Capsular tension ring implantation
after capsulorhexis in
phacoemulsification of
cataracts associated with
pseudoexfoliation syndrome
Intraoperative complications and early
postoperative findings
Şükrü Bayraktar, MD, Tuğrul Altan, MD,
Yaşar Küçümser, MD, Ömer Faruk Yılmaz, MD
ABSTRACT
Purpose: To evaluate the effect of an endocapsular tension ring in preventing zonular
complications during phacoemulsification of cataracts associated with pseudoexfoliation syndrome.
Setting: Eye Clinic of Beyoğlu Education anad Research Hospital, İstanbul, Turkey.
Methods: A prospective randomized study comprised 78 eye with catarct and preudoexfoliation syndrome that were randomly divided into 2 groups. The age sex cataract
densitiy, irldodonesis, axial length anterior chamber depth best corrected visual acuity
( BCVA ) and intraocular pressure ( IOP) were matched between groups in 39 eyes, a
capsular tension ring ( CTR ) was implanted after capsulorhexis and hydrodissection but
before nucleus emulsification. Thirty-nine eyet that did not have a CTR implanted
served as a control. The main outcome measures were the rates of intraoperative
zonular separation and capsular fixation of a foldable intraocular lens (IOL) Posterior
capsule rupture without zonular dialysis, vitreous loss, corneal edema, flon in the
anterior chamber, BCVA, and IOP in the immediate postoperative pedod were also
compared between the 2 groups.
Results: Five eyes ( 12,8%) in the control group and no eye in the CTR group had intraOperative zonular separation ( P = 02) Posterior capsule rupture without zonular separation occurred in 3 eyes (7,7%) in the control group and 2 ( 5,2%) in the CTR group
Capsular IOL fixation was achieved in 37 eyes ( 94,9%) in the CTR group and 31 eyes
( 74,3%) in the control group ( P=44); however uncorrected visual acuity ( UCVA )
was significantly beter in the CTR group ( P=026)
Conclusion: In cases of cataract associated with pseudoexfoliation syndrome implanting
a CTR before phacoemulsification of the nucleus reduced intraoperative zonular separation, increased the rate of capsular IOL fxation and impoved UCVA. J Cataract
Refract Surg 2001; 27;1620- 1628 © 2001 ASCRS and ESCRS
© 2001 ASCRS and ESCRS
Published by Elsevier Science Inc.
0886-3350/01/$-see front matter
PII S0886-3350(01) 00965-8
LSIFICATION IN PSEUDOEXFOLIATION SYNDROME
CTR IMPLANTATION IN PHACOEMULSIFICATION IN PSEUDOEXFOLIATION SYNDROME
C
ataract
surgery in the
presence
of
pseudoexfoliation syndrome has been associated
with an increased
incidence of intraoperative complications.1-17 In
pseudoexfoliation syndrome, lysosomal proteinases
destroy the normal basement membrane structure of
the nonpigmented epithelium of the ciliary body and
anterior lens capsule.18,19 The breakdown of the
basement membrane structure loosens the zonulelens capsule complex and causes adhesions between
the zonules and nonpigmented epithelium.18,19 The
rotational and anterior—posterior forces created
during nucleus emulsifi-cation may lead to total
separation of these weakened zonules, resulting in
vitreous loss. Other factors thought to contribute to
the
increased
incidence
of
intraoperative
complications during cataract surgery in eyes with
pseudoexfoliation syndrome are poorly dilating
pupils, corneal endothelial changes, and bloodaqueous barrier (BAB) breakdown.20-25
In this study, we evaluated the effect of implanting a capsular tension ring (CTR) after capsulorhexis
and hydrodissection on intraoperative complications
resulting
from
zonular
weakness
during
phacoemulsification of the cataract associated with
pseudoexfoliation syndrome.
Patients and Methods
This prospective randomized study comprised 78
eyes diagnosed as having cataract associated with
pseudoexfoliation syndrome that had cataract surgery
between August 1998 and January 2000. Patients
were randomly assigned to 1 of 2 groups. Thirty-nine
eyes had a CTR implanted after capsulorhexis and
hydrodissection were performed but before
phacoemulsification was started. The other 39 eyes
had no CTR and served as a control group.
Accepted for publication May 15, 2001.
From the Eye Clinic ofBeyoglu Education and Research Hospital, Istanbul,
Turkey.
Presented at the Symposium on Cataract, IOL and Refractive Surgery, Boston,
Massachusetts, USA, May 2000.
None of the authors has afinancial orproprietary interest in any material or method
mentioned
Reprint requests to §ukrii Bayraktar, MD, Bankaalaar sok. Number 12/30,
Merdivenkoy 81080, Istanbul, Turkey.
Table 1 shows the patients' characteristics. There
were no statistically significant differences
difference between the 2 groups in age, sex, right or
left eye, cataract density, evidence of iridodonesis,
miotic pupils, axial length, anterior chamber depth
(ACD), best corrected visual acuity (BCVA),
presence of coexisting glaucoma, intraocular
pressure (IOP), and number of glaucoma
medications. Most nuclei in both groups were grade
2 or 3; 14 eyes in the CTR group and 10 in the
control group had white mature cataract (P = .33).
Eyes with uncontrolled glaucoma that had combined surgery were not enrolled in this study.
However, 17 patients (21.7%) with medically
controlled mild or moderate glaucoma and 5 (6.4%)
with previous filtering surgery and controlled
glaucoma were enrolled; 12 of the eyes (30.8%)
were in the CTR group and 10 (25.6%) in the control
group. Eyes with advanced glaucoma with
compromised optic discs, exudative age-related
macular degeneration, diabetic retinopathy, or other
disease that would result in low postoperative BCVA
were excluded from the study.
The mean preoperative IOP was 15.2 mm Hg ±
5.5 (SD) in the CTR group and 15.1 ± 3.7 mm Hg in
the control group (P = .96). The mean number of
glaucoma medications was 0.23 ± 0.54 and 0.26 ±
0.55, respectively (P = .95).
Preoperatively, a dilated fundus examination was
performed except in eyes with very dense or white
cataract.
All operations were performed by 1 of 2
experienced surgeons. Surgeon 1 (§.B.) performed
surgery in 34 eyes (19 with a CTR), and surgeon 2
(O.F.Y.) operated on 44 eyes (20 with a CTR) There
was no statistically significant difference between
the percentage of eyes operated on by each surgeon
or the percentage of eyes implanted with a CTR (P =
.25, chi-square test).
Surgical Technique
After sub-Tenon's or topical anesthesia was
administered, a 3.2 mm temporal clear corneal
incision was made with a diamond knife. The
anterior chamber was filled with sodium hyaluronate
3.0%-chondroitin sulfate 4.0% (Viscoat®). In eyes
with poor pharmacological pupil dilation, a Beehler
dilator or iris hooks were used to enlarge the pupil.
Capsulorhexis was performed with a Utrata forceps.
CTR IMPLANTATION IN PHACOEMULSIFICATION IN PSEUDOEXFOLIATION SYNDROME
In eyes with mature cataract, trypan blue vital dye
staining was used to visualize the anterior
1621
J CATARACT REFRACT SURG—VOL 27, OCTOBER
2001
Group
Characcteristic
CTR
( n = 39 )
CTR
± 5.4
(73.7
n = 39
)
P Value
73.7 ± 5.4
21 (53.8)
Control
( n = 39 )
Control
71.5 ±8.1
( n = 39 )
71.5 ±8.1
15 (38.4)
Female
Male
18(53.8)
(46.2)
21
24 (38.4)
(61.6)
15
Eye,n(%)
Female
18 (46.2)
24 (61.6)
.82
Right
Eye,n(%)
18(46.1)
20 (51.2)
.82
Left
Right
21 (53.9)
18(46.1)
19(51.2)
(48.8)
20
Nucleus, n (%)
Left
21 (53.9)
19 (48.8)
Characcteristic
Mean age (years)
Sex, n (%)
Mean age (years)
Malen (%)
Sex,
Grade 1 n (%)
Nucleus,
3 (7.7)
Group
0
Grade12
Grade
15
(38.4)
3 (7.7)
21
0 (53.8)
Grade23
Grade
(17.9)
157 (38.4)
(20.6)
218(53.8)
Grade34
Grade
(2.6)
71(17.9)
80 (20.6)
Mature4cataract, n (%)
Grade
13
(33.4)
1 (2.6)
10(25.6)
0
Preoperative
iridodonesis,
n (%)
Mature
cataract,
n (%)
13 (33.4)
10(25.6)
Yes
Preoperative
iridodonesis, n (%)
7(17.9)
5 (12.8)
32
(82.1)
7(17.9)
34
(87.2)
5 (12.8)
No
Yes
P Value
.16
.17
.16
.17
.17
.17
.76
.76
Miotic pupil*, n (%)
17(82.1)
(43.6)
14(87.2)
(35.9)
.58
No
32
34
Mean axial length (mm)
23.1 ±1.6
23.0 ±1.8
.63
Miotic
pupil*,
n (%)
17 (43.6)
14
(35.9)
.58
Mean ACD
(mm)
2.55
±0.46
2.74
± 0.42
.14
Mean
length
(mm)
23.1 ±1.6
23.0±±1.8
.63
Meanaxial
BCVA
(Snellen)
20/180
± 135
20/165
120
.83
Mean
ACD (mm)
2.55
±0.46
2.74
± 0.42
.14
Coexisting
glaucoma, n (%)
12 (30.8)
10(25.6)
.80
Mean
BCVA
(Snellen)
20/180
135
20/165
± 120
.83
Mean-lOP
(mm/Hg)
15.2±±5.5
15.1
± 3.7
.96
Coexisting
glaucoma,
n (%) medications
12 (30.8)
10(25.6)
.80
Mean number
of glaucoma
0.23
± 0.54
0.26 ± 0.55
.95
Mean-lOP (mm/Hg)
15.2 ±5.5
15.1 ± 3.7
.96
0
5(12.8)
.02*
Table
1.
Preoperative
patient
Mean number of glaucoma medications
0.23 ± 0.54
0.26 ± 0.55
.95
characteristics.
5(12.8)
.02*
Table 1.
Preoperative patient 0
All means ± SD
characteristics.
CTR = capsular tension ring; ACD =
All means ± SD
anterior chamber depth; BCVA =
CTR = capsular tension ring; ACD =
best corrected visual acuity; IOP =
anterior chamber depth; BCVA =
intraocular pressure "Pupils 4.0 mm
best corrected visual acuity; IOP =
or smaller after full dilation
intraocular pressure "Pupils 4.0 mm
Zonular separation
or
smaller
after
full dilation
Group
P Value
Characcteristic
Whole
lens
dropped
into vitreous
0
2 (5.1)
.24
Zonular
separation
Conversion to ICCE
0
2 (5.1)
.24. CTR
Control
Whole lens dropped into vitreous
00
21(5.1)
.24
(2.6)
.02 ( n = 39 )
Zonular dialysis during IOL
( n = 39 )
Conversion to ICCE
0
2 (5.1)
.24.
implantation
Mean
age
(years)
71.5 ±8.1
.16
0
1 (2.6)
.02 73.7 ± 5.4
Zonular dialysis during IOL
Sex,
n (%)capsule perforation without 2(5.1)
3 (7.7)
.24
.17
Posterior
implantation
zonular
Male separation
15 (38.4)
3 (7.7)
.24 21 (53.8)
Posterior
capsule perforation without 2(5.1)
Anterior vitrectomy
2(5.1)
8(20.5)
.01*
zonular
separation
Female
18
(46.2)
24
(61.6)
lens
capsule. tension
All capsulocortical
attachments were loos- intraocular lens (IOL) (AcrySof®)
was implanted in the
CTR = capsular
ring; ICCE
Anterior
vitrectomy
2(5.1) Group
8(20.5)
.01*
Eye,n(%)
.82
ened
by
careful,
thorough
hydrodissection.
Then,
an
bag
in
uneventful
cases.
In
cases
with
posterior capsule
= intracapsular
extraction;
CTR
= capsular cataract
tension ring;
ICCE
Group
Right
18(46.1)
20
(51.2)
IOL
=
intraocular
lens
*Statistically
Ophtec
or Morcher
CTR was implanted under the cap- rupture without-zonular dialysis, an AcrySof IOL was
=
intracapsular
cataract extraction;
significant
Left= intraocular
21 (53.9)implanted in the sulcus19
(48.8)
sulorhexis
edge
a forceps (Figure 1). In eyes with
after
anterior vitrectomy.
IOL
lenswith
*Statistically
significant
Nucleus,
n (%)
axial
lengths
.17
longer than 25.0 mm (n = 2), a 13.0 mm
CTR
Control
Value
Gradewas
1
3 (7.7) Outcome Parameters
0
CTR
implanted. In the other eyes, a 12.0 or 11.0 mm
In the capsular bag
37 (94.9)
31 (79.5) Value
.01*
CTR
Control
Grade
2
15
(38.4)
21
(53.8)measures were the rate of
CTR
was
used.
The primary outcome
In the sulcus
2 (5.1)
3 (7.7)
In the capsular bag
37 (94.9)
31 (79.5)
.01*
Grade
3
7 (17.9)intraoperative zonular 8separation
(20.6)
was performed
using
a stop-and(zonular dialysis, lens
In
thePhacoemulsification
sulcus
20(5.1)
32(7.7)
Scleral
(secondary)
(5.1)
-- 1 (2.6) drop into the vitreous,0 phakodonesis with vitreous preGradetechnique
4
chop
in
all
cases.
After
the
cortex
was
removed,
Scleral
(secondary)
00
2 (5.1)
Anterior
chamber
1
(2.6)
-1%
Mature
cataract,bag
n (%)was filled with sodium hyaluronate
13 (33.4)sentation) and in-the-bag
10(25.6)
the
capsular
fixation of a foldable IOL. Other
No
IOL
implanted
fleft
aphakic)
0
1
(2.6)
Anterior chamber
0
1 (2.6)
Preoperative iridodonesis,
.76
(Healon®).
Then, an (%)foldable hydrophobic acrylic
parameters included posterior capsule rupture without
No
IOL implanted
fleft aphakic)
11 (2.6)
(2.6)
Secondary
CTR, implanted
in the 00
Yes
bag
1 (2.6)
Secondary
CTR, implanted in the 0
No
Table 3. Intraocular lens fixation.
bag
n (%)
.Miotic
CTR =pupil*,
capsular
tension ring; IOL = intraocular lens
Table
3. Intraocular
Mean axial
length
(mm)lens fixation.
*Statistically
significant
.Mean
CTR =ACD
capsular
(mm)tension ring; IOL = intraocular lens
Table
4. Postoperative
findings.
*Statistically
Mean BCVAsignificant
(Snellen)
Corneal edema, n (%)
-—
7(17.9)
— 32 (82.1)
12 (30.8)
17 (43.6)
12
(30.8)
23.1
±1.6
2.55 ±0.46
20/180 ± 135
5 (12.8)
34 (87.2)
13 (33.3)
14 (35.9)
13 23.0
(33.3)±1.8
2.74 ± 0.42
20/165 ± 120
.58
.63
.14
.83
.77
CTR IMPLANTATION IN PHACOEMULSIFICATION IN PSEUDOEXFOLIATION SYNDROME
zonular separation, vitreous loss, postoperative corneal
edema, fibrin reaction in the anterior chamber,
uncorrected visual acuity (UCVA), BCVA, IOP, num-
Figure 1. (Bayraktar) A CTR is inserted after capsulorhexis and
hydrodissection.
ber of glaucoma medications, and transient IOP
spikes in the early postoperative period.
Intraoperative zonular separation was defined as
zonular dialysis of at least 90 degrees with or
without lens drop into the vitreous cavity and
conversion to intracapsular cataract extraction
(ICCE). To evaluate the influence of the surgeon
factor, the intraoperative zonular complication rates
of the 2 surgeons were compared.
The exact IOL placement was verified by intraoperative assessment and a postoperative biomicroscopic examination performed through a dilated
pupil. Placement was classified as bag, sulcus,
fixated to the sclera, anterior chamber, or null.
Corneal edema, defined as striate keratitis with
or without accompanying stromal thickening in the
early postoperative period, was graded on a 4-point
scale: 0 = no edema; 1 = minimal corneal striae and
edema with no reduction in visual acuity; 2 = mild
corneal edema with reduction in visual acuity; 3 =
moderate corneal edema with reduction in visual
acuity; 4 = severe corneal edema with reduction in
visual acuity.
Fibrin in the anterior segment was determined
by a biomicroscopic examination 1 day
postoperatively.
Intraocular pressure was measured by
applanation tonometry at all visits. When the IOP at
the first postoperative examination was higher than
25 mm Hg but returned to a normal level (^ 17 mm
Hg), the diagnosis was a transient IOP spike. The
preoperative and the last postoperative IOPs in the
CTR and control groups were compared. A similar
comparison was done for the number of glaucoma
abdications.
Statistical Analysis
For averaging, visual acuities (Snellen at 6
meters) were converted to logMAR values. The
calculated mean logMAR acuities were then
reconverted to the Snellen scale. The best UCVA and
BCVA in each patient throughout the follow-up were
used for group comparisons. The predictors of
BCVA were also analyzed by univariate and
multivariate regression analysis.
Statistical comparisons were done using the
SPSS software for Windows (release 7.0). A chisquare test was used to compare proportions or
percentages and the Student t test, to compare
numerical values. A P value less than 0.05 was
considered statistically significant.
Results
Intraoperative Zonular Complications
No eye in the CTR group had zonular separation
during surgery. In the control group, zonular
complications occurred in 5 eyes (12.8%) (Table 2).
The rate of intraoperative zonular complications was
statistically significantly different between the 2
groups (P = .021).
The zonular complication rate was not
statistically significant between the 2 surgeons (P =
.87, chi-square test). Surgeon 1 had 2 eyes with
zonular complications and surgeon 2, 3 eyes.
Intraocular Lens Fixation
In-the-bag fixation of a foldable IOL was
achieved in 37 eyes (94.9%) in the CTR group and
31 eyes (79.5%) in the control group (Table 3). The
rate of
Table 2, Intraoperative complications.
Characcteristic
CTR
( n = 39 )
Mean age (years)
Sex, n (%)
73.7 ± 5.4
Male
21 (53.8)
Female
18 (46.2)
Eye,n(%)
Right
1622
J CATARACT REFRACT SURG—VOL 27,Left
OCTOBER 2001
Characcteristic
Nucleus, n (%)
Grade 1
Mean age (years)
18(46.1)
21 (53.9)
CTR
( n3=(7.7)
39 )
73.7 ± 5.4
CTR IMPLANTATION IN PHACOEMULSIFICATION IN PSEUDOEXFOLIATION SYNDROME
Group fibrin reaction in the anteriorPchamber
Value
Postoperative
Control
seen in Group
3 eyes (7.7%) in
the CTR group andP in
7 eyes
Value
Characcteristic
( n = 39 )
CTR± 5.4
(17.9%) in the control
The difference between
Mean age (years)
73.7
71.5group.
±8.1
.16
Control
( n = 39 )
Sex, n (%)
( n = 39significant
)
groups was not statistically
( P = .17.17).
Mean
73.7
± 5.4
71.5
±8.1
.16
Male age (years)
21 (53.8)
15 (38.4)
Intensive topical corticosteroid
therapy dissolved
the
Sex, n (%)
.17
Female
18 (46.2)membrane without sequela
24 (61.6)
in
all
cases.
Male
21 (53.8)
15 (38.4)
Eye,n(%)
.82
Postoperatively,
the
mean BCVA was not statistically
Female
18 (46.2)
24 (61.6)
Right
18(46.1)significandy different between
20 (51.2) groups ( P = .44) However,
Eye,n(%)
.82
Left
21 (53.9)the mean UCVA was statistically
19 (48.8)
significandy
better
in the
Right
18(46.1)
20 (51.2)
Nucleus, n (%)
.17
CTR
group
than
in
the
control
group
(
P
=
.026)
(Table
Left
21 (53.9)
19 (48.8)
Grade 1
3 (7.7) 4).
0
Nucleus, n (%)
.17
Grade 2
15 (38.4)
21
(53.8) showed that preoperative
The univariate analysis
Grade 1
3 (7.7)
0
Group
Characcteristic
Grade 3
7 (17.9)
8 (20.6)
P = .011),
preoperative ACDP(rValue
= 0.36, P
Grade
2
15 (38.4)BCVA (r = 0.29,
21 (53.8)
CTR
Group
P Value
Characcteristic
Grade 4
1 (2.6)
0 Control
=
.02),
and
capsular
IOL
fixation
(r
=
0.29,
P
=
.009)
were
(
n
=
39
)
CTR
Grade 3
7 (17.9)
8 (20.6)
( nControl
= 39 )
Mature cataract, n (%)
13
(33.4)
10(25.6)
(
n
=
39
)
age (r =
Mean
age4 (years)
73.71±(2.6)
5.4 positively related to postoperative
71.50±8.1( n = 39 ) BCVA. Patient.16
capsular
fixation was statistically significantly different
Grade
Sex,
Preoperative
n (%)
iridodonesis, n (%)
.17.76
Mean
age groups
(years)
73.7 ± 5.4
71.5 ±8.1
.16
—0.25,
P
=
.03),
intraoperative
zonular
separation
(r = between
(P=
.01).
Mature
cataract, n (%)
13 (33.4)
10(25.6)
Sex,
.17
Male
Yes n (%)
21 (53.8)
7(17.9)0.28, P = .014), anterior
15 (38.4)
5 (12.8)
vitrectomy
(r
=
-0.29,
P
=
In the iridodonesis,
CTR group,
Preoperative
n (%)2 eyes (5.1%) with posterior
.76.009),
Male
21
(53.8)
15
(38.4)
Female
No
1832
(46.2)
(82.1)
2434
(61.6)
(87.2)
fibrin in the anterior chamber
capsule
rupture without zonular separation had implanYes
7(17.9)
5 (12.8) (r = -0.23, P = .044), and
Female
18
(46.2)
24
Eye,n(%)
Miotic pupil*, n (%)
17
(43.6)
14 (61.6)
(35.9)
.58
corneal
edema
(r
=
-0.39,
P = .0001) were .82
inversely
tation
of length
a 6.0(mm)
mm optic, 13.0 mm diameter foldable
No
32 (82.1)
34
(87.2)
Mean axial
23.1
±1.6
23.0
±1.8
.63
Eye,n(%)
.82
Right
18(46.1)
20 (51.2)
related.
Mean pupil*,
ACD
(mm)
2.55
±0.46
2.74
± 0.42
.14
acrylic
IOL
in
the
sulcus
after
anterior
vitrectomy.
In
the
3
Miotic
n
(%)
17
(43.6)
14
(35.9)
.58
Right
18(46.1)
20
Left
Meanaxial
BCVA
(Snellen)
20/180
2123.1
(53.9)
± 135
20/165
1923.0
(48.8)
±(51.2)
120
.83
Mean
length
±1.6
±1.8
.63
The multivariate
regression
analysis showed that
the
eyes
(7-7%)
in(mm)
thencontrol
group in which the posterior
Coexisting
glaucoma,
(%)
12 (53.9)
(30.8)
10(25.6)
.80
Left
21
19
(48.8)
Mean
ACD
(mm)
2.55
±0.46
2.74
±
0.42
.14
Nucleus, n (%)
.17
of
BCVA was.83
patient
Mean-lOP
(mm/Hg)
15.2±±5.5
15.1
± 3.7
.96
capsule
ruptured
Mean
BCVA
(Snellen) without zonular dialysis, a foldable
20/180
135principal determinant
20/165
±postoperative
120
Nucleus,
n (%)
.17
Grade
Mean
1 number
of glaucoma
medications
30.23
(7.7)
± 0.54
2
010(25.6)
0.26 ± 0.55
.95
Coexisting
glaucoma,
n
(%)
12
(30.8)
.80
age
(r
=
-0.50,
r
=
0.25,
P
=
.001).
When
patient
age
was
acrylic
IOL was implanted in 0the sulcus
after anterior
5(12.8)
.02*
Grade
3 (7.7)
0 ± 3.7
Table
Preoperative patient
Mean-lOP
±5.5
.96
Grade
2 1 1.(mm/Hg)
1515.2
(38.4)
2115.1
(53.8)
excluded from the 0.26
analysis,
the single statistically
vitrectomy.
rate ofmedications
posterior capsule rupture without
Mean
number The
of glaucoma
0.23(38.4)
± 0.54
± 0.55
.95
characteristics.
Grade
(53.8)
Grade
3 2
7 15
(17.9)
821
(20.6)
0
5(12.8)
.02*
All
means
±
SD
significant
predictor
was
preoperative
ACD (r = 0.36,,r2=
Table 1.separation
Preoperative
patient
zonular
was
not
statistically
significantly
Grade
3
7 (17.9)
Grade
1 (2.6)
0 8 (20.6)
characteristics.
CTR4= capsular tension ring; ACD =
0.13, P = . 02).
different
between groups ( P = .23).
Grade
4
1
(2.6)
0
All
means
± SDn (%) depth; BCVA =
anterior
chamber
Mature
cataract,
13 (33.4)
During the first10(25.6)
postoperative examination, transient
.In
2
eyes
in
the
control
group,
surgery
was
converted
CTR
=
capsular
tension
ring;
ACD
=
best
corrected
visual
acuity;
IOP
=
Mature cataract,
n (%) n (%)
13 (33.4)
10(25.6)
Preoperative
iridodonesis,
.76
to
anterior
ICCE
chamber
because
depth;
ofnBCVA
extensive
=
intraoperative zonular IOP spikes were observed in 16 eyes in the control.76group
intraocular
pressure
"Pupils
4.0 mm
Preoperative
iridodonesis,
(%)
Yes
7(17.9)
(12.8)
best
corrected
visual
acuity;scleral
IOP = fixation was performed.
or smaller
after full
dilation
and 8 eyes in the 5CTR
group. The difference was
dialysis
and
secondary
Yes
7(17.9)
5 (12.8)
Zonular separation
Nointraocular
32 (82.1)
34 (87.2)
pressure "Pupils 4.0 mm
( P(87.2)
= .03). At the last follow-up
The
whole
lens into
dropped
vitreous
2 (82.1)statistically significant 34
Whole
lens dropped
vitreousinto the
0
2 (5.1)cavity.24in 32
Nosmaller
or
Miotic
pupil*,after
n (%)full dilation
17 (43.6)
14 (35.9)
.58
Conversion
to
ICCE
0
2
(5.1)
.24.
visit,
the
mean
IOP
was
significandy
lower than
preopcontrol
eyes;
1
was
left
aphakic,
and
the
other
received
an
Zonular
separation
Mean
axial
length
(mm)
23.117±1.6
23.0
.63.58
Miotic
pupil*,
n (%)
(43.6)
14±1.8
(35.9)
0
1
(2.6)
.02
Zonular
dialysis
during
IOL
Whole
lens
dropped
into
vitreous
0
2
(5.1)
.24
Mean
ACD
(mm)
2.55
±0.46
2.74
±
0.42
.14
( P = .025, CTR; P =.63.037,
Mean axialchamber
length (mm)
23.1 ±1.6eratively in both groups
23.0 ±1.8
anterior
IOL. In the 01 control2 (5.1)
eye in .24.
which
Conversion
to ICCE
implantation
Mean
BCVA
20/180
± 135
20/165 2.74
± 120± 0.42
.83.14
Mean
ACD(Snellen)
(mm)
2.55
±0.46
control)
(Table
4).
zonular
dialysis
occurred
during
IOL
implantation,
a
0
1
(2.6)
.02
3 (7.7)
.24
Zonular
dialysis
during
IOL without 2(5.1)
Coexisting
glaucoma,
n (%)
12 (30.8)
10(25.6)
.80.83
Posterior
capsule
perforation
Mean
BCVA
(Snellen)
20/180
± 135
20/165
± 120
Mean-lOP
15.1
± 3.7
The mean number
of
glaucoma medications.96
was
implantation
Coexisting
glaucoma,
n (%)
12±5.5
(30.8)
10(25.6)
.80 less
zonular (mm/Hg)
separation
foldable
acrylic
IOL
was implanted in the capsular15.2
bag
Mean
number
of glaucoma
medications
0.23
± 0.54
0.26
± 0.55
.95.96
2(5.1)
38(20.5)
(7.7)
.24
Mean-lOP
(mm/Hg)
15.2
±5.5
15.1
± 3.7
Anterior
vitrectomy
2(5.1)
.01*
Posterior
capsule
perforation
without
than
preoperatively
in
the
CTR-group
and
the
same
in the
after
anterior
vitrectomy
and
secondary
CTR
implantation
5(12.8)
.02* 0.23 ± 0.54
Mean
oftension
glaucoma
medications
0.26 ± 0.55
.95
Table
1.
Preoperative
patient
CTR =number
capsular
ring;
ICCE 0
zonular
separation
Group
control group, with no significant differences over time
0
5(12.8)
.02*
were
performed.
characteristics.
Table
1. cataract
Preoperative
patient 2(5.1)
Anterior
vitrectomy
8(20.5)
.01*
= intracapsular
extraction;
AllCTR
means
±
SD
characteristics.
(Table 4).
=
capsular
tension
ring;
ICCE
Group
IOL = intraocular lens *Statistically
CTR
All
=means
capsular
± SDtension
ring;
ACD =
=
intracapsular
cataract
extraction;
significant
Other
Parameters
anterior
CTR= =
chamber
capsular lens
tension
depth;
ring;
BCVA
ACD
= =
IOL
intraocular
*Statistically
Discussion
The
mean
follow-up
was
best
anterior
corrected
chamber
visual
depth;
acuity;
BCVA
IOP
= = 44.7 ± 92.9 days in the
significant
CTR
intraocular
best corrected
pressure
visual
"Pupils
acuity;
mm
IOP =
Cataract surgery is generally considered to be a chalCTR
group
and
50.8
±4.047.8
days in theControl
control Value
group.
In
the capsular
37 (94.9)
31 (79.5)
.01*
or intraocular
smaller
afterpressure
fullbag
dilation
"Pupils 4.0 mm
lenge
and associated with an increased incidence of comThe
difference
between
groups
was
not
statistically
sigCTR
Control
In
sulcus
2 (5.1)
3 (7.7) Value
Zonular
separation
or the
smaller
after full dilation
plications in eyes with pseudoexfoliation syndrome.1-17 The
nificant
(P=
.71).
Whole
dropped
0 (94.9) 2 (5.1)
.24
In
thelens
capsular
baginto vitreous
37
31 2
(79.5)
Zonular
separation
Scleral
(secondary)
0
(5.1) .01*
Conversion
to
ICCE
0
2
(5.1)
.24.
In
theOne
sulcus
3 (7.7) reducing
Whole
lens day
dropped
into vitreous 2 (5.1)
0
2 (5.1)
.24
risks were first described for planned extracapsular cataract
postoperatively,
corneal
edema
0
1 (2.6)
Zonular
Conversion
dialysis
toduring
ICCE IOL
2 (5.1)
Anterior
chamber
0 0
1 (2.6).02.24.
Scleral
(secondary)
0
2
(5.1)
visual
acuity
present
(35.9%)
CTR extraction (ECCE)1"11 and later for phacoemulsification
0
1 (2.6)in the.02
Zonular
dialysiswas
during
IOL in 140 eyes
implantation
No IOL implanted
fleft aphakic)
1 (2.6)
3 (7.7)1 (2.6)
.24 Posterior
capsule
without 02(5.1)
group
implantation
and
12perforation
eyes (30.8%)
in the control
group.
The surgery.11"17 Pseudoexfoliation syndrome is reported to be
Anterior
chamber
1 (2.6) .24—
3 (7.7)
Secondary
CTR,
in without
the 00 2(5.1)
zonular
Posterior
separation
capsule
perforation
difference
No
IOL
implanted
wasimplanted
fleft
not
aphakic)
statistically
significant
1 (2.6)
( P = -.77). associated with an increased incidence of glaucoma (both
Anterior
2(5.1)
8(20.5)
.01*
bag vitrectomy
zonular
separation
cloCorneal
edema
resolved
in
2
to
15
days
in
all
eyes. .01*
1 (2.6)
— 12 (30.8) open angle and angle13
Anterior
vitrectomy
(33.3)
Secondary
CTR,
implanted
in the 0 2(5.1)
CTR
= capsular
tension
ring; ICCE
Group 8(20.5)
Characcteristic
CTR
( n = 39 )was
Table 3. Intraocular lens fixation.
bag
CTR
tension
ring;
= intracapsular
. CTR==capsular
capsular
cataract
tension
extraction;
ring;ICCE
IOL = intraocular
lens
Group
*Statistically
significant
12 (30.8)
= =intracapsular
cataract
extraction;
IOL
intraocular
lens
*Statistically
Table
3. Intraocular
lens
fixation.
4.
Postoperative
findings.
.Table
CTR==intraocular
capsular
tension
ring;
IOL = intraocular lens
IOL
lens *Statistically
significant
Corneal edema,
n (%)
*Statistically
significant
significant
Grade 04. Postoperative findings.
Table
CTRJ CATARACT
Control
Value
Grade 1edema, n (%)
13 (33.3) 27, OCTOBER 2001
1624
REFRACT
SURG—VOL
Corneal
Value
0
In Grade
the capsular
bag
37CTR
(94.9)
31Control
(79.5)
.01*
1
13 (33.3)
In Grade
the
sulcus
2 (5.1)
331(7.7)
In the
capsular
bag
37 (94.9)
(79.5)
.01*
Grade
2
10 (25.6)
In
the sulcus
2 (5.1)
3 (7.7)
Scleral (secondary)
0
2 (5.1)
-
13 (33.3)
.77
14 (35.9)
14 (35.9)
9 (23.1)
-
.77
-
CTR IMPLANTATION IN PHACOEMULSIFICATION IN PSEUDOEXFOLIATION SYNDROME
Group
Characcteristic
CTR
( n = 39 )
Mean age (years)
Sex, n (%)
73.7 ± 5.4
Male
Characcteristic
Female
Characcteristic
Eye,n(%)
21 (53.8)
18CTR
(46.2)
( n = 39 )
CTR
( 73.7
n = 39
± 5.4
)
18(46.1)
P Value
Control
( n = 39 )
71.5 ±8.1
Group
Group
15 (38.4)
24 (61.6)
Control
( n = 39 )
Control
±8.1
2071.5
(51.2)
( n = 39 )
71.5
±8.1
19
(48.8)
15 (38.4)
.16
.17
P Value
P Value
.82
Mean age (years)
.16
Right
Sex, n (%)
.17
Mean age (years)
73.7
± 5.4
.16
Left
21
(53.9)
Malen (%)
21 (53.8)
Sex,
.17
Nucleus, n (%)
.17
Female
18(53.8)
(46.2)
24(38.4)
(61.6)
Male
21
15
Grade 1
3 (7.7)
0
Eye,n(%)
.82
Female
18 (46.2)
24 (61.6)
Grade 2
15 (38.4)
21 (53.8)
Right
18(46.1)
20 (51.2)
Eye,n(%)
.82
Grade 3
7 (17.9)
8 (20.6)
Left
21 (53.9)
19(51.2)
(48.8)
Right
18(46.1)
20
Grade 4
1 (2.6)
0
Nucleus, n (%)
.17
Left
21 (53.9)
19 (48.8)
Mature cataract, n (%)
13 (33.4)
10(25.6)
Grade 1 n (%)
3 (7.7)
0
Nucleus,
.17
Preoperative iridodonesis, n (%)
.76
Grade12
15
(38.4)
21
Grade
3 (7.7)
0 (53.8)
Yes
7(17.9)
5 (12.8)
Grade23
(17.9)
(20.6)
Grade
157(38.4)
218(53.8)
No
32 (82.1)
34 (87.2)
Group
P Value
Characcteristic
Grade34
(2.6)
Grade
71(17.9)
80(20.6)
Miotic pupil*, n (%)
17
(43.6)
14 (35.9)
.58
CTR
Control
Mature
cataract,
n
(%)
13
(33.4)
10(25.6)
Grade
4 length (mm)
(2.6)
0 ±1.8
Mean
axial
±1.6
23.0
.63
(23.1
n =139
)
n = 39 )
Mean
ACD
(mm)
2.55
2.74
±( 0.42
.14.76
Preoperative
iridodonesis,
n (%)
Mature
cataract,
n (%)
13 ±0.46
(33.4)
10(25.6)
Mean
(years)
73.7 ± 5.4
71.5± ±8.1
.16
Meanage
BCVA
(Snellen)
20/180
135
20/165
120
.83
Yes
7(17.9)
5 (12.8)
Sex,
n (%) glaucoma,
.17
Preoperative
iridodonesis,
.76
Coexisting
n (%) n (%)
12 (30.8)
10(25.6)
.80
Mean-lOP
(mm/Hg)
15.2
±5.5
15.1
±
3.7
.96
No
(82.1)
(87.2)
Male
2132
(53.8)
1534
Yes
7(17.9)
5(38.4)
(12.8)
Mean number of glaucoma medications
0.23 ± 0.54
0.26 ± 0.55
.95
Marchesani
syndrome,
and long-standing silicone
sure),
by alterations
Miotic cataract,
pupil*, n (%) phakodonesis0 caused 5(12.8)
17
(43.6)
14
(35.9)
.58
Female
18
(46.2)
24
(61.6)
No
32
(82.1)
34
(87.2)
.02*
Table 1.
Preoperative patient
Mean
axial
length apparatus,
(mm)
23.1 ±1.6
23.0 ±1.8 eyes.32
.63
tamponade
in
vitrectgmized
of
the
zonular
BAB
breakdown,
anterior
characteristics.
Eye,n(%)
.82
Miotic
n (%)
17
(43.6)
14
(35.9)
.58
Mean pupil*,
ACD (mm)
2.55
±0.46
2.74
± 0.42
.14
Mean
axial
length
(mm) poor pupil dilation, and early
23.1 ±1.6
23.0
All
means
± SD
rings
any
chamber
hypoxia,
Mean
BCVA
(Snellen)
20/180
± 135 Capsular tension
20/165
±±1.8
120 may be inserted at.63
.83
Right
18(46.1)
20 (51.2)
Mean
ACD
(mm)
2.55
±0.46
2.74
±
0.42
.14
CTR
= capsular
tensionnring;
=
Coexisting
glaucoma,
(%) ACDdecompensation
12 (30.8)
10(25.6)
.80 or
time
during
cataract
surgery
to
maintain
diffuse
corneal
endothelial
resulting
Left
21 (53.9)
19 (48.8)
Mean
BCVA
(Snellen)
20/180
135
20/165
± 120
.83
anterior
Mean-lOP
chamber
(mm/Hg)
depth; BCVA =
15.2±±5.5
15.1
± 3.7
.96
32
Coexisting
glaucoma,
n (%) medications
12 (30.8)
10(25.6)
.80
reestablish the capsular
In the current
from
decreased
endothelial
cell counts.19-25 These0.23
Mean
number
glaucoma
± 0.54
0.26 diaphragm.
± 0.55
Nucleus,
n (%) of
.17.95
best
corrected
visual
acuity;
IOP
=
Mean-lOP (mm/Hg)
15.2 ±5.5
15.1 ± 3.7
.96
0
5(12.8)
Table
1.
intraocular
pressure
"Pupilsmedications
4.0patient
factors
are
believed
tomm increase
the rate.02*of
study, we evaluated the
use of CTRs
Grade
1number
3 (7.7)
0
Mean
ofPreoperative
glaucoma
0.23
± 0.54
0.26 prophylactic
± 0.55
.95 in
characteristics.
or
smaller
after
full
dilation
0
5(12.8)
.02*
Table
Preoperative
syndrome. Therefore,
intraoperative
zonular patient
separation, vitreous loss,
Grade
2 1.
15 (38.4)eyes with pseudoexfoliation
21 (53.8)
All means
± SD
Zonular
separation
characteristics.
the
rings
were
inserted
before
phacoemulsification
postoperative
IOP
spikes,
corneal
edema,
and
fibrin
Grade
3
7
(17.9)
8
(20.6)
Whole
lens
dropped
into vitreous
0
2 (5.1)
.24
CTR
= capsular
All
means
± SD tension ring; ACD =
Conversion
to
ICCE
0
2
(5.1)
.24.
anterior
chamber
depth;
BCVA
=
no case of intraoperative
reaction
in thetension
anterior
Grade
1 (2.6) began. In our study,
0
CTR 4= capsular
ring;chamber;
ACD =0 affect1 the
(2.6)
.02
Zonular
dialysis during
bestof
corrected
visualIOL
acuity; IOP
site
anterior
IOL
chamber
and
== reduce postoperative
Mature
cataract,
n placement;
(%)depth; BCVA
13 (33.4)zonular dialysis occurred
10(25.6)in eyes with a CTR. In the
implantation
intraocular
pressure
4.0
best
corrected
visual"Pupils
acuity;
IOPmm
=
control group without a ring, however,
visual
3 (7.7)
.24
Preoperative
iridodonesis,
n (%)
.76
Posterior
capsule
perforation
without 2(5.1)
or
smaller
after
full
dilation
intraocular
pressure "Pupils 4.0 mm
19-23
zonular
separation
Zonular
separation
acuity.
Yes
7(17.9) complications resulting
5 (12.8)from zonular separation
or smaller
after full dilation
Anterior
8(20.5)
.01*
Whole vitrectomy
lens dropped into vitreous 2(5.1)
0
2 (5.1)
.24
occurred in 12.8% of
eyes. The absence of zonular
No
Zonular
separation
34 (87.2)
Conversion
totension
ICCE ring; ICCE
0 Group2 (5.1)
.24.32 (82.1)
CTR
=
capsular
Whole lens dropped into vitreous
00
21(5.1)
.24
(2.6) first.02
group
ring is
Capsular
tension
was
deMiotic
pupil*,
n (%)
17 (43.6)dialysis in the CTR 14
(35.9) is evidence that the .58
Zonular
dialysis
duringextraction;
IOLring implantation
=Conversion
intracapsular
tocataract
ICCE
0
2 (5.1)
.24.
Mean
axial length (mm)
23.1 ±1.6
23.0 ±1.8
.63
26
implantation
effective
in
preventing
zonular
separation
during
scribed
by
Legler
and
Witschel
in
1993.
When
the
IOL
= intraocular
lens *Statistically
0
1 (2.6)
.02
Zonular
Mean
ACDdialysis
(mm) during IOL
2.74 ± 0.42
.14
3 (7.7)
.242.55 ±0.46
Posterior capsule perforation without 2(5.1)
significant
implantation
eyes with pseudoexfoliation
poly(methyl
methacrylate) ring is inserted in20/180
the ± 135phacoemulsification
Mean
BCVA (Snellen)
20/165in
± 120
.83
zonular separation
(7.7)
Coexisting
glaucoma,
n (%)
12 (30.8)
10(25.6)
.80
Posterior
capsule
without
syndrome. We believe
that the different rates
of
capsular
bag, itperforation
stretches
the2(5.1)
capsule38(20.5)
equator.24
and
Anterior(mm/Hg)
vitrectomy
2(5.1)
.01*
Mean-lOP
15.2 ±5.5
15.1 ± 3.7
.96
zonular separation
CTR
Control
Value
26-32
CTRnumber
= capsular
tension
ICCE over
distributes
theglaucoma
forcesring;
equally
Group
zonules.
In ± 0.54intraoperative zonular
complications
between.95the 2
Mean
of
medications
0.26 ±
0.55
Anterior
vitrectomy
2(5.1) all
8(20.5)
.01*0.23
In=the
capsular
bag
370(94.9)
31 (79.5) .02*
.01*
5(12.8)
intracapsular
cataract
extraction;
Table
1.
Preoperative
patient
groups
were
not
surgeon-dependent
because the
the
regions
in
which
zonular
support
is
absent
or
CTR
=
capsular
tension
ring;
ICCE
In the sulcus
2 (5.1) Group3 (7.7)
characteristics.
IOL
= intraocular
lens *Statistically
=
intracapsular
cataract
extraction;
rates of the 2 surgeons in the study were not
inadequate,
the ring supports
the capsular
bag and
All
means
± SD
significant
Scleral
(secondary)
2 (5.1)
IOL
= intraocular
lens *Statistically 0
statistically different.
facilitates
surgery.
The
CTR
helps
prevent
CTR = capsular tension ring; ACD =
significant
Anterior
chamber
0
1 (2.6)
anterior
chamber
depth;
BCVA
=
Capsular tension rings can also be used to help
postoperative IOL decentration
in eyes Control
with zonular
CTR
Value
No IOL
implanted
fleft aphakic)
1 (2.6)
best
corrected
visual
acuity; IOP =0 30
prevent
intraoperative posterior capsule rupture by
dialysis
up
to
6
clock
hours.
The
2
recommended
In the capsular bag
37 (94.9)
31 (79.5) Value
.01*
Control
intraocular pressure "Pupils 4.0 mm0CTR
1 (2.6)
—
Secondary
CTR,
implanted
in
the
In
the
sulcus
2
(5.1)
3
(7.7)
indications
CTR implantation
are zonular
keeping the posterior capsule taut, preventing its
the capsular
bag
37 (94.9)
31 (79.5)rupture
.01*
orInsmaller
afterfor
full
dilation
bag
In
the
sulcus
20(5.1)
32(7.7)
Zonular
separation
Scleral
(secondary)after blunt or
(5.1)
anterior bulging 13and
protecting it from being
or
dehiscence
surgical trauma
and
(33.3)
Tablelens
3. dropped
Intraocular
lens
fixation. 0
Whole
into
vitreous
2 (5.1)
.24 12 (30.8)
Scleral
(secondary)
000such lens
aspirated by phaco or irrigation/aspiration tips
inherent
zonular
as2 (5.1)
in21 (5.1)
cases
Anterior
chamber
(2.6)
. CTR
= capsular
tensionweakness
ring; IOL = intraocular
Conversion
to
ICCE
.24. of
*Statistically
significant
0
1
(2.6)
.02
during phacoemulsification and cortical aspiration.31
pseudoexfoliation,
Marian's
syndrome,
WeillZonular
dialysis
during
IOL
No
IOL
implanted
fleft
aphakic)
0
1
(2.6)
Anterior chamber
0
1 (2.6)
Table
4.
Postoperative
findings.
implantation
No
IOLedema,
implanted
fleft aphakic)
11 (2.6)
(2.6)
Corneal
n (%)
.77
Secondary
CTR,
implanted
in the 002(5.1)
3 (7.7)
.24 —
Posterior
capsule
perforation
without
Grade
0
bag separation
0
1 (2.6)
—
Secondary
CTR,
implanted
in
the
zonular
Grade 1
13 (33.3)
14 (35.9)
Tablevitrectomy
3. Intraocular lens fixation. 2(5.1) J CATARACT
1625
REFRACT
SURG—VOL 27, OCTOBER 200113 (33.3)
Anterior
8(20.5)
.01* 12 (30.8)
bag
. CTR
= capsular
tension
ring; IOL = intraocular
lens
CTR
= capsular
tension
ring;
12 (30.8)
13 (33.3)
Group
Table
3.
Intraocular
lens ICCE
fixation.
*Statistically significant
=Grade
cataract
extraction;
10 (25.6)
9 (23.1)
.intracapsular
CTR2= capsular
tension
ring; IOL = intraocular lens
Table
4. Postoperative
findings.
*Statistically
significant
IOL
= intraocular
lens *Statistically
Grade
3
4 (10.3)
2 (5.1)
-
--
-
CTR IMPLANTATION IN PHACOEMULSIFICATION IN PSEUDOEXFOLIATION SYNDROME
In our study, the rate of posterior capsule rupture
was not statistically different between the CTR and
control groups. Thus, we could not prove that the
ring protects the posterior capsule.
Most eyes (94.9%) in our CTR group had a foldable IOL implanted in the capsular bag; in-the-bag
fixation was possible in only 79.5% in the control
group. This indicates that by decreasing the rate of
intraoperative zonular separation, the CTR increases
the rate of primary in-the-bag IOL implantation, preventing the complications of implantation of a different type IOL at a different site and of secondary
procedures.
Complication rates between 1% and 25% have
been reported for cataract surgery in eyes with
pseudoexfoliation syndrome.1"17 The rates reported
after ECCE are commonly higher than those after
phacoemulsification.11,12 Other risk factors are the
presence of preoperative phakodonesis, pupil miosis,
and a shallow anterior chamber.9,11,12,16,17 Our study
included many eyes presenting with several risk
factors. Approximately one half of the eyes had
cataract with a hard nucleus (grade 3 and 4), one
sixth had preoperative iri-dodonesis, two fifths had a
miotic pupil, one third had coexisting glaucoma, and
one half had an ACD of 2.5 mm or less. The
vitreous loss rate was 5.1% and 20.5% in the CTR
and control groups, respectively, with a statistically
significant difference between groups. The
complication rate in the CTR group was comparable
to rates reported in the literature11-16; however, the
rate in the control group was higher. We believe that
the relatively high intraoperative complication rate
in both groups was the result of the high incidence
of preoperative risk factors in our cohort.
On the first postoperative day, approximately
one third of the eyes in both groups had corneal
edema that reduced BCVA. The insertion of a CTR
did not influence the incidence of corneal edema.
Although specular microscopy was not performed,
we believe that the reduced endothelial cell counts
and prolonged effective phacoemulsification times
required for hard nuclei were responsible for the
edema.
In our study, a fibrin reaction in the anterior
chamber was seen in 17.9% and 7.7% of eyes in the
control
and
CTR
groups,
respectively.
Approximately half the eyes in both groups had
miotic pupils that required mechanical dilation. The
difference between the 2 groups was not statistically
significant because that complication was thought to
be a direct consequence of the preoperative BAB
breakdown and pupil-expanding manipulations.19,2124
In the early postoperative period, BCVA was not
statistically different between the 2 groups.
However, UCVA was better in eyes with a CTR.
This shows that the prophylactic insertion of a CTR
influenced UCVA but not BCVA. We believe the
discrepancy occurred because a lower percentage of
eyes in the control group had in-the-bag IOL
fixation. The exact position of the IOL could not be
accurately predicted, and errors in IOL power
selection were made in some of these cases. Three
eyes in the control group could not be implanted
with an IOL in the first operation because of
intraoperative complications. One was left aphakic,
and 2 had secondary scleral fixation.
Multivariate regression analysis showed that the
single significant predictor of early postoperative
BCVA was patient age. Although correlated with
BCVA in the univariate analysis, the presence of
intraoperative zonular dialysis, vitreous loss,
postoperative fibrin, and corneal edema were not
statistically significant predictors of postoperative
BCVA in the multivariate regression analysis. In
elderly patients, the pathological alterations of
pseudoexfoliation syndrome generally proceed to a
relatively advanced stage. When patient age was
excluded from the multivariate analysis, ACD
became the principal determinant of BCVA. In a
recent study, an inverse correlation between the
incidence of intraoperative complications and ACD
was observed in eyes with pseudoexfoliation
syndrome.16 The authors report that the risk was
considerably higher when the ACD was less than 2.5
mm.16 In our study, the ACD was 2.5 mm or less in
48.7% in the CTR group and 41.1% in the control
group.
At the postoperative first visit at"24 hours,
transient IOP spikes were observed in more control
eyes than in eyes with a CTR. At the last visit,
however, mean IOP was not significantly different
between the 2 groups, both of which had statistically
significant drops in IOP. The decrease in IOP after
uneventful cataract surgery has been reported in
many studies, and it is more commonly observed in
eyes with occluded or closed angles and in patients
J CATARACT REFRACT SURG—VOL 27, OCTOBER 2001
1625
CTR IMPLANTATION IN PHACOEMULSIFICATION IN PSEUDOEXFOLIATION SYNDROME
with a shallow anterior chamber.33"35 Many eyes in
our study had a shallow anterior chamber
preoperatively. We believe that the IOP reduction
despite relatively high intraoperative complication
rates in our study was a result of the deepening of
the anterior chamber and widening of the filtration
angle achieved by the phacoemulsification surgery.
We implanted the CTRs just after the
hydrodissection but before phacoemulsification. No
attempt was made to rotate the nucleus before
inserting the ring. Rotational and anterior-posterior
forces that stretch the weakened zonules are created
during nucleus manipulation (grooving, rotation).
Therefore, the CTR should be inserted before this
stage. Although the ring helps stabilize the capsular
bag and helps the surgeon during nucleus
manipulations, as shown in our current study, it
might create difficulties for the surgeon during
cortex aspiration, especially if the cortex is not
totally cleaved from the capsule. Thus, we believe
that cortical cleaving hydrodissection as described
by Fine36 should be performed in those cases and
that the ring should be inserted just beneath the lens
capsule, not between the superficial cortical fibers.
In addition to meticulous cortical cleaving
hydrodissection, a viscoelastic injection along the
path of the ring may help separate the lens capsule
from the cortex.
Our study had limitations. First was the small
number in each group, which may have caused us to
miss small but statistically significant differences
between the 2 groups. Second, it would have been
better had 1 surgeon performed all operations to
prevent differences caused by surgical experience.
We tried to overcome this by having each of the 2
surgeons operate on the same number of eyes. Third,
the mean follow-up was short; thus, we could only
assess the influence of the CTR intraoperatively and
in the early postoperative period. Several studies
report high rates of posterior capsule opacification
(PCO) and anterior capsule contraction resulting in
late IOL dislocation in eyes with pseudoexfoliation
syndrome.37"39 Capsular tension rings are reported to
be effective in reducing these late complications in
eyes with the syndrome.32,40 A minimum of 1 to 2
years of follow-up will be needed to confirm that
CTR implantation reduces the rates of IOL
decentration and PCO. We are currendy evaluating
the late postoperative course of patients in both our
study groups.
In conclusion, in this prospective randomized
study, CTR implantation after capsulorhexis and hydrodissection but before nucleus emulsification reduced intraoperative complications caused by
zonular separation, increased the rate of in-the-bag
IOL fixation, and improved UCVA.
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