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• W1495243353 abstract "Suction posterior capsulorhexis (SPC) is a relatively new technique for creating a posterior capsulorhexis. We present a case series of seven patients who required Nd:YAG laser treatment 27 months after SPC. No patient had pre-existing risk factors for increased postoperative inflammation and all received a one-piece polymethylmethacrylate intraocular lens placed in-the-bag. Although it reduces the need for Nd:YAG laser treatment, SPC, like the more usual forceps posterior capsulorhexis, does not completely eliminate it. Suction posterior capsulorhexis (SPC), as a technique for managing posterior capsule problems, such as tears or plaque, was first described in 1999 (Hugkulstone 1999); the early results were presented 3 years later (Hugkulstone 2002). At that time, no patients had required subsequent Nd:YAG laser treatment. We present here a series of patients who have since undergone such treatment. Seven patients who underwent two-port phacoemulsification via a sutureless scleral tunnel, SPC and in-the-bag polymethylmethacrylate (PMMA) intraocular lens (IOL) implantation between 1999 and 2001 subsequently required Nd:YAG laser treatment. No patient had concomitant ocular or systemic pathology associated with increased postoperative inflammation. Patient demographics and surgical details are summarized in Table 1. All patients later developed visual deterioration as a result of lens epithelial cell (LEC) proliferation across the posterior capsulorhexis 14–45 months after their initial surgery. The postoperative and pre- and post-laser visual acuities and timing of laser treatment are detailed in Table 2. Suction posterior capsulorhexis was introduced into clinical practice in June 1998. During the time between then and December 2001, which includes the period when the index cases underwent surgery, 249 eyes have required SPC, of which 233 (94%) received a PMMA IOL. This gives an incidence of 3.0% of eyes with a PMMA IOL requiring subsequent Nd:YAG laser treatment. Table 3 shows the number of SPCs per year and those undergoing subsequent laser treatment. Interestingly, during the same period, two further patients (both male, aged 74 and 59 years) who had required SPC (both for posterior capsule tears) were subsequently noted to have developed LEC ingrowth within the posterior capsulorhexis, at 12 and 42 months, respectively, following surgery. However, neither was affected by this ingrowth, with respective visual acuities of 6/4 and 6/5, and Nd:YAG laser treatment has not been required to date. Posterior capsule opacification (PCO) is a common reason for visual deterioration following cataract surgery (Apple et al. 1992) and there has been considerable interest in strategies to reduce PCO (Apple et al. 1992; Spalton 1999) and its effects on visual function after cataract surgery. Posterior capsulorhexis has been proposed as one option to achieve this (Galand et al. 1996). However, Tassignon et al. (1998) found that, whilst rare in low risk eyes, secondary closure does occur in those at high risk of postoperative inflammation (young patients or those with uveitis or diabetes) (Tassignon et al. 1996, 1998), with between 2.5% (Tassignon et al. 1998) and 4% (Tassignon et al. 1996) requiring subsequent Nd:YAG laser treatment, with a mean follow-up of 17.1 months (SD 9.8 months) (Tassignon et al. 1998). Conversely, Lam et al. (1998) reported no cases requiring Nd:YAG laser treatment in a series of patients uveitic cataracts undergoing primary posterior capsulorhexis after a similar follow-up of 16.9 months (SD 7.3 months). None of our patients had high risk characteristics but still 3% required laser treatment, although after a longer time interval of 27.7 months (SD 9.9 months). Intraocular lens material may play a role in the development of posterior capsulorhexis closure. Lam et al. (1998) used a one-piece, heparin-surface-modified PMMA IOL, whilst Tassignon et al. (1996, 1998) used a one-piece PMMA IOL, as in our series. All IOLs were implanted in-the-bag. A recent study demonstrated lens epithelial cell ingrowth across the posterior capsulorhexis in 40% of eyes receiving a hydrogel IOL and 8% of eyes receiving a silicone IOL at 12 months postoperatively (Georgopoulos et al. 2001). By 2 years postoperatively, 3% of eyes in each IOL group required Nd:YAG laser treatment (Georgopoulos et al. 2003). However, a capsule tension ring was used in all cases in this series (Georgopoulos et al. 2001, 2003). Our results are broadly in line with these reports (Tassignon et al. 1996, 1998; Lam et al. 1998; Georgopoulos et al. 2001, 2003), all of which used different IOL materials although all IOLs had a round edge to the optic. Another point of interest is the support for LEC regrowth within the posterior capsulorhexis. In a recent in vitro study, De Groot et al. (2003) demonstrated that such LEC regrowth occurs on a basal lamina of loosely arranged fibres. Scanning electron microscopic studies suggested that this lamina corresponds to the anterior hyaloid membrane (De Groot et al. 2003). In support of this, careful removal of this membrane from some prepared capsular bags, before cell culture, appeared to prevent LEC proliferation within the posterior capsulorhexis area (De Groot et al. 2003). As one would expect the anterior hyaloid membrane to be disrupted during Nd:YAG laser treatment, this may suggest that subsequent repeat treatments would not be required. However, this is not always the case following conventional laser posterior capsulotomy, as detailed both in our accompanying article and by other authors (Jones et al. 1995; Roger et al. 1995; Kato et al. 1997; Oshika et al. 2001; Kurosaka et al. 2002). Suction is a novel way to produce a posterior capsulorhexis compared to the more usual use of forceps (Galand et al. 1996; Tassignon et al. 1996, 1998; Lam et al. 1998; Georgopoulos et al. 2001). Our series confirms that secondary opacification within the area of the posterior capsulorhexis is a real, although rare, problem in the long term, despite the different techniques employed to create the posterior capsulorhexis. However, these rates are considerably lower than the 26% reported in cases without posterior capsulorhexis (Hollick et al. 1999), and approach that offered by Acrysof™ IOLs (Hollick et al. 1999), thus offering a further strategy in our search to improve the results of modern cataract surgery." @default.
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• W1495243353 date "2005-03-02" @default.
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• W1495243353 title "YAG curios #2: Nd:YAG laser treatment following suction posterior capsulorhexis" @default.
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