Rupal H. Trivedi

Pediatric cataract surgery and intraocular lens implantation: Practice styles and preferences of the 2001 ASCRS and AAPOS memberships☆

&NA; A survey of pediatric cataract surgery and intraocular lens (IOL) implantation practice patterns of adult and pediatric cataract surgeons was performed in October 2001. Questionnaires were distributed to the American Society of Cataract and Refractive Surgery and the American Association for Pediatric Ophthalmology and Strabismus. The overall return rate was 12.6% and 41.0%, respectively. Results show that pediatric cataract surgery with IOL implantation is being performed at a younger age than 8 years ago. Also, pediatric cataract surgery practice patterns are evolving in step with advances in adult surgery but with notable differences.

Macular thickness assessment in healthy eyes based on ethnicity using Stratus OCT optical coherence tomography.

PURPOSE To assess the variation in macular thickness measurements in healthy Caucasian and African American men and women through Stratus OCT optical coherence tomography (OCT-3). METHODS One hundred sixty-six eyes of 83 healthy patients underwent complete ophthalmologic examination in this prospective study. Exclusion criteria included a diagnosis of diabetes mellitus, hypertension, intraocular pressure (IOP) greater than 21 mm Hg, history of eye surgery or trauma, or evidence of eye disease. For analysis purposes, the authors excluded those participants in whom OCT signal strength was <7 in each eye. A fast macular thickness protocol consisting of a 6-mm radial scan centered on the fovea was used for the analysis, and the data were analyzed using the t-test for independence and linear regression. Both eyes of each patient were analyzed using the OCT-3, and analysis showed a statistically significant correlation between right and left eyes. Therefore, only one eye from each patient was randomly selected for final correlation and analysis. RESULTS Mean foveal thickness (MFT) for Caucasians was 32 microm greater than for African Americans (217 vs. 185 microm, respectively; P < 0.001). The MFT was significantly thicker in males than in females (220 vs. 197 microm, respectively; P < 0.001). CONCLUSIONS The fovea is significantly less thick in African Americans and females than in Caucasians and males. Racial and sexual differences should be considered when interpreting an OCT scan.

Post cataract-intraocular lens (IOL) surgery opacification.

Intraocular lens (IOL) implantation has no doubt been one of the most satisfying advances of medicine. Millions of individuals with visual disability or frank blindness from cataracts had and continue to have benefit from this procedure. It has been reported by ophthalmologists that the modern cataract-intraocular lens (IOL) surgery is safe and complication-free most of the time. This makes the watchword for any cataract surgeon to be ‘implantation,’ ‘implantation,’ ‘implantation.’ In the mid-1980s, as IOLs were evolving rapidly, the watchword of the implant surgeon was ‘fixation,’ ‘fixation,’ ‘fixation.’ Most techniques, lenses and surgical adjuncts now allow us to achieve the basic requirement for successful IOL implantation, namely long-term stable IOL fixation in the capsular bag. However despite this advancement some items ‘slipped through cracks.’ In this article, we would like to alert the reader to a new watchword, namely ‘opacification,’ ‘opacification,’ ‘opacification.’ Here we will be talking about the good, the bad, and the ugly. Examples of the ‘good’ include the recent successes now being achieved in reducing the incidence of posterior capsule opacification. Examples of the ‘bad’ include various proliferations of anterior capsule cells, problems caused by silicone oil adherence to IOLs and problems with piggyback IOLs. The ‘ugly’ include the sometimes striking and often visually disabling opacifications occurring on and within IOL optics, both on some modern foldable IOLs as well as a poly(methyl methacrylate) (PMMA) optic degradation occurring with some models a decade or more after implantation.

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.

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.

Capsular bag opacification after experimental implantation of a new accommodating intraocular lens in rabbit eyes.

Purpose: To evaluate the development of capsular bag opacification in rabbit eyes after implantation of an intraocular lens (IOL) designed to minimize contact between the anterior capsule and the IOL and ensure expansion of the capsular bag. Setting: David J. Apple, MD Laboratories for Ophthalmic Devices Research, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. Methods: Ten New Zealand white rabbits had a study IOL (new accommodating silicone IOL [Synchrony, Visiogen, Inc.]) implanted in 1 eye and a control IOL (1‐piece plate silicone IOL with large fixation holes) implanted in the other eye. Intraocular lens position, anterior capsule opacification (ACO), and posterior capsule opacification (PCO) were qualitatively assessed using slitlamp retroillumination photographs of the dilated eyes. Anterior capsule opacification and PCO were graded on a 0 to 4 scale after the eyes were enucleated (Miyake‐Apple posterior and anterior views after excision of the cornea and iris). The eyes were also evaluated histopathologically. Results: The rate of ACO and PCO was significantly higher in the control group. Fibrosis and ACO were almost absent in the study group; the control group exhibited extensive capsulorhexis contraction, including capsulorhexis occlusion. Postoperative IOL dislocation into the anterior chamber and pupillary block syndrome were observed in some eyes in the study group. Conclusions: The special design features associated with the study IOL appeared to help prevent PCO. Complications in the study group were probably caused by the increased posterior vitreous pressure in rabbit eyes compared to human eyes and the relatively large size of the study IOL relative to the anterior segment of rabbit eyes.

Single-piece acrylic intraocular lens implantation in children

Purpose: To assess the short‐term outcomes of single‐piece acrylic intraocular lens (IOL) implantation in children by determining the incidence of postoperative visual axis opacification and the need for a second procedure to clear the axis, cell deposits on the IOL optic, posterior synechias, and IOL decentration. Setting: Miles Center for Pediatric Ophthalmology, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. Methods: This retrospective case review comprised 43 consecutive implantations (33 patients) of a single‐piece hydrophobic acrylic IOL (AcrySof® SA30AL or SA60AT, Alcon). An analysis of 42 eyes with posterior capsulectomy and vitrectomy was performed. Eyes with traumatic cataract and secondary IOLs were excluded. Results: Single‐piece acrylic IOLs were implanted in 42 eyes. The mean age was 33.5 months ± 28.9 (SD) (range 0.5 to 110 months) and the mean follow‐up, 12.0 ± 8.2 months (range 1.0 to 27.5 months). Postoperative opacification of the visual axis occurred in 7 eyes (16.7%). Secondary surgical procedures were required in 5 eyes (11.9%). Lens deposits were observed in 8 eyes (19.0%) and synechias, in 5 eyes (11.9%). All IOLs were well centered postoperatively. Conclusion: The short‐term data suggest implantation of the AcrySof single‐piece hydrophobic acrylic IOL is safe in the pediatric eye.

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.

Comparison of the incidence and visual significance of posterior capsule opacification between multifocal spherical, monofocal spherical, and monofocal aspheric intraocular lenses.

PURPOSE: To determine and compare the incidence of posterior capsule opacification (PCO) and neodymium:YAG (Nd:YAG) laser capsulotomy after implantation of 3 intraocular lens types (IOLs). SETTING: Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: This retrospective chart review comprised eyes having uneventful phacoemulsification and implantation of 1 of 3 AcrySof IOLs: ReSTOR SN60D3 (multifocal spherical group), Natural SN60AT (monofocal spherical group), or IQ SN60WF (monofocal aspheric group). Eyes were matched by age, sex, and follow‐up. The PCO rate, Nd:YAG capsulotomy rate, time from surgery to PCO diagnosis, and time from surgery to Nd:YAG capsulotomy were assessed. RESULTS: Charts of 225 eyes (75 in each group) with a mean follow‐up of 15.9 months ± 6.5 (SD) were evaluated. The PCO rate was 42.7% in the multifocal spherical group, 28.0% in the monofocal spherical group, and 14.7% in the monofocal aspheric group. The Nd:YAG capsulotomy rate was 25.3%, 17.3%, and 4.0%, respectively. The difference in the Nd:YAG rate was statistically significantly higher in the multifocal and monofocal spherical groups than in the monofocal aspheric group (P<.001 and P<.008, respectively) but was not significantly different between the 2 spherical IOL groups (P = .232). The time from surgery to PCO documentation was not significantly different between the 3 groups. CONCLUSIONS: Intraocular lens configuration may have contributed to the difference in the PCO rate between the 2 spherical IOLs and the aspheric IOL. Based on the Nd:YAG rate as an indicator for visual significance, PCO may be less visually significant in eyes with the aspheric IOL than in eyes with 1 of the spherical IOLs.