Robert J. Cionni

Management of profound zonular dialysis or weakness with a new endocapsular ring designed for scleral fixation

Abstract The endocapsular tension ring has helped in the management of patients with moderate loss of zonular support. However, the eye with profound zonular dialysis or weakness may require scleral fixation of the ring for centration and long‐term stabilization. We used a new, modified endocapsular tension ring designed to provide scleral support without violating the integrity of the capsular bag in 4 patients. All patients had extreme loss of zonular support preoperatively or a significant risk of progressive zonular weakness. In each case, the new ring provided excellent support and centration of the capsular bag and intraocular lens intraoperatively and postoperatively.

Visualizing vitreous using Kenalog suspension.

&NA; We developed and evaluated a method of visualizing vitreous gel in the anterior segment. In this study, 0.2 mL of injectable triamcinolone (Kenalog®) 40 mg/mL was captured in a 5 &mgr;m filter and rinsed with 2 mL of balanced salt solution (BSS®). It was then resuspended in 5 mL of BSS and recaptured to thoroughly remove the preservative. The Kenalog particles were ultimately resuspended in 2 mL of BSS and injected into the anterior chamber through a 27‐gauge cannula. Kenalog particles were trapped on and within the vitreous gel, making it clearly visible. The visualization provided direct observation of vitreous behavior in various experimental settings and assisted surgeons intraoperatively in the identification and removal of vitreous in the anterior segment.

Endocapsular ring approach to the subluxed cataractous lens.

Abstract The surgical management of the cataract associated with extensive zonular dialysis presents a challenge for the anterior segment surgeon. In 1993, a poly(methyl methacrylate) endocapsular ring was introduced to stabilize the capsular bag. We describe the use of this endocapsular ring in phacoemulsification and intraocular lens (IOL) implantation in the capsular bag in four patients with extensive traumatic or congenital zonular dialysis. The endocapsular ring allows expansion and stabilization of the capsular bag to facilitate cortical aspiration and uncomplicated IOL implantation. With follow‐up of 4 to 10 months, all IOLs have remained well centered and the patients have had excellent vision free of complications.

Prosthetic iris implantation for congenital, traumatic, or functional iris deficiencies

Purpose: To determine the efficacy and safety of surgical implantation of prosthetic iris devices in patients with anatomic or functional iris deficiencies. Setting: Cincinnati Eye Institute, Cincinnati, Ohio, USA. Methods: Twenty‐five patients were enrolled in an interventional prospective noncomparative case series. Twenty‐eight eyes had prosthetic iris diaphragm implantation for traumatic iris defects, congenital aniridia or iris coloboma, herpetic iris atrophy, surgical iris loss, or ocular albinism. Prosthetic iris implantation was performed with phacoemulsification and intraocular lens (IOL) implantation in 20 eyes, secondary IOL implantation in 6 eyes, and IOL exchange in 1 eye. A single pseudophakic eye with disabling glare secondary to traumatic aniridia had secondary prosthetic iris implantation alone. The surgical ease of insertion, intraoperative and postoperative complications, postoperative anatomic results, visual acuity, and subjective glare reduction were evaluated. Results: Patients were followed postoperatively for a mean of 10.2 months (range 1.4 to 25.7 months). All eyes achieved the desired anatomic result. Visual acuity was improved in 22 of 28 eyes (79%), unchanged in 5 eyes, and worsened by a single line in 1 eye. Patients were surveyed postoperatively to determine the change in glare disability. The severity of glare disability was subjectively improved in 23 of 24 patients (96%) who responded to the survey. Intraoperative complications included 3 fractured implants as well as an incomplete or torn capsulorhexis in 3 eyes. Postoperative complications included transient hypotony in 2 eyes, mild persistent inflammation in 1 eye, and macular edema followed by a retinal detachment in 1 eye with recent severe trauma. Conclusions: Implantation of prosthetic iris devices improved postoperative outcomes by reducing glare disability and, in selected cases, by correcting aphakia. Although operating on traumatized, congenitally aniridic, or uveitic eyes presents special challenges, implantation of prosthetic iris devices appears to be a safe and effective method for reducing the ubiquitous glare in patients with iris deficiency.

Modified capsular tension ring for patients with congenital loss of zonular support.

Purpose: To evaluate the results of implantation of a modified capsular tension ring (MCTR) and a posterior chamber intraocular lens (PC IOL) in patients with congenitally subluxated crystalline lenses. Setting: Cincinnati Eye Institute, Cincinnati, Ohio, USA. Methods: Ninety eyes of 57 patients with congenital loss of zonular support (Weill‐Marchesani syndrome, idiopathic ectopia lentis, and Marfans syndrome) had phacoemulsification with PC IOL and MCTR implantation. The preoperative examination included best corrected visual acuity (BCVA) and the presence or absence of phacodonesis, lens decentration, and vitreous prolapse. The postoperative evaluation included BCVA and the presence or absence of pseudophacodonesis, PC IOL centration, and posterior capsule opacification (PCO). Results: At the last postoperative examination, the BCVA was 20/40 or better in 80 eyes (88.9%); 1 eye (1.1%) lost 1 line of acuity. Preoperatively, 18 eyes (20%) had phacodonesis; 1 eye had postoperative pseudophacodonesis. Decentration before surgery was present in 86 eyes (95.6%); 6 eyes (6.7%) developed late symptomatic PC IOL decentration a median of 17.84 months ± 10.73 (SD) after surgery. Other complications were increased intraocular pressure (2.2%), persistent iritis (3.3%), broken suture (10.0%), retinal detachment (1.1%), and PCO (20.0%). Conclusions: Use of the MCTR resulted in centration of the capsular bag and PC IOL in 90 eyes with congenitally subluxated crystalline lenses. Fixation of a 9‐0 polypropylene suture is recommended to decrease the risk for late suture breakage.

Functional outcomes after bilateral implantation of apodized diffractive aspheric acrylic intraocular lenses with a + 3.0 or + 4.0 diopter addition power Randomized multicenter clinical study

PURPOSE: To evaluate functional outcomes after bilateral implantation of apodized diffractive aspheric acrylic intraocular lenses (IOLs) with a +3.0 or +4.0 diopter (D) addition (add) power. SETTING: Twelve study centers in the United States. METHODS: This randomized patient‐masked parallel‐group 6‐month follow‐up study comprised patients having bilateral cataract extraction with implantation of an AcrySof IQ ReSTOR SN6AD3 IOL with a +4.0 D add power (+4.0 D group) or an AcrySof IQ ReSTOR SN6AD1 IOL with a +3.0 D add power (+3.0 D group) (both IOLs, Alcon, Inc.). Visual acuity, defocus testing, patient‐reported outcomes, and safety measures were assessed. RESULTS: Of the 279 patients, 141 were in the +3.0 D group and 138 were in the +4.0 D group. Binocular distance‐corrected intermediate visual acuity was statistically significantly better in the +3.0 D group than in the +4.0 D group (P<.0001); there was no difference in binocular near or distance visual acuity. There were no statistically significant differences in visual disturbances between the 2 groups. Patients in both groups reported excellent overall spectacle independence, near visual function, and satisfaction with the IOLs. CONCLUSIONS: Intermediate vision at a mean reading distance of approximately 40 cm was better with the aspheric IOL with a +3.0 D add than with the aspheric IOL with a +4.0 D add, as shown by the near peak in the mean binocular defocus curve; near and distance acuity were similar between the 2 IOLs. Patients reported excellent overall quality of vision, spectacle independence, and satisfaction.

The torn posterior capsule: Its intraoperative behavior, surgical management, and long-term consequences

ABSTRACT A retrospective study of cataract surgery performed between January 1983 and December 31, 1989, disclosed 48 eyes in which the posterior capsule was torn. The overall incidence of this complication was approximately 1% but was further reduced when the technique of capsulorhexis was mastered. Our review of the video tapes of these surgical procedures revealed that the tear occurred most frequently during nucleus removal (41%) and posterior capsular vacuuming (28%). The anatomy of each tear was classified and related to the event responsible for the torn capsule, as well as to the likelihood of vitreous involvement. Vitreous presented through the tear in 32% of the 48 cases, entered the wound in 6%, and remained posterior to the torn capsule in 62%. Intraocular lenses were implanted in every case; only posterior chamber lenses were used during the last four years of the study. Vitreous‐related complications included vitreous prolapse, peaked pupils, and vitreous‐induced pupillary block. Acute postoperative intraocular pressure elevation was a frequent finding and was managed by conservative therapy. Transient cystoid macular edema developed in one case which had a rotating anterior chamber intraocular lens. No retinal detachments occurred in this series. Final visual acuity of 20/40 or better was achieved in 89% of the 48 cases. When properly managed, a torn posterior capsule is compatible with an excellent visual outcome.

Incidence of ocular misalignment and diplopia after uneventful cataract surgery

PURPOSE To evaluate the incidence of ocular misalignment and diplopia after uneventful cataract surgery. SETTING An outpatient private practice eye institute. METHODS One hundred thirty-eight patients referred to 1 cataract surgeon were prospectively evaluated. Orthoptic evaluations were performed within 1 month before and then 1 day, 1 week, and 1 month after cataract surgery. Anesthesia was by retrobulbar injection, and cataract extraction was done by phacoemulsification. RESULTS Cataract surgery was performed in 118 patients. Preoperatively, 16 patients had ocular misalignment; 10 were phoric, 4 were intermittently tropic, and 2 were tropic. Follow-up evaluation was obtained for 101 patients (86%) at 1 day, 91 (77%) at 1 week, and 88 (75%) at 1 month. A change in ocular alignment occurred in 22 of 101 patients (22%) at 1 day, 9 of 91 (10%) at 1 week, and 6 of 88 (7%) at 1 month. Only 1 patient who had a change in alignment at 1 month was symptomatic. CONCLUSIONS A persistent change in ocular alignment after uneventful cataract surgery occurred in 7% of patients. However, symptomatic diplopia was uncommon (1 in 118; 0.85%) in this relatively small series.

Visual outcome comparison of unilateral versus bilateral implantation of apodized diffractive multifocal intraocular lenses after cataract extraction: Prospective 6-month study

PURPOSE: To evaluate the visual outcomes and patient satisfaction after unilateral implantation or stepwise bilateral implantation of an apodized diffractive multifocal intraocular lens (IOL). SETTING: Private practice, Cincinnati, Ohio, USA. METHODS: Patients requiring cataract surgery in 1 eye were recruited. AcrySof ReSTOR IOLs were implanted in 1 eye of patients with phakic contralateral eyes, patients with contralateral monofocal IOLs, and patients with a contralateral multifocal IOL of the same model. Six months postoperatively, patients were assessed for visual acuity (31.0 cm, 50.0 cm, 4.0 m), contrast sensitivity, and stereopsis. Patients were surveyed for visual disturbances and lifestyle visual quality. RESULTS: Of unilateral multifocal IOL patients, 75% were satisfied with their vision (score 7.3 out of 10) and a majority (56% multifocal–phakic, 65% multifocal–monofocal) achieved spectacle independence. These values were slightly lower than values for bilateral multifocal patients (92% satisfied, 77% spectacle independent), but not at a statistically significant level. Mean overall patient satisfaction was statistically significantly different: 8.9 for bilateral patients versus 7.3 for unilateral patients. Objectively, significant differences favored bilateral implantation over unilateral implantation for stereopsis, uncorrected near visual acuity, and best corrected near and intermediate visual acuities. Contrast sensitivity was similar between groups in most cases. The incidence of halos was lower in unilateral patients (57%) than in bilateral patients (77%), although the difference did not reach statistical significance. CONCLUSION: Although unilateral implantation of a multifocal IOL provided patients with high levels of spectacle freedom and good visual acuity without compromising contrast sensitivity, overall clinical results favored bilateral implantation.

Collagen metabolism following corneal laceration in rabbits

We investigated the synthesis and degradation of collagen in lacerated rabbit corneas. The rate of collagen synthesis was measured by the incorporation and hydroxylation of [14C]proline up to 5 weeks after a penetrating laceration. Our results indicate that protein and collagen synthesis is initially reduced during the 24 h period after laceration and then increases in two phases. A moderate increase in protein and collagen synthesis occurs up to day 5 after laceration. Synthesis then decreases to a low level through the 10th day after injury. A second wave of increase in protein and collagen synthesis takes place reaching a new peak of approximately twice the activity as found in control corneas after 5 weeks of healing. Afterwards, the rate of protein and collagen synthesis declines and reaches the basal level after 7 weeks of healing. In a separate set of experiments, rabbit corneas were lacerated and allowed to heal for one or three weeks at which point 100 microCi of [14C]proline was injected into each anterior chamber. The corneas were excised 1 to 17 days later and subjected to collagen analysis. Our data indicates that the degradation of collagen synthesized by the cornea 1 week after laceration followed biphasic kinetics. In the first phase, the half-life of newly-synthesized collagen is 20 days, whereas it is approximately 4 days in the second phase. It is of particular interest that the accelerated degradation of the newly-synthesized [14C]collagen is concomitant with the increased rate of collagen synthesis during the wound healing process. The degradation of collagen synthesized 3 weeks after injury was slower and followed monophasic kinetics having a half-life of 14 days. The degradation of non-collagenous 14C-proteins follow a monophasic kinetics having a half-life of 6-7 days. Polyacrylamide gel electrophoresis of newly-synthesized collagen indicated that the collagen(I) and collagen(V) were the main collagenous components synthesized by the lacerated corneas.