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Posterior polar cataract (PPC) is a blazon of developmental cataract which is considered to arise before birth or in early infancy.[one] The exact pathogenesis remains unknown and various causes accept been proposed to contribute to its development. These include persistence of the hyaloid artery,[2] mesoblastic tissue invasion of the crystalline lens,[3 4] and various genetic mutations.[5 6] A positive family history has been reported in xl–55% of the cases.[7 8]
A mature PPC presents as a dense, circular plaque with concentric rings in the posterior cardinal part of the lens involving mainly the posterior subcapsular and capsular region. Information technology has classically been described to have a "Balderdash'southward eye" or onion peel appearance. Ultrastructurally, PPC is associated with either a sparse and fragile posterior capsule with the discoid opacity being adherent to it,[9] or in upto 20% of cases the posterior sheathing may be congenitally deficient.[7] Surgery of PPC hence remains a surgical challenge considering of the always-nowadays gamble of posterior capsular rupture (PCR) and nucleus drop. Reported rates of PCR in these eyes vary widely from 0 to 36%.[7 8 10 11 12 13 fourteen 15 sixteen]
At that place are several techniques described earlier past various surgeons in an endeavour to reduce the risk of PCR while operating on a PPC. These include among others "within out hydrodelineation" by Vasavada et al.,[xv] "λ technique of nucleofractis" by Lee and Lee,[16] "V" groove phaco by Kelman,[17] "layer by layer" phacoemulsification past Vajpayee,[eighteen] viscodissection of epinucleus and cortex using a dispersive viscoelastic by Allen et al.,[19] and Fine et al.,[20] and "inverse horseshoe technique" by Salahuddin.[21]
The present study was conducted to evaluate the PCR rate and assess the postoperative outcomes using a combination of controlled hydrodelineation, "Five", or λ (lambda) technique for nucleofractis and viscodissection of the epinucleus, prior to cortical aspiration.
Methods
This was a retrospective study conducted at a tertiary eye intendance heart in Northward India. Eighty optics of 64 patients with PPC having visual symptoms attributable to the presence of the cataract were included in the study. All surgeries were performed by a unmarried surgeon (AKJ).
All patients had preoperative detailed ophthalmological exam including recording of uncorrected distance visual vigil (UDVA), corrected distance visual acuity (CDVA), intraocular pressure measurement with non-contact tonometer, slit-lamp biomicroscopy, and dilated fundus test. Pupillary retroillumination was attempted in every instance to look for pre-existing capsular dehiscence. If the fundus exam was precluded due to presence of a dumbo cataract, B-scan ultrasonography was done to document the status of the posterior segment. PPC was graded according to the classification given by Singh,[22] that is, Type 1: posterior polar opacity associated with a posterior subcapsular cataract (PSC); Type 2: sharply defined round or oval opacity with ringed advent similar an onion, with or without greyish spots at the edge; Blazon 3: sharply defined round or oval white opacity with dense white spots at the edge often associated with thin or absent posterior capsule; Type 4: combination of the to a higher place 3 types with nuclear sclerosis.
Biometry was performed using partial coherence light amplification by stimulated emission of radiation interferometry (IOL Main, Zeiss, Jena, Deutschland). In cases of dense cataract where IOL master was unable to acquire the readings, axial length was obtained by immersion A-scan and manually fed into the IOL master. Inclusion criteria: Patients aged 12–90 years with visually disabling posterior polar cataract who had minimum 3 months follow-upwardly subsequently surgery were included for analysis. Exclusion criteria: Secondary causes of cataract were excluded. Eyes with corneal opacity or posterior segment disease including glaucoma, age related macular degeneration, diabetic retinopathy, etc., were also excluded.
Surgical technique
Under peribulbar anesthesia, the chief incision was made with a 2.two mm dual bevel keratome at the limbus and the site was planned according to the steepest keratometric readings to neutralize maximum corporeality of preoperatively existing astigmatism. Anterior chamber was formed with a cohesive dispersive viscoelastic, DisCovisc (Alcon Laboratories, Fort Worth, Texas) containing 17 mg/ml of sodium hyaluronate and 40 mg/ml of sodium chondroitin sulfate. Side ports were made with 15° blade. Continuous curvilinear capsulorrhexis of most 5 mm was initiated with a needle cystitome and completed with microcapsulorrhexis forceps. Fig. 1 shows the steps of surgery in a Type 2 PPC [Fig. 1a]. Hydrodelineation was performed with the assistance of hydrodissection cannula, burying the cannula under the epinuclear part of the lens followed by slow and controlled injection of the balanced common salt solution [Fig. 1b]. The formation of a complete golden ring ensured the completion of the stride. This was followed past a multiquadrant viscodissection, taking care that the ocular viscoelastic device (OVD) moving ridge did not cantankerous the PPC plaque [Fig. 1c]. The surgeries were performed on an Infiniti phaco car (Alcon Laboratories Ltd, Fort Worth, TX, The states). In all cases, the nucleus was removed with a modified stop and chop technique. Sculpting was done with canteen height of seventy–75 cm, torsional energy 90%, vacuum threescore mmHg, and aspiration catamenia rate (AFR) 21 ml/min. For chopping, a bottle height of 70 cm, torsional free energy 65–75%, vacuum 250–350 mm Hg, and AFR 24–28 ml/min were used depending upon the hardness of cataract.
(a) Type ii posterior polar cataract (PPC)- intraoperative photo. (b) Complete hydrodelineation visible every bit gilt ring. (c) Viscodissection. (d) "Five" groove for nucleotomy. (due east) Viscoelastic injection after completing the nucleotomy and earlier taking out the phaco probe. (f) Posterior bedchamber IOL implantation in the capsular pocketbook
In type 2 and blazon 3 cataracts, the Five groove (also known as "victory") technique described by Kelman in 1994 was used for nucleotomy.[17] The endonucleus was sculpted, creating a "V" shaped trough so as to ensure that the posterior epinuclear shell remains intact [Fig. 1d]. The arms of the "V" trough were cracked in slow and modest manual rotatory movements from either side with the help of a Drysdale hook and the phaco needle tip. Then the "V"-shaped endonuclear quadrant was emulsified get-go, thus creating infinite for manipulation of the remaining endonucleus within an epinuclear shell. The remaining endonucleus was rotated minimally (just enough so every bit to enable access and a good hold of the phaco tip onto the remaining endonucleus) and chopped into multiple pieces and emulsified. It was ensured that the posterior epinuclear plate with the polar cataract remains intact during nucleofractis. Anterior chamber was e'er maintained throughout the procedure, injecting a dispersive OVD every time before withdrawing the phaco tip from main incision, ensuring that the sleeping room never shallowed suddenly [Fig. 1e]. In eyes with type 4 PPC, the "lambda" technique described by Lee[sixteen] was used. In this particular technique, nucleus sculpting was done in the shape of the Greek letter lambda (λ) [Fig. 2a and b]. Cracking was done along both arms of the lambda and the central slice was removed first.
(a) Type 4 posterior polar cataract. (b) Lambda/inverted Y technique for nucleotomy. (c) Another patient with Type 4 cataract. (d) Pre-existing posterior sheathing rent, best visible subsequently completion of lens extraction under retroillumination
After nucleotomy, in all cases the epinuclear plate was viscodissected from under the border of the capsulorrhexis in multiple quadrants as described by Allen et al.,[19] and Fine et al.[20] Care was exercised that the wave of viscoelastic extended just short of the posterior polar plaque, without actually crossing it. Under low parameters (canteen height 70–74 cm, vacuum 220–230 mmHg, AFR 22–24 ml/min), the epinucleus was peeled from equator toward the centre with the help of phaco needle, and the function which was attached to the posterior pole was emulsified at terminal. For the cortex removal, vacuum was set to 500 mmHg and aspiration charge per unit was 22–24 ml/min. Cortical matter was stripped from the equator to the centre. Cohesive viscoelastic Healon GV (Abbott Medical Eyes, Usa) containing 14 mg/ml sodium hyaluronate was injected to inflate the handbag. If the posterior capsule was intact, IOL was implanted in the bag [Fig. 1f]. After the IOL insertion, rest viscoelastic was removed with the bimanual irrigation and aspiration tip from below the IOL by tilting the lens and inserting the irrigation tip under the lens surface and also from above the IOL.
In cases where pre-existing capsular dehiscence (north = 4 eyes) was noted on slit-lamp examination, the surgical technique and precautions exercised were similar to cases where the posterior sheathing was intact preoperatively, except that the technique of nucleofractis was the "lambda" technique, since all these were grade 4 PPCs. Whenever a posterior capsular rent (PCR) was encountered (whether pre-existing or occurring de novo), the phaco probe was withdrawn later injecting a dispersive OVD into the pocketbook. The extent of the PCR was assessed subjectively as beingness less than or greater than 50% of the anterior capsulorrhexis size. Infusion canteen height was reduced to 55 cm, and inductive vitrectomy was done in cases with vitreous disturbance using cut rate of 800/s and vacuum of 200 mm Hg. Viscoelstic was injected in the capsular handbag and ciliary sulcus. In cases with PCR >50% of the inductive capsulorrhexis size, a iii-slice acrylic hydrophobic IOL was placed in the sulcus, the optic of which was captured within the capsulorrhexis. In cases of PCR <l% of the inductive capsulorrhexis, the IOLs were placed "in the bag." OVD removal in these cases was washed at the end, with the vitrectomy probe in the aspiration mode.
Postoperatively, patients were given a combination of moxifloxacin 0.5% and dexamethasone 0.1% 4–half dozen times a 24-hour interval, topical non-steroidal anti-inflammatory drug (NSAID) nepafenac 0.1% 3 times a 24-hour interval and tear substitutes four times per day. The antibiotic–steroid combination was tapered over three–4 weeks while the NSAID was connected for vi–8 weeks to forestall the development of cystoid macular edema[23]
Statistical analysis: Demographic data and case details including visual vigil, type of PPC, complications were studied using descriptive statistics in form of frequency, mean, and standard difference. For normally distributed measurable data, Student's t-test and for not-unremarkably distributed information Wilcoxon-signed rank test were used. P value < 0.05 was considered meaning.
Results
Mean age of the study cohort was 52.21 ± xiv.49 years (range 12–86 years). Of the 64 patients included in the study, at that place were 33 (51.6%) males and 31 (48.4%) females. Seven patients (10.ix%) were less than 35 years of historic period. Of the 80 operated optics, 38 (47.v%) were correct and 42 (52.five%) were left optics. Eighteen (28.1%) patients presented with bilateral cataract and 46 (71.8%) with unilateral cataract.
Type 2, Type three, and Type 4 cataract was seen in 34 eyes (42.5%), xx eyes (25%) and 26 eyes (32.5%), respectively. Mean historic period of patients with type 2, type three, and blazon four cataract was 44.48 ± 12.79 years, 48.64 ± 12.40 years, and 64.68 ± 12.83 years, respectively. The combined mean historic period of presentation of patients with type two and type 3 cataract (46.sixteen ± 12.66 years; n = 42 subjects) was significantly lower compared to patients with type 4 cataract (64.68 ± 12.83 years, n = 22 subjects) (P value: < 0.0001). 8 eyes (10%) of seven patients had very dumbo type 4 cataracts with visual acuity limited to counting fingers close to face; in them the diagnosis of PPC was made on the basis of "onion skin" morphology of cataract which was visible on slit-lamp biomicroscopy. Ultrasonography (B scan) was however needed in these cases for evaluation of posterior segment as visualization of the fundus was inadequate.
Phacoemulsification was completed in 79 eyes. 1 patient had Fuch'south endothelial dystrophy with Type 4 posterior polar cataract and dense nuclear sclerosis. Due to intraoperative occurrence of zonular dehiscence, an intracapsular cataract extraction (ICCE) was performed and patient was left aphakic. Posterior capsular rupture was seen in half-dozen (7.vi%) out of the 79 eyes in which phacoemulsification was completed.
Of these six optics with PCR, four eyes had type 4 polar cataract and two optics had type 2 polar cataract. Based on slit-lamp biomicroscopy, the existence of a posterior capsular dehiscence had been documented preoperatively in the clinical records, for the four optics with blazon 4 PPC in whom the PCR was also documented during surgery. The mean age of these four patients was 61.v years (range 55–seventy years). Fig. 2c and 2nd prove a patient of Type 4 cataract preoperatively and an intraoperative image of PCR visible on retroillumination, respectively. Anterior vitrectomy was required in all these four cases because of associated vitreous disturbance. IOL was implanted in the sulcus in all these cases equally the size of the capsular dehiscence was >l% of the anterior capsulorrhexis. The remaining two optics had Type 2 posterior polar cataract in which PCR occurred intraoperatively during removal of the epinucleus. In these two eyes, inductive vitrectomy was required in one instance with vitreous disturbance, whereas other case did not require vitrectomy because of intact vitreous stage. An "in the purse" implantation of the IOL was possible in these two eyes, the PCR being smaller in size. In that location was no example of nucleus driblet in the nowadays series. Postoperatively, four optics had a persistent posterior capsular plaque. Intraocular lenses (IOLs) could be implanted in 79 of the 80 eyes operated (98.75% eyes) of which single piece hydrophobic acrylic IOLs were implanted in 36 (45%) eyes and iii-piece hydrophobic acrylic IOLs in 38 (47.5%) eyes. Rigid PMMA IOLs were implanted in five (half-dozen.25%) eyes of five patients who were unable to beget foldable lenses due to financial constraints.
Mean CDVA improved significantly from a preoperative value of 0.67 ± 0.52 log MAR to 0.11 ± 0.xx log MAR at 3 months postoperatively (P < 0.001, Wilcoxon-signed ranks test). Overall 70 eyes (87.five%) accomplished a CDVA of 20/forty or better, while 55 eyes (68.75%) achieved a CDVA of xx/20 or amend. CDVA of 20/20 or ameliorate was achieved in 97% eyes (33 of 34) with Type 2 PPC, xc% eyes (18 of 20) with Type iii PPC, and 73% eyes (19 of 26) with Blazon four PPC. In the six eyes with PCR, CDVA of 20/20 was accomplished in three eyes (fifty%), 20/40 in i eye (16.7%), and xx/threescore in two eyes (33.3%). None of the optics adult any delayed posterior segment complications, for example, cystoid macular edema or retinal detachment. Table 1 shows the distribution of cases co-ordinate to the type of cataract and visual outcome.
Distribution of cases co-ordinate to the Type of PPC and visual effect
Discussion
The chief complaint in patients with PPC is reduced vision in bright sunlight and glare and haloes specially when exposed to potent sources of focussed low-cal, for example, headlights of oncoming vehicles. Quality of life may thus exist dumb significantly, relatively early on in the disease procedure fifty-fifty though visual acuity under loftier contrast testing weather condition may yet exist good. Performing surgery in PPC without disrupting the integrity of the posterior capsule thus remains a constant challenge. Due to the inherent weakness/absenteeism of the posterior capsule in PPC, a rupture can occur at every step including hydroprocedures, nuclear rotation, phacoemulsification, and cortical aspiration.
Variable incidence of capsular rupture has been reported in literature for posterior polar cataracts. Osher et al.[7] reported a 26% incidence in a series of 31 eyes while Vasavada and colleagues reported a 36% incidence in a series of 22 optics.[eight] Hayashi et al.[ten] take reported posterior capsule tear occurring in seven.1% of 28 optics while Haripriya et al.[xi] reported PCR in 12.v% cases in a series of eight patients. The nowadays study showed a lower PCR rate of 7.6% which is lower than most reported series of posterior polar cataracts. If cases of pre-existing PCR, that is, the four optics documented preoperatively on slit-lamp biomicroscopy to accept a capsular dehiscence are excluded, the bodily "intraoperative" incidence of PCR in the present series was only 2.5% (2 of eighty eyes). The lower incidence of PCR in our serial may be attributed to all patients beingness operated upon past a unmarried surgeon (AKJ) with meticulous attending beingness paid to intraoperative surgical precautions (e.m., lowering of machine parameters and avoidance of sudden anterior chamber shallowing past using dispersive viscoelastic) likewise as combining the nuances of multiple techniques which have been previously described to reduce the incidence of PCR in polar cataracts. These include a guarded, limited, slow hydrodelineation (instead of hydrodissection), using nucleotomy techniques which purportedly take the reward of non stretching the capsule while removing the pieces,[16 17] and viscodissection for removal of epinuclear plate. In the present series, the "lambda technique" was reserved for blazon 4 posterior polar cataracts and the "V" groove nucleotomy for Type two and Type 3 PPC. The rationale for this subtle variation in the nucleotomy technique was that in Blazon 4 cataracts (where the polar opacity is associated with nuclear sclerosis and hence are likely to be harder than type two and blazon 3 PPC), removal of the smaller piece between the two oblique artillery of the lambda would occur without causing undue anteroposterior or lateral stretch of the capsule, and make the subsequent manoeuvres easier considering of the enhanced space in the capsular bag. On the reverse, creating the lambda groove in the softer type 2 and type 3 cataracts could inadvertently increase the risk of the tip of the phacoprobe going deeper than intended in the endonucleus (and perhaps besides across the epinucleus) at the junction of the three limbs of the lambda (λ), that is, the vertical and the two oblique arms while the "V" groove with only a single point of convergence at the apex of the Five would be associated with a relatively lower risk. Apart from the four eyes with blazon four PPC, where a pre-existing PCR was suspected and confirmed intraoperatively, the authors did not encounter any other incidence of PCR in any of the optics where the "lambda" technique was used. Lee et al.[16] originally described the "lambda" technique, in which nucleus was sculpted in the shape of a Greek letter of the alphabet lambda (λ), followed past cracking along both "artillery" and removal of the central slice reported PCR in 4 out of 36 eyes (eleven.ane%). The incidence of PCR was apparently college with the lambda (λ) technique of nucleotomy (iv of 25 eyes with type 4 PPC [excluding one heart which had zonular dialysis]; PCR rate = xvi% eyes) vis-a-vis the "V" groove technique (2 of 54 eyes with type 2 and type 3 PPC; PCR charge per unit = 3.7%). Still, this difference in all probability reflects the greater predilection of type four PPCs to be associated with posterior capsular dehiscence (as as well noted preoperatively in all 4 eyes) every bit compared to blazon 2 and type three PPCs and hence is non a true reflection of safety of this technique.
All the cases of PCR with vitreous disturbance in the present series were managed with anterior vitrectomy and depending on the size of the PCR, a 3-slice acrylic IOL was implanted either in the sulcus with the optic capture into the capsular bag (four eyes) or in the purse (2 eyes). The incidence of nucleus drops and retinal detachment in different serial has been reported to vary from 0 to iv%[8 10 16 24] and 0 to 7.ane%,[viii x 24] respectively. A report past Osher et al.[7] had studied 31 eyes and establish PCR in 26% cases, vitreous loss in xiii%, and decentred IOL in 6% cases. None of the cases in the present series had nucleus drop, vitreous prolapse into the anterior chamber, or decentered IOL postoperatively. However, 5% cases had rest posterior capsular plaques which were later managed with Nd:YAG laser capsulotomy. Tabular array two lists the comparison of present study with other studies.
Comparison of Present Study Consequence with other Studies
The utilize of femtosecond light amplification by stimulated emission of radiation-assisted cataract surgery (FLACS) for PPC is increasingly being reported.[25 26 27] Notwithstanding, there is controversy regarding the safety of FLACS over conventional phacoemulsification for PPC. A case report past Alder et al.[25] comparing traditional phacoemulsification versus FLACS in PPC plant posterior capsular tear in one eye each of two patients operated using femtosecond light amplification by stimulated emission of radiation in comparison to the contralateral eyes which had an uneventful intraoperative grade with traditional phacoemulsification. They hypothesized that femtolaser surgery-associated PCR was secondary to cavitation bubbling getting trapped behind the lens material or hydrodelineation not occurring through the usual planes leading to inadvertent hydrodissection. Recently, Vasavada et al.[26] described a technique of femtodelineation in which femtosecond laser was used with cylindrical pattern to create multiple cylinders in the lens with the number, diameter, and depth of each cylinder being customized by the surgeon aided by the alive inductive segment optical coherence tomography (ASOCT) view. The nucleus was emulsified without performing hydroprocedure and they reported PCR rate of 4.iv% (in 2 patients out of 45). Titiyal et al.[27] have also recently described a femtosecond laser-assisted hybrid technique of three cylinders and three chops for such cases in which they found 100% success charge per unit in 25 eyes without any case of PCR and all eyes were implanted with IOL in capsular pocketbook. Though FLACS may go the preferred technique for routine every bit well as complicated cataract surgeries in the future, at the present time, its widespread use is limited past the relatively higher cost as well as lack of access to femtosecond laser technology for a majority of the cataract surgeons in developing countries similar Republic of india. Hence, the need for adopting a meticulous technique and ensuring safer outcomes with conventional phacoemulsification cannot be overemphasized.
Limitations: The authors would like to admit certain limitations of the study. Being retrospective in nature, data about the size of the polar opacity was not bachelor for a majority of the patients and hence is not reported in the results. Polar cataracts of >4 mm in size have been reported to accept nearly v times higher take a chance of intraoperative capsular dehiscence vis-a-vis cataracts <4 mm in diameter.[24] ASOCT which has been shown to have a reasonably high sensitivity (87.v–100%) and specificity (62–94.nine%)[28 29] to preoperatively find posterior capsular dehiscence was likewise non done due to lack of availability of OCT technology with penetration sufficient enough to image the posterior lens capsule, during the period when the patients included in the study were operated.
Conclusion
The charge per unit of posterior capsular ruptures in the nowadays series were lower than most published studies, which the authors believe is a summative effect of combining the techniques which take been described in literature over time to tackle posterior polar cataracts more safely and finer. Managing posterior polar cataracts always remains a challenge, and advancements in diagnostic and operative engineering science, that is, ASOCT and FLACS will help the surgeons to better prognosticate the cases preoperatively, as well equally make the intraoperative events more predictable. Even so, the authors would like to reemphasize that given the socioeconomic mileu of our land where a majority of cataract surgeons may non have easy access to the sophisticated equipments, polar cataracts tin however be managed very effectively past adopting techniques at every footstep of phacoemulsification which assistance to minimize the occurrence of posterior capsular dehiscence.
Financial support and sponsorship
Nix.
Conflicts of interest
There are no conflicts of interest.
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Keywords:
Femtosecond laser assisted cataract surgery; FLACS; hydrodelineation; lambda technique; posterior polar cataract; V groove; viscodissection
Source: https://journals.lww.com/ijo/Fulltext/2020/68040/Phacoemulsification_in_posterior_polar_cataract_.11.aspx
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