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BACKGROUND AND OBJECTIVE: To evalu- group achieved a best-corrected visual acuity of 20/25 or
ate the clinical results of reverse optic capture (ROC) better. Ninety-four percent of eyes in the ROC group and
with single-piece posterior chamber intraocular lenses 100% in the control group had postoperative spherical
(PC-IOLs) in cases of phacoemulsification cataract and equivalent 1.00 D of the intended refraction. Refraction
IOL surgery with posterior capsular rupture. was stable between 1 month and final follow-up in both
groups. In all eyes with ROC, the IOL remained well cen-
PATIENTS AND METHODS: Preoperative di- tered with a securely captured optic. There were no vision-
agnosis, intraoperative events, surgical parameters, threatening complications throughout the follow-up.
intraoperative and postoperative complications, and
preoperative and postoperative visual acuity and refrac- CONCLUSION: The comparable outcomes in
tion of 16 eyes that underwent ROC were reviewed both groups suggests that optic capture of a single-
and analyzed. The fellow eye of 12 patients undergoing piece acrylic IOL through an anterior capsulorhexis
uneventful phacoemulsification without optic capture merits consideration for IOL placement in selected
served as the control group. cases of insufficient posterior capsule support.
RESULTS: Over a mean of 19 months follow-up, [Ophthalmic Surg Lasers Imaging 2012;43:480-
94% of eyes in the ROC group and 92% in the control 488.]
From Jones Eye Clinic and Surgery Center (JJJ, GJCJ), Sioux City, Iowa; the Department of Ophthalmology (TAO, GMR), University of Iowa, Iowa; and the
Department of Ophthalmology and Visual Sciences (GJCJ), University of Utah, Salt Lake City, Utah.
Originally submitted October 6, 2011. Accepted for publication July 16, 2012. Posted online September 6, 2012.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to George J. C. Jin, MD, PhD, Jones Eye Clinic and Surgery Center, 4405 Hamilton Boulevard, Sioux City, IA 51104. E-mail: george-
jin@live.com
doi: 10.3928/15428877-20120830-02
OPHTHALMIC SURGERY, LASERS & IMAGING VOL. 43, NO. 6, 2012 481
esthesia were used. A paracentesis and a 2.7-mm clear The single-piece acrylic foldable IOLs (AcrySof
corneal incision were created with keratome blades. The IOLs; Alcon Laboratories, Inc.) used in this study were
anterior chamber was inflated with a dispersive oph- AcrySof SN60WF in 15 eyes and AcrySof ReSTOR
thalmic viscoelastic device, and a round, well-centered SN6AD3 in one eye. In the control group, all had an
CCC was fashioned with Utrata forceps. The CCC was AcrySof SN60WF IOL implanted into the capsular bag.
sized approximately 5.0 to 5.5 mm to ensure complete
overlap of the intended in-the-bag IOL optic. This was Statistical Analysis
followed by hydrodissection and phacoemulsification. Descriptive statistics (patient age, IOL power, pre-
The nucleus was removed with the phacoemulsifica- operative and postoperative visual acuity, and postopera-
tion handpiece and second instrument. Residual cortex tive objective refraction) were analyzed using SPSS for
was removed with the irrigation/aspiration handpiece. Windows (version 13.0; SPSS, Inc., Chicago, IL). Data
A cohesive ophthalmic viscoelastic device was used for analysis was based on the number of eyes. Snellen acuity
capsular bag expansion, and the IOL was implanted in was converted to the logarithm of the minimum angle of
the capsular bag with an injector system. resolution (LogMAR) values. Predicted refractive error
In cases where the PCR was recognized following was calculated using the actual postoperative refraction
IOL implantation into the bag, ROC was achieved by at the last follow-up visit minus the target postopera-
positioning a spatula (modified Baes ICL manipulator; tive refraction. The Students t test was used to evaluate
Rhein Medical, St. Petersburg, FL) or a Kuglen hook the significance of the difference. The paired t test was
through the main incision reaching underneath the optic used to evaluate the significance of measurements preop-
and pulling the optic forward gently, thus vaulting the en- eratively versus postoperatively and 1 month postopera-
tire optic through the opening of intact CCC. The optic tively versus last follow-up. Data were expressed as mean
was therefore entrapped centrally in front of the bag and standard deviation, and a P value of less than .05 was
the haptics remained in the capsular bag. Care was taken considered statistically significant.
to ensure that the optic was completely but not partially
captured by inspecting the shape of the CCC. RESULTS
The ophthalmic viscoelastic device was aspirated
slowly from the anterior chamber using irrigation/as- Patient Characteristics
piration or automated vitrector. The ophthalmic visco- The study group enrolled 16 eyes of 16 patients (9
elastic device behind the IOL was left in place. The an- women, 7 men). The mean age of the patients at the time
terior chamber was restored with balanced salt solution of surgery was 74.3 12.0 years (range: 42 to 89 years).
and the incisions were hydrated and tested for leakage. The mean follow-up was 19.1 months (range: 1 to 43
In cases where the PCR was recognized prior to im- months). The control group included 12 patients fellow
plantation of the IOL, the spatula was placed through eyes. There was no significant difference of the age, axial
the paracentesis and underneath the IOL as it was be- length, keratometry, IOP, and follow-up periods between
ing injected to avoid descent into the vitreous. Either the two groups (Table 1).
a syringe-style plunger injector or assistant activation
of the screw mechanism of a traditional injector aided Visual Acuity
in this process. As the anterior segment was fully stabi- Table 2 shows the postoperative visual acuity in
lized with ophthalmic viscoelastic device, the lens was each group. The final mean LogMAR UCVA was simi-
temporarily suspended and allowed for opening of the lar in these two groups (P = .780). At last follow-up,
haptics and entrapment of the optic as described above. 50% of eyes in each group had UCVA of 20/25 or bet-
At the end of the operation, a drop of antibiotic ter and 81% of eyes in the ROC group and 75% in the
was placed on the surface of the eye. In some cases at control group had UCVA of 20/40 or better.
high risk for ocular hypertension, sustained-release ac- The preoperative mean LogMAR BCVA was 0.52
etazolamide 500 mg was taken after surgery. Further 0.46 in the ROC group and 0.53 0.33 in the con-
postoperative treatment included topical antibiotic for trol group. There was no significant difference between
1 week, steroid for 4 weeks, and nonsteroidal anti-in- the groups (P = .939). At last visit, the mean LogMAR
flammatory drops for 4 to 8 weeks. BCVA was 0.07 0.13 in the ROC group and 0.05
0.12 in the control group. The improvement of BCVA (D) and within 1.00 D of emmetropia during the
from preoperatively to postoperatively was significant follow-up. In the ROC group, the mean spherical equiv-
in each group (P = .001 in the ROC group and P = alent decreased from 0.66 2.00 D preoperatively to
.000 in the control group, paired t test), which cor- -0.53 0.73 D at 1 month postoperatively and -0.39
responds to 94% of eyes in the ROC group and 92% 0.77 D at last follow-up. In the control group, the mean
of eyes in the control group achieving a postoperative spherical equivalent was 0.29 3.00 D preoperatively,
visual acuity of 20/25 or better. No eye lost BCVA in -0.23 0.31 D 1 month postoperatively, and -0.18
either group. There was preexisting age-related macular 0.28 D at last visit. There was no significant difference
degeneration in 1 eye in each group having BCVA of in the mean spherical equivalent preoperatively (P =
20/60. There was no significant difference in BCVA at .690), at 1 month postoperatively (P = .191), and at the
last follow-up between the groups (P = .717). last follow-up visit (P = .369) between the groups. The
mean spherical equivalent remained stable between 1
Predictability month postoperatively and the last visit in both groups
Table 3 shows the refractive changes following sur- (P = .252 in ROC group and P = .210 in control group,
gery and the percentage of eyes within 0.50 diopters paired t test). At the last visit, 88% of eyes in the ROC
OPHTHALMIC SURGERY, LASERS & IMAGING VOL. 43, NO. 6, 2012 483
TABLE 2
target refraction and predicted refractive error was not
Postoperative Visual Acuity at Last Visit significant in the ROC group (P = .326) or the control
group (P = .373). No difference of the target refraction
Control
ROC Group Group (P = .859) and the predicted refractive error (P = .112)
Visual Acuity (n = 16) (n = 12) P occurred between these two groups. However, there was
UCVA a slight myopic shift in the ROC group (-0.32 D). At
(LogMAR) the last follow-up, 63% of eyes in the ROC group and
Mean SD 0.21 0.19 0.19 0.21 .780 100% in the control group achieved predicted refractive
20/20 (%) 4 (25) 5 (42) error within 0.50 D, and 94% of eyes in the ROC
20/25 (%) 8 (50) 6 (50)
group were within 1.00 D of the target refraction.
20/40 (%) 13 (81) 9 (75)
Complications and Visual Quality
BCVA ROC was performed uneventfully on all eyes in the
(LogMAR)
series. No complications occurred during the ROC pro-
Mean SD 0.07 0.13 0.05 0.12 .717
cedure. At the same-day or 1-day postoperative exami-
20/20 (%) 7 (44) 8 (67) nation, no eyes in either group had hyphema or severe
20/25 (%) 15 (94) 11 (92) anterior chamber reaction (anterior chamber cells were
< 20/40 (%) 1 (6.3) 1 (8.3) trace or 1+ or less in all eyes). The IOP was higher than
ROC = reverse optic capture; UCVA = uncorrected visual acuity; 25 mm Hg in 5 eyes (31%, range: 25 to 34 mm Hg)
LogMAR = logarithm of the minimum angle of resolution; SD =
standard deviation; BCVA = best-corrected visual acuity.
in the ROC group and 1 eye (8%) in the control group.
These patients were treated with oral carbonic anhydrase
inhibitors, topical aqueous suppressants, or both. IOP
group and 100% of eyes in the control group achieved was rapidly controlled and became normal (less than 21
refraction within 1.00 D of emmetropia. mm Hg) without medication in all patients at the 1-week
Table 4 shows the IOL power and predicted refrac- follow-up. There were no vision-threatening postopera-
tive error in both groups. The difference between the tive complications such as cystoid macular edema, retinal
TABLE 3
Refraction Over Time
Preoperativea Postoperative 1 Monthb Last Visitc
ROC Control ROC Control ROC Control
Time Groups (n = 16) (n = 12) (n = 16) (n = 12) (n = 16) (n = 12)
SE (D)
Mean 0.66 0.29 -0.53 -0.23 -0.39 -0.18
SD 2.02 3.00 0.73 0.31 0.77 0.28
Range
Minimal -3.00 -5.50 -2.50 -0.63 -2.50 -0.63
Maximal +4.25 +4.63 +0.75 +0.38 +0.75 +0.25
Eyes (%)
0.50 D 4 (25) 0 8 (50) 9 (75) 9 (56) 10 (83)
1.00 D 7 (44) 3 (25) 14(88) 12 (100) 14 (88) 12 (100)
1.50 D 9 (56) 8 (67) 1 (6) 1 (6) 0
ROC = reverse optic capture; SE = spherical equivalent; D = diopters.
a
P = .690.
b
P = .191.
c
P = .369.
OPHTHALMIC SURGERY, LASERS & IMAGING VOL. 43, NO. 6, 2012 485
acrylic PC-IOLs in eyes presenting with an unantici-
pated PCR.
Efficacy was evaluated by postoperative UCVA.
The LogMAR UCVA at last visit was similar in the
ROC and control groups (P = .780). Fifty percent
of eyes in each group had a UCVA of 20/25 or bet-
ter and 81% of eyes in the ROC group and 75% of
control eyes had a UCVA of 20/40 or better, which
corresponds to 75% of patients not wearing glasses for
distance in our series. Almost all of our patients (92%)
were satisfied with their outcomes, and this may indi-
cate that patients not achieving a UCVA of 20/40 are
still pleased with the visual improvement after surgery.
With regard to safety, no eye lost more than one
line of BCVA in either group. There were no significant
differences in preoperative and postoperative LogMAR
BCVA between the groups. At the final visit, 94% of
Figure 1. Red reflex photograph of study patient 1 day following eyes in the ROC group and 92% in the control group
surgery showing the reverse optic capture. Filled arrow shows an had a BCVA of 20/25 or better. The final visual acu-
edge of the torn posterior capsule. Open arrow shows the anterior
capsule posterior to the optic but anterior to the haptics.
ity results in the ROC group in this study compared
favorably with those in other studies of phacoemulsifi-
cation in the presence of PCR, which reported 68% to
combination with ROC. In all eyes, the optic was cap- 89% of patients achieved BCVA of 20/40 or better.18-20
tured through the CCC centrally in the sulcus and the However, comparison between studies should be done
haptics were fixated in the bag (Figure 1). with caution because of different inclusion criteria,
sample size, and follow-up periods.
DISCUSSION The other important safety issues are postoperative
complications and a need for further surgery. In our
PCR is a significant intraoperative complication series, there were no vision-threatening complications,
of current cataract surgery that is estimated to occur such as endophthalmitis, cystoid macular edema, and
in approximately 1% of phacoemulsification cases. retinal detachment, in our patients in the follow-up
Even an experienced surgeon, with the best technique, period. No further surgery was needed except for YAG
cannot eliminate this unanticipated complication. capsulotomy.
Management of PCR, and in particular the selection, Contact between the IOL and the iris is one of
placement, and implantation technique of an IOL in the major concerns when all or a portion of the IOL is
cases of incomplete or insufficient capsule support, is placed in the sulcus. A valid concern with ROC is that
an important and controversial topic.7 Various options the optic is in the sulcus and could come in contact
including an anterior chamber IOL, iris suture-fixated with the iris. However, we did not detect this compli-
PC-IOL, or sclera-sutured PC-IOL are acceptable. cation in our series. As shown in the study by Chang
A report by the American Academy of Ophthalmol- et al.,13 complications such as induced pigment disper-
ogy concluded that there was insufficient evidence to sion, secondary IOP elevation, recurrent iridocyclitis,
demonstrate the superiority of one lens type or fixation and lens decentration requiring surgical intervention
site.8 Many alternative fixation techniques have been are the most common issues after sulcus placement of
described and compared in the literature.9-12 Among a single-piece foldable acrylic IOL and seemed to be
them, sulcus implantation of a foldable three-piece related to the large haptics being in the sulcus, unlike
PC-IOL and IOL optic capture technique have attract- ROC where only the optic and not the haptics are in
ed the most attention.3,13-17 The current study evalu- the sulcus. Our lack of any iris issues from the ROC
ated outcomes and the merit of ROC of single-piece is most likely related to the secure fixation of the lens
OPHTHALMIC SURGERY, LASERS & IMAGING VOL. 43, NO. 6, 2012 487
its consideration in selected cases with PCR. The rates rupture. J Cataract Refract Surg. 2011;37:1183-1188.
12. Akura J, Hatta S, Kaneda S, Ishihara M, Matsuura K, Tamai A. Man-
of postoperative complications were low, and there agement of posterior capsule rupture during phacoemulsification us-
were no vision-threatening complications throughout ing the dry technique. J Cataract Refract Surg. 2001;27:982-989.
13. Chang DF, Masket S, Miller KM, et al. Complications of sulcus
the follow-up. Future studies with a larger number and placement of single-piece acrylic intraocular lenses: recommendations
longer follow-up are necessary to assess the late-onset for backup IOL implantation following posterior capsule rupture. J
Cataract Refract Surg. 2009;35:1445-1458.
complications and monitor the long-term stability of 14. Mimura T, Amano S, Sugiura T, et al. 10-year follow-up study of sec-
the IOLs. ondary transscleral ciliary sulcus fixated posterior chamber intraocular
lenses. Am J Ophthalmol. 2003;136:931-933.
15. Zarei-Ghanavati S, Gharaii H, Zarei-Ghanavati M. Simple method
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