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Buttonhole posterior capsule IOL implantation prevents PCO, surgeon says
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VIENNA — Buttonhole posterior capsule IOL implantation, which is normally used in pediatric patients, can help prevent posterior capsular opacification in adults and could offer an alternative to in-the-bag implantation, according to a surgeon speaking here.
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"We have seen from our results that in the medium- to long-term, the square edge is a weak line of defense against posterior capsular opacification. Patients with 5 to 10 years of follow-up still have a 40% YAG [capsulotomy] rate," said Rupert Menapace, MD, at the joint meeting of the European Society of Ophthalmology and American Academy of Ophthalmology.
Posterior capsulorrhexis could theoretically provide a second line of defense, but often leads to epithelial cell ingrowth and posterior continuous curvilinear capsulorrhexis reclosure.
"Looking for a better alternative, I tried on adult patients the pediatric approach of buttonholing the IOL into the posterior capsulorrhexis and found it extremely effective," Dr. Menapace said.
With this technique, the edge of the posterior capsule lies on top of the anterior optic surface of the IOL, so when the lens epithelial cells migrate, they cannot gain access to the retrolental space.
After phacoemulsification and removal of the cortex, the anterior chamber is filled with low-viscosity viscoelastic, leaving an empty capsular bag. The residual anterior capsule ring is flattened against the posterior capsule to obtain one horizontal plane.
The center of the posterior capsule is then punctured using a 30-gauge needle, paying attention not to perforate the anterior hyaloid.
Posterior continuous curvilinear capsulorrhexis is then performed, following the line of the anterior capsulorrhexis, to obtain a perfectly coinciding diameter and a perfect centration. Healon (Advanced Medical Optics) is injected toward the periphery to keep the capsule rim well separated from the anterior hyaloid. At this point, the lens is injected and "buttonholed" into the residual posterior capsule, inserting the loops and the edges of the lens in the capsular bag fornix.
"I now have over 1,000 cases implanted with this technique," Dr. Menapace said. "It is effective in preventing PCO and has a high safety profile. There is no difference from standard in-the-bag IOL implantation concerning IOP and flare, and the position of the lens guarantees permanent stability and centration. The posterior placement of the lens stabilizes the vitreous and the hermetic sealing of the posterior capsule does not allow infiltration of inflammatory agents, preventing retinal detachment and [cystoid macular edema]."
This technique could become a valid alternative to traditional in-the-bag implantation. At present, it should be first choice in pediatrics cataract surgery, pseudoexfoliative glaucoma, high myopia and peripheral retinal disease, Dr. Menapace said.
An interesting future indication could be the implantation of toric IOLs because the buttonhole fixation prevents the rotation of the lens, he noted.