Eyeworld

EW FEATURE 48 Highlights from ESCRS 2016 • December 2016 AT A GLANCE • Bag-in-the-lens (BIL) cataract surgery involves the capture of anterior and posterior capsular rhexis in the BIL lens groove. • Negative dysphotopsia is not present because of the anterior location of the IOL. Posterior capsule opacifica- tion is confined to the capsule bag periphery, thus preserving vision and ensuring stable lens position. • The ophthalmic surgeon can choose the precise placement of the BIL IOL along the visual axis of the eye. • Negative dysphotopsia can be corrected after cataract surgery and prevented using reverse optic capture with the grooved 90S IOL. by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer Grooved, capsulorhexis- centered IOLs eliminate some of cataract surgery's most elusive complications C ataract surgery with IOL implantation is the most common ophthalmic surgical procedure, esti- mated at 20 million per year worldwide. Roughly 30% of uncomplicated cataract surgical out- comes are complicated by posterior capsular opacification (PCO) within 5 years after surgery, 1 impacting vi- sual acuity, contrast sensitivity, and visual alignment. While a number of surgical techniques have been shown to reduce PCO to varying degrees and durations of time, such as continuous curvilinear capsulor- hexis (CCC), cortical clean-up, and anterior capsule polishing, only bag- in-the-lens (BIL) IOL implantation boasts 100% PCO elimination. Cataract specialists Marie-José Tassignon MD, PhD, University Hospital Antwerp, Antwerp, Bel- gium, and Samuel Masket, MD, Advanced Vision Care, Los Angeles, and clinical professor of ophthal- mology, Jules Stein Eye Institute, David Geffen School of Medicine, University of California, Los An- geles, shared their expertise with grooved capsulorhexis-centered IOLs at the 2016 European Society of Cataract and Refractive Surgeons (ESCRS) annual meeting. final position of the IOL in the eye is influenced by the edges of the hap- tics and optic zone, the contact area of the capsular bag with the IOL, and the size of the anterior rhexis. The BIL IOL gives the surgeon the freedom to choose the best place to perform capsulorhexis for ideal lens centration. With respect to the visual axis, Dr. Tassignon thinks that her IOL design has everything to do with the excellent visual results she obtained with the BIL IOL, again owing to its independence of the capsular bag. In an examination of BIL centration and visual outcomes conducted in 180 eyes of 125 patients, she demon- strated that surgeon-controlled BIL centration was predictable and remained unchanged 6 months and 1 year after cataract surgery. In the Posterior capsular opacification The bag-in-the-lens IOL and its specially developed surgical im- plantation technique have proven effective in providing stable vision without PCO in a wide variety of patients, including pediatric and toric patients, for almost 10 years. As opposed to the conventional lens-in- the-bag approach to cataract surgery, BIL involves both an anterior and a posterior rhexis, a specially grooved IOL, and a uniquely effective capsu- lar tuck technique. In an interview with EyeWorld, Dr. Tassignon, the technique and IOL inventor, shared her wealth of experience on the subject. "I think many ophthalmol- ogists are not aware of the impact and the power of the lens epithe- lial cells and how they can act to decenter the lens. About 10 years ago, I set out to get rid of capsular opacification, which meant that I needed to limit the capsular healing process, brought about by these cells after cataract surgery, to the periph- ery of the capsular bag. On the one hand, PCO on the central posterior capsule impedes vision, while on the other hand, the irregular growth of epithelial cells and their fibrotic reaction cause capsule contraction, which can decenter the IOL. These different healing mechanisms are a very important principle," she said. Dr. Tassignon created the BIL IOL (Morcher, Stuttgart, Germany) with a novel feature: a groove at the equator of the optic, designed to fit into the carefully sized capsulorhex- is, receiving the cut ends of both the anterior and posterior capsular rhexis ridges. "Both the anterior and posterior capsule are positioned within the lens groove. This has proven more than 10 years to limit Soemmering's ring to the capsulor- hexis rim with no effect on vision or IOL position. Newer grooved lenses that make use of an optic groove to tuck the anterior capsule leaf do not have a solution for PCO," she said. Tucking in both the anterior and posterior capsule edges allows a permanently symmetrical periphery of the capsular bag. Although the capsule bag refills with lens epithe- lial cells after cataract surgery/IOL implantation, it occurs symmetri- cally and prohibits any cells from migrating behind and potentially changing the position of the lens. The capsular bag healing process is associated with capsular contraction, loss of elasticity, loss of transpar- ency, and the stretching of zonular fibers. Dr. Tassignon chalks up the prevention of PCO growth behind the IOL to the cutting and tucking of the posterior rhexis, as removing the tissue behind the IOL precludes the growth of cells in the Berger space. Position Unlike most other IOLs, position- ing the BIL IOL is independent of the capsule bag, as its design has nothing to do with the traditional placement of haptics into the bag. Most haptics have a 12 to 13 mm to- tal diameter, meaning that the lens position will be affected by the area the haptics take up within the cap- sular bag, causing a slight tilt. The New techniques for cataract surgery complications Bag-in-the-lens solution for PCO Source: Marie-José Tassignon, MD, PhD Positioning of both capsules in the lens groove

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