Current after-cataract prevention relies on optimizing the natural barrier effect of the optic rim against lens epithelial cell (LEC) migration. However, deficiencies in circumferential capsular bag closure caused by the intraocular lens (IOL) haptic or delayed secondary re-division of the fused capsules by Soemmering´s ring formation lead to primary or secondary barrier failure. Consequently, surprisingly high posterior laser capsulotomy rates have been reported long-term, even with optimal capsular surgery and the most widespread hydrophobic acrylic IOLs, considered to be the most advanced. Intraoperative removal of the central posterior capsule has been shown to be effective in further reducing LEC immigration. However, efficacy has turned out to be limited because of the propensity of LECs to use the posterior optic surface as an alternative scaffold. Technique: in pediatric cataract surgery, buttoning-in of the optic into an adequately-centered posterior capsulorhexis opening has been described previously. This technique was further elaborated and applied as the standard technique in a large series of adult eyes. In general, the diameter aimed at was 5–6 mm for the anterior, and 4–5 mm for the posterior capsulorhexis. Between September 2004 and June 2007, 1000 consecutive cases have thus been performed and systematically evaluated. One hundred and fifty eyes additionally underwent extensive anterior LEC abrasion. Another sub-series investigated the option of further reducing capsular fibrosis by creating an anterior capsulorhexis larger than the optic. Evaluation: special scrutiny was applied to detect postoperative vitreous entrapment. Regeneratory and fibrotic after-cataract formation were both meticulously followed-up. Postoperative pressure course, anterior segment inflammation, macular thickness and morphology, as well as axial optic stability and optic centration, were evaluated in intraindividual comparison studies. Technique: in pediatric cataract surgery, buttoning-in of the optic into an adequately-centered posterior capsulorhexis opening has been described previously. This technique was further elaborated and applied as the standard technique in a large series of adult eyes. In general, the diameter aimed at was 5–6 mm for the anterior, and 4–5 mm for the posterior capsulorhexis. Between September 2004 and June 2007, 1000 consecutive cases have thus been performed and systematically evaluated. One hundred and fifty eyes additionally underwent extensive anterior LEC abrasion. Another sub-series investigated the option of further reducing capsular fibrosis by creating an anterior capsulorhexis larger than the optic. Evaluation: special scrutiny was applied to detect postoperative vitreous entrapment. Regeneratory and fibrotic after-cataract formation were both meticulously followed-up. Postoperative pressure course, anterior segment inflammation, macular thickness and morphology, as well as axial optic stability and optic centration, were evaluated in intraindividual comparison studies. A low rate of vitreous complications was found, which can be avoided by appropriate surgery. Vitreous entanglement occurred in six eyes, and vitreous herniation after PPCCC over-sizing in two. In three, anterior vitrectomy was performed. There was only one single case of retinal detachment—supposedly unrelated to the technique itself—and no case of cystoid macular edema. Retro-optical regenerate formation was completely abolished, while fibrosis was drastically reduced by the posterior capsule sandwiched in between the anterior LEC layer on the backside of the anterior capsule and the anterior optic surface, thereby blocking contact-mediated myofibroblastic LEC transdifferentiation. Additional capsular polishing further reduced residual fibrosis emerging from the anterior capsule contacting the optic adjacent to the haptic junction, as well as regeneratory LEC re-proliferation on the posterior capsule overlying the optic. Postoperative pressure course was almost identical to that found after standard in-the-bag implantation of the IOL, as was flare, and macular thickness and morphology. As opposed to bag-fixated IOLs, no axial movement of the optic was detected. IOL optics always perfectly centered even when the capsular opening was not optimally centered. Due to the exquisite stretchability and elasticity of the posterior capsule, the 6-mm IOL optic could safely be buttoned-in in a posterior capsulorhexis of 4 mm and smaller. Posterior optic buttonholing (POBH) is a safe and effective technique which not only excludes retro-optical opacification, but also withholds capsular fibrosis by obviating direct contact between the anterior capsular leaf and the optic surface. Anterior LEC abrasion significantly reduced both the residual fibrosis and regeneratory LEC proliferation. Apart from pediatric cataract, POBH is currently recommended for eyes with pseudoexfoliation syndrome, high axial myopia, peripheral retinal disease, and multifocal IOL implantation. Toric IOLs and magnet-driven accommodative IOL systems are other potential applications. Generally, POBH holds promise for becoming a routine alternative to standard in-the-bag IOL implantation in the future.

To compare the long-term effect of extensive polishing and nonpolishing of the anterior lens capsule on posterior capsule opacification (PCO) and neodymium:YAG (Nd:YAG) capsulotomy rates. Department of Ophthalmology, Medical University of Vienna, Vienna, Austria. This prospective randomized bilateral double-masked study included 108 eyes of 54 consecutive patients with age-related cataract. Following phacoemulsification, 3-piece intraocular lenses (IOLs) with round-edged silicone optics were implanted. Patients received an Allergan SI-40 IOL with a truncated, round optic edge or a Domilens Silens6 IOL with a fully round optic edge. Patients were randomly assigned to have extensive anterior capsule polishing with the Menapace aspiration curette or no treatment in the first eye; the second eye received the opposite treatment. Digital retroillumination images were taken at 1 week, 1 year, and 3 years, and Nd:YAG capsulotomy rates were evaluated. Posterior capsule opacification was objectively scored using automated image analysis software (AQUA) or estimated based on clearly defined assumptions if a capsulotomy had been performed. Thirty-nine patients (78 eyes) concluded the study. Three-year PCO scores after polishing did not differ significantly (P>.05). However, 21 polished eyes (53.8%) required Nd:YAG laser capsulotomy compared with 14 nonpolished eyes (35.9%). The mismatch between PCO scores and Nd:YAG rates resulted from a change in PCO morphology that is not detected by scoring methods based on retroillumination photography but is visually disturbing to patients. Polishing the anterior capsule was effective in reducing fibrotic opacification but ineffective in reducing regeneratory opacification. Changes in regeneratory PCO morphology not picked up by retroillumination photography increased the need for Nd:YAG laser capsulotomy.

Background To evaluate rotation and its influencing factors of an aspheric one-piece hydrophobic acrylic intraocular lens (IOL) Vivinex XY1 during 6 months after operation. Methods In this institutional trial, 122 eyes of 66 patients were implanted with a non-toric aspheric IOL Vivinex XY1 (Hoya Corporation, Tokyo, Japan). IOL alignment was assessed at the end of surgery, 1 hour, 1 week, 1 month and 6 months after implantation. Confounding factors such as axial length, presence of anterior fibrosis and randomised implantation in four different intended axes (0°, 45°, 90°, 135°) were evaluated. Decentration and tilt were measured using a Purkinje metre. Results Assessment of rotational stability was possible for 103 of 122 implanted IOLs 6 months after eye surgery. The median absolute rotation was 1.1° (range: 0°–5°). Rotation was significantly increased within the first hour after operation compared with later time-points (p<0.001). No correlation was found with axial length and rotation (Spearman’s r=0.048, p=0.63). No significant difference was observed regarding different implantation axes (p=0.75). Rotation was not influenced by the presence of anterior fibrosis (p=0.98). Conclusion Assessing the true IOL position at the end of surgery is crucial for the evaluation of rotational stability of IOLs. No IOL rotation exceeding 5° could be detected 6 months after surgery.

To assess the influence of artificial tears of different viscosity on K-readings prior to cataract surgery. Prospective randomized crossover, before-and-after clinical study. Setting: Department of Ophthalmology, Medical University of Vienna. A total of 123 eyes of 80 patients prior to cataract surgery were assigned to 2 groups based on normal and dry eyes. Two native baseline keratometries were followed by instillation of either high- or low-viscosity eye drops. Keratometry was repeated 30 seconds, 2 minutes, and 5 minutes after instillation. Influence of eye drops of different viscosity in normal and dry eyes on short time K-readings. Repeatability between native baseline measurements was high (standard deviation = 0.02 mm in normal and in dry eyes). In normal and dry eyes, a statistically significant increase in measurement variability after instillation of both low-viscosity and high-viscosity eye drops was observed (P < .01). Measurement variability was most pronounced between baseline measurement and 30 seconds and diminished over time. Variability of K-readings appeared higher in dry eyes compared with normal eyes. Astigmatism changed more than 0.5 diopters in 13.2% of normal eyes and 34.4% in dry eyes using eye drops of high viscosity. Tear film-stabilizing eye drops prior to keratometry measurements influenced K-readings significantly, especially in dry eyes. A time period of more than 5 minutes should be allowed to pass after instillation of eye drops. The higher the viscosity of the eye drops, the stronger the influence and the longer its persistence.