Eyeworld

EW NEWS & OPINION 16 August 2016 by Lisa Brothers Arbisser, MD now. In the rabbit model it easily permitted optic capture into Berg- er's without rupturing hyaloid or the capsule edge. Other devices to reduce the learning curve such as the CAPSULaser (Los Gatos, Califor- nia) are in development. Posterior capsulotomy has been successfully accomplished by Burkhard Dick on the Catalys (Abbott Medical Optics, Abbott Park, Illinois) and Abhay Vasavada 9 on the femto laser platforms with sterile redocking off label. Other disadvantages include a slight increase in time of procedure (less with manual and Zepto than femto) compared with standard surgery. Management of the posteri- or capsule is a bold new territory for many surgeons today. Not as be- nign as a laser capsulotomy routine which I have coined the acronym SBCC. Think what it would mean to the developing world if this tech- nique can be taught and mastered; it would make secondary cataract extinct. I predict this novel surgical lens placement would ultimately spur a new generation of lens design, but it need not await FDA approval as currently available IOLs can be employed. The main downside of manual PCCC is the learning curve. I have just completed an ex vivo rabbit and cadaver eye lab with Mynosys, and we think that with minimal product adjustment, we have proof of con- cept for posterior capsulotomy with the Zepto without rupturing the hyaloid. They have a 510k awaiting approval for anterior capsulotomy anterior and posterior capsule edges together. Unlike BIL, its stability is not dependent entirely on the zonules and a perfectly centered cap- sulotomy for centration. Rather, it will always center based on the fit in the sulcus. Unlike today's standard lens-in-the-bag operation, the CCC is stented by the optic and thus phi- mosis is excluded, and possibly late bag-lens subluxations eliminated. Because the capsule might remain flexible in that metaplasia will not be stimulated since there is virtually no touch of IOL to lens epithelial cells, I think there is a chance that, as long as Wieger's ligament remains intact, there is some hope of accom- modative movement as described by Dan Goldberg, 7 which can be enhanced by the extended depth of focus lens design. No square edge would be needed in an IOL implant- ed with this technique, reducing dysphotopsia. Most importantly, as long as the optic is not PMMA, which has been shown to cause opacity of the vit- reous face in babies, no one would ever need a secondary Nd:YAG capsulotomy, and the hyaloid would theoretically remain intact, protect- ing the posterior segment for life. SBCC has special appeal for refrac- tive lens exchange since stray light studies show superior vision when the posterior capsule is absent com- pared to even "clear" PC with 20/20 Snellen acuity. The technique would reduce risk for pseudoexfoliation eyes and for high myopes as well. The technique offers special promise for pediatric cases. This pro- cedure leaves room for a secondary refractive purely sulcus IOL should it be needed as the pediatric eye grows since the primary lens will be in the plane of the bag even if sulcus based. Theoretically, like the stan- dard buttonhole technique, it could significantly reduce the devastat- ingly high incidence of consecutive glaucoma post congenital cataract surgery by sparing the immature trabeculum the exposure to vitreous elements. Rupert Menapace has done beautiful work, as has Howard Gimbel before him, 8 on the safe- ty of bag-based PCCC capture or posterior optic buttonholing. To my knowledge, no one has suggested the technique I have described here as a planned routine procedure for Dr. Arbisser introduces new technique called sulcus bi-capsulotomy capture I propose a new kind of cataract surgical goal that I call sulcus bi-capsulotomy capture (SBCC). After standard lens remov- al through a 5 mm anterior capsulotomy (manual, femto, or Zepto capsulotomy instrument, Mynosys, Fremont, California), the anterior and posterior capsules may be polished with the surgeon's preferred method for 360 degrees. An ophthalmic viscosurgical device (OVD) is placed in the sulcus to flatten the anterior capsule rim and posterior capsules together. A 30 g bevel up needle lifts and punctures the central posterior capsule, lifting it away from the hyaloid. Cohesive OVD is instilled between the ante- rior hyaloid and posterior capsule to define Berger's space, pushing the hyaloid out of harm's way to its border at Wieger's ligament. A 5 mm central PCCC is created (as described by Rupert Menapace manually, 1 by Burkhard Dick with femto laser sterile redocking, 2 by Marie-Jose Tassignon with ring caliper, 3 or as shown by me with the same Zepto capsulotomy instrument 4 that one could employee to create the anteri- or opening). Then, rather than the standard buttonhole method of in- flating the capsule fornix to implant a 3-piece lens in the bag and captur- ing the optic through the PCCC into Berger's, the 2 capsules are left sealed together and the lens is implanted into the sulcus. The optic is then captured through both the anterior and posterior capsulotomies into Berger's space (with intact hyaloid of course), hence the acronym SBCC. Although any current 3-piece IOL would suffice, I think the surgi- cal goal will drive IOL design in the future and permit toric implantation as well. I hypothesize this technique will result in the most stable lens possible at the plane of the bag, zero PCO even in pediatric cataract, and allow potentially flexible capsules equator to equator. Although a Soemmering's ring may form (like with the bag-in-the-lens [BIL] design by Marie-Jose Tassignon 5,6 ), it would be confined to the equatorial space by the optic capture that seals the Scleral bi-capsulotomy capture: New era for cataract surgery as final visual rehabilitation Use of the Zepto device on the anterior and posterior capsules of an ex vivo rabbit with optic capture into Berger's space Implantation of a three-piece IOL following cataract surgery with hyaloid sparing posterior capsulorhexis with haptics in the sulcus and optic captured through the anterior and posterior capsular openings into Berger's space Source: Lisa Arbisser, MD

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