four foldable lens types.

Klinische Ergebnisse nach Implantation einer faltbaren „one-piece“ Acryllinse

ZusammenfassungProblemstellungIn der vorliegenden Arbeit wurde eine faltbare bikonvexe hydrophile „one-piece“ Acryllinse 6 Monate nach Implantation überprüft.Patienten und MethodeIn dieser Studie wurde 30 Kataraktpatienten eine hydrophile „one-piece“ Corneal Acrygel® Intraokularlinse nach Phakoemulsifikation durch eine temporale 3.2 mm Clear-Corneal-Incision mittels Implantationspinzette implantiert. Die Operationsmethode und das postoperative Management waren standardisiert. Alle Operationen wurden von einem erfahrenen Chirurgen durchgeführt. Die postoperative Inflammation wurde mit dem Laser-Flare-Cellmeter KOWA FC-1000 am 1., 3., 7., 28. Tag und nach 6 Monaten in dilatiertem Zustand gemessen. Die biomikroskopische Untersuchung erfasste semiquantitativ die Zentrierung und die vordere und hintere Linsenkapselmorphologie. Weiters wurden der bestkorrigierte Visus und der Augendruck erhoben.ErgebnisseDie Tyndallometrie ergab einen postoperativen Anstieg der Messwerte bis zur ersten Woche postoperativ, um nach 6 Monaten wieder auf annähernd präoperative Werte zu sinken. Die Linse war in allen Fällen gut zentriert. In 86,3% beobachten wir eine Fibrose des Rhexisrandes, wobei sie in 52,6% nur Grad 1 von 4 erreichte. Ein Vorwachsen von Linsenepithelzellen auf die Linsenvorderfläche fand sich in 77,2% aller Augen. In 36,3% beobachteten wir Spannfalten im Bereich der hinteren Kapsel und eine minimale regeneratorische Nachstarrate in 72,7%. Einen bestkorrigierten Visus über 6/12 erreichten alle Patienten. Komplikationen, insbesondere ein Druckanstieg oder Fibrinreaktionen, konnten nicht beobachtet werden.DiskussionDie Linse weist gute Biokompatibilität und gutes Zentrierungsverhalten auf. Das Haptikdesign und das Linsenmaterial mögen für die Form der Regeneratbildung auf der hinteren Kapsel verantwortlich sein.SummaryPurposeTo describe a foldable biconvex hydrophilic „one-piece“ acrylic intraocular lens 6 month after implantation.Patients and methodsThirty patients were included for this study. The operation method and the postoperative therapy were standardized. Photometric measurements with the laser-flare-cell-meter KOWA FC-1000 were performed on day before the operation, on the 1st, 3rd, 7th, 14th, 28th day and 6 month after surgery. Cellular reactions on the anterior and posterior capsule as well as centration of the lens were examined by using a slitlamp. Visual acuity and intraocular pressure were performed in all cases.ResultsFlare values increased on the first postoperative days and successively decreased on the following days. Centration of the lens was satisfactory. A low degree of fibrosis on the anterior capsular rim occured in 86,3% of all cases. Lens epithel cells on the anterior optic surface could be found in 77,2% of the cases. Folds in the posterior capsule were demonstrated in 36,3% and a low degree of posterior capsule opacification was seen in 72,7% of all eyes. All patients reached best corrected visual acuity 6/12 or better. At no time we observed complications such as an increase of intraocular pressure or fibrin reactions.DiscussionThis lens shows a good biokompatibility. Clinically results are satisfactory. Type of regeneration on the posterior capsule might be the results of haptic-design and lense material.

Persistierender hyperplastischer primärer Vitreus (PHPV) als Ursache der monokularen Katarakt im Kindesalter — chirurgisches und postoperatives Management

ZusammenfassungIm Rahmen unserer prospektiven, randomisierten Kinderkataraktstudie wurden seit April 1998 24 Augen von 18 Kindern operiert. Dabei handelte es sich bei 11 Augen um monolaterale Katarakte, von denen 8 Augen einem PHPV-Syndrom zuzuordnen waren (= 70%).Je nach Alter der Kinder wurden 3 Gruppen gebildet: Bei Gruppe A (0-2a) wurde nach vorderer Rhexis, Linsenabsaugung und hinterer Rhexis eine vordere Vitrektomie (VE) durchgeführt, bei Gruppe B (2-5a) wurde eine Hinterkammerlinse mit 2 unterschiedlichen Methoden implantiert: bei Gruppe B1 wurde eine hintere Kapsulorhexis und vordere VE, bei Gruppe B2 zusätzlich ein hinteres „optic capture“ initiiert. In der Gruppe C (5-16a), eine Altersgruppe, bei der die Nachstarproblematik bereits eine geringere Rolle spielt, wurde auf eine vordere Vitrektomie verzichtet und eine zusätzliche Gruppe geschaffen, bei der auch keine posteriore Rhexis angelegt wurde.Von den 10 Augen der Gruppe A waren 5 Katarakte, von den 6 Augen der Gruppe B zwei Katarakte und von den 8 Augen der Gruppe C eine Katarakt durch einen PHPV verursacht. In allen Fällen war die Linsentrübung monolateral, verbunden mit einer unterschiedlich stark ausgeprägten retrolentalen, fibrovaskulären Membran. Bei Kindern unter dem 1. LJ fand sich immer eine persistierende Arteria hyaloidea, die in 2 Fällen noch ein echtes blutführendes Gefäß darstellte und in 1 Fall begleitet war von teils gliösen, teils bindegewebigen Strukturen, die die Sehnervenscheibe als präpapilläre Membran bedeckten.Wir versuchten auch in diesen Fällen den chirurgischen Eingriff so atraumatisch wie möglich zu gestalten. Es wurden lediglich die anterioren Anteile des persistierenden fötalen Gewebes nach Hämostypsis im Rahmen einer vorderen „trockenen“ Vitrektomie (VE) entfernt.Die Strategie der postoperativen Nachsorge bestand bei Gruppe A in einer möglichst baldigen Kontaktlinsenkorrektur (Silflex) innerhalb der 1. postoperativen Woche und einer intermittierenden Okklusionsbehandlung des phaken Auges bis zur halben Wachzeit. Bei Gruppe B und C wurde auf Basis einer postoperativen Skiaskopie eine Bifokalbrille verordnet.Wenn auch in der Literatur bei diesen Augen von schlechten funktioneilen Resultaten berichtet wird [9], bestätigen die teilweise überraschend guten Visus-Ergebnisse unserer Studie das therapeutisches Vorgehen im Sinne einer möglichst frühzeitigen Operation und anschließenden konsequenten Amblyopiebehandlung. Bei Kataraktoperationen im Kindesalter, insbesondere monolateralen Formen, sollte immer mit dem Vorliegen von persistierenden fetalen vaskulären Strukturen gerechnet werden. Bei präoperativ echographisch diagnostizierten ausgedehnten posterioren PHPV-Formen sollte man zusätzlich auf eine pars plana VE in Kombination mit einem netzhautchirurgischen Eingriff vorbereitet sein.SummaryOur prospective, randomized clinical trial performed since April 1998 comprised 24 eyes of 18 children. Of the 11 eyes with unilateral cataract 8 eyes had various presentations of PHPV (= 70%).We formed three groups according to age: Group A (0-2a) received after lens aspiration, posterior CCC and anterior vitrectomy contact lens rehabilitation. In Group B (2-5a) two different methods of IOL implantation were performed and in an anterior vitrectomy in addition. In Group C (5-16a) three different methods of IOL implantation were performed without anterior vitrectomy.Of the 10 eyes of Gr. A five cataracts, of the 6 eyes of Gr. B two cataracts were caused by PHPV, and of the 8 eyes of Gr. C one cataract was caused by PHPV. In all cases lens opacification was unilateral in an otherwise healthy, fullterm newborn. Most of these eyes were microphthalmic. While the lens was clear initially in some cases, a progressive cataract develops with time or a dense retrolental fibrovascular membrane was present. In all children under 1 year of age an arteria hyaloidea persistens was present with varied amounts of perfusion in 2 cases.We tried to make the surgical treatment as atraumatic as possible. In eyes with a fibrovascular stalk or retinal abnormalities we removed only the anterior persistent fetal vasculature and membranes. After aphakic rehabilitation (CL, IOL, bifocal spectacles) an aggressive amblyopic therapy consisting of occlusive therapy for several waking hours each day was performed. After a mean follow up time of 11 months (2.5 to 19.5) visual outcomes was good in all but one eye.In unilateral cases of congenital or developmental cataracts one must calculate with the presence of persistent fetal vasculature. In cases with combinded anterior and posterior disease and retinal abnormalities a pars plana vitrectomy or extensive retinal surgery could be necessary. With modern vitreoretinal techniques, aphakic rehabilitation and aggressive amblyopic therapy, useful vision can be obtained in most of the children with combined anterior and posterior persistent hyperplastic primary vitreous.