Types of capsular opacification - anterior - posterior

A: anterior capsular P: - fibrosis - proliferation/pearl - linear - mixed

3 - Dronka Flashcards by Elyse Kohl

Anatomy

-lens capsule

Elastic membrane

Barrier

Permeable

Reproducing

basal membrane of epith -> anteriorly
basal membrane of elongating fiber cells -> posteriorly

Thickness

thickest at equator
thinnest at post capsular poles

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Characteristics

lens
surgery

Surrounded by capsule (ant and post)

Anterior = capsulorhexis
Posterior = remains intact to hold IOL implant
-PCO: growth and proliferation of lens epi cells from original ct migrate on lens capsule

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Types of capsular opacification

anterior
posterior

A: anterior capsular

fibrosis
proliferation/pearl
linear
mixed

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Anterior capsular opacification

starts
location is occurs
complications (2)

Starts by 1st post-op month -> 6 weeks

Occurs at continuous curvilinear capsulorhexis (CCC)

Decenter IOL
-multifocal IOL: must maintain good centraiton
Lens tilt
-induces astigmatism

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Anterior capsular opacification
-incidence
—lens material (highest and lowest)

Highest

silicone IOL with sharp optic edges
plate haptic silicone design

Lowest
-acrylic IOL

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Anterior capsular opacification

-disease (2)

Retinitis pigmentosa

Diabetes

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Describe Soemmering’s ring

Looks like anterior capsular opacification, but ONLY IN APHAKIC patients

absence of IOL
congenital aphakia
Lowe syndrome, Hallermann-Streiff-Francois syndrome

Result of ant capsule edges attachment to posterior capsule

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Posterior capsular opacification

-fibrosis form

Anterior epi cells form spindle-shaped fibroblasts -> migrate to PC

Pretty thick

Appearance

white opacities
fine folds
wrinkles

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Posterior capsular opacification

-proliferation/pearl form

Pre-equatorial zone lens epi cells form swollen cells, called bladder or Wedl cells -> migrate to PC

Appearance

circular opacification
Elschnig pearls = almost jelly-like, easy to blast thru

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Posterior capsular opacification

-mixed form

Combo of fibrosis and proliferation

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Posterior capsular opacification

-linear form

PCO along persistent striae -> creates channel, allowing epi cells to bypass the barrier created by the square-edge design of the IOL
-little burrows = looks like the lens is cracked

Appearance
-linear striae

Can cause visual distortion

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Incidence and impact
-PCO
—how common
—when occurs
—who’s at higher risk

Most common complication of ct sx

Occurs days-years post-op

b/w 30-50% within 3-5 years
average 2-3 mo

Younger pts at higher risk
-cells regenerate faster/body works more effectively

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Incidence and impact

-PCO within 3mm zone affects (3)

High contrast sensitivity

Low contrast acuity

Psychophysical test results with differing degrees of sensitivity
-forward light scatter -> contrast sensitivity -> VA

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Prevention of PCO

Removal of all epi cells/cortical remnants

Lavage the intracapsular space with saline during surgery to denature residual epi cells

Clean AC well

Implanting IOL

Pharmacological drops
-stops mitosis - binds tubulin and inhibits formation of microtubules

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Treatment options

P: surgical cutting/peeling, polishing posterior capsule

N: Nd:YAG 1064

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Laser type

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Nd:YAG 1064:
pigment independent

4 nanoseconds
-large amount of energy in small spot size for brief time

photodisrupive = shock wave
-high light energy causes tissue to reduce to plasma
-disintegrate tissue
-no thermal/coag effect
-hydrodynamic waves and acoustic pulses travel back toward surgeon
—focal point must be posterior to target tissue =offset

Contraindications

absolute (2)
relative (4)

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corneal haze/pathology
unable to hold steady/fixate

glass IOL
active intraocular inflamm
known/suspect CME
high risk for RD

Complications

-IOP spike

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Most common besides floaters

Reduced facility for AH outflow
-debris, acute inflamm cells, liquification of vitreous, shock wave damage to TM

> 10mmHg

peaks at 3-4 hours
decreases, but may remain elevated for 24 hours, returns to baseline in 1 week

Assoc with: glaucoma, capsulotomy size, lack of IOL, sulcus fixation, energy, myopia, vitreoretinal disease

Complications

-stromal haze/edema/endo cell count

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2.3-7%

Can lead to Fuch’s dystrophy
-caution with energy into the eye

Complication

-CSME

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0.55-2.5%

Within 3 weeks - 11 mo

Decr risk by incr time between ECCE and capsulotomy
-minimum time 3 mo

Complications
-IOL damage/pitting
—describe
—material

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Significant glare and image degradation
-problem if hemibeams are not in contact/are out of focus

Minimally impacts VA

Glass = fractures
PMMA = sustain cracks, central defects with radiating fractures
Silicone = blistered lesions, localized pits
Acrylic = white haze, looks like a little cataract, highest risk of pitting

Complications

RD
retinal breaks

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RD:
Lifetime risk after cataract surgery = 1%
After capsulotomy = 2%

Occurs immediately or 1+ years

RB: asymptomatic breaks found in 2.1% within 1 mo

Complications

-endophthalmitis

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Rare

Propionbacterium acnes endophthalmitis reported following capsulotomy

Presumed opportunity for organisms within capsule -> vitreous

Complications

-risk factors for RD

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Higher total laser energy

Higher axial length (>24mm)
-avoid large capsulotomy in pts with high axial length

Candidates for YAG CAP

Vision 20/30 or worse Symptomatic -glare, blur, vision, contrast >3 mo post-op

``` Posterior capsulotomy -settings —energy —spot size —duration —pulses —amount of burns —offset ```

energy: 1.3-1.7mJ spot size: fixed 8-11 microns duration: fixed 4 nanoseconds pulses: 1 amount of burns: 10-40 offset: +150 to +500 microns posteriorly

``` Posterior capsulotomy -pattern —cruciate —horseshoe —christmas tree —can-opener ```

Cru: superior -> inferior H: upside-down U from 7:00 to 5:00 ChT: 12:00 to 4:30 and 12:00 to 7:30, no shots in central optical zone Can: circular, large floater within vision

Posterior capsulotomy - marker shot - treatment zone

Optional shot Use with off-center pupil or to tell where the center of their pupil is for LOS ~4mm cruciate pattern (larger than undilated pupil) -if make is smaller, get PH effect = do for really severe/thick

``` Anterior capsulotomy -settings —energy —spot size —duration —pulses —amount of burns —pattern —offset ```

energy: 1.3-1.8mJ spot size: fixed 8-11 microns duration: fixed 4 nanoseconds pulses: 1 amount of burns: 10-14 pattern: radial burns at the clock hours offset: -150 to -500 microns anteriorly

Anterior capsulotomy | -treatment pattern

Radial pattern at clock hours to release phimosis If untreated, will tighten around the lens and create lens movement, astigmatism, etc.

YAG CAP follow up - 1 day - 1-2 weeks

High risk pts: high myopes, hx of severe infection Check IOP, AC reaction, dilate

Post-op | -if pt RTC with secondary decreased vision

Assess for: - refractive error shift - CME - RD - glaucoma - vitreous hemorrhage

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