Multifocal intraocular lens optic anteriorization capture to correct residual refractive error

Multifocal intraocular lens optic anteriorizationcapture to correct residual refractive errorLeonardo Akaishi, MD, Tiago Bessa, MD, Rodrigo Vaz, MD, Fabio Canamary, MD,

Patrick F. Tzelikis, MD, PhD

PURPOSE: To evaluate the efficacy and safety of capturing the intraocular lens (IOL) optic throughthe anterior capsulorhexis opening in eyes with multifocal IOLs and a residual refractive error.

SETTING: Hospital Oftalmologico de Brasılia, Brasılia, Brazil.

METHODS: Eyes with previous cataract surgery and Tecnis ZM900 multifocal IOL implantation wereprospectively analyzed. After at least 1 month, patients had second surgery in which the IOL opticwas captured through the anterior capsulorhexis opening to correct the residual refractive error.Preoperative and postoperative examinations at 1 day and 3 months included spherical equivalent(SE); uncorrected distance (UDVA), near (UNVA), and intermediate (UIVA) visual acuities; and cor-rected distance visual acuity (CDVA).

RESULTS: The study included 16 eyes of 14 patients. The mean UDVA was 0.32 logMAR preoper-atively and 0.10 logMAR after anterior optic capture and the mean SE, C1.09 diopters (D) andC0.26 D, respectively; both improvements were statistically significant (P<.001). The change inCDVA and UNVA from before anterior optic capture to the last follow-up was not statistically signif-icant. The UIVA was significantly worse postoperatively (P Z .011). No eye lost lines of CDVA. Oneeye (6.25%) developed glaucoma postoperatively. At the last follow-up, 13 patients (92.85%) werespectacle-independent for near and distance vision.

CONCLUSION: Early outcomes indicate that anterior optic capture is a safe, accurate procedure ineyes with multifocal IOLs and a mild hyperopic residual refractive error postoperatively.

J Cataract Refract Surg 2009; 35:2077–2083 Q 2009 ASCRS and ESCRS

ARTICLE

0886-3350/09/$dsee front matter 2077doi:10.1016/j.jcrs.2009.08.014

The expectations of patients who have multifocal in-traocular lens (IOL) implantation are high becausethey believe they will have little or no dependenceon spectacles postoperatively. Meeting this expecta-tion requires eliminating ocular astigmatism andachieving a precise postoperative refraction (G0.25diopter [D]). Despite advances in biometry and in-creasingly sophisticated cataract surgery techniques,inaccurate preoperative measurements, postoperative

Submitted: March 31, 2009.Final revision submitted: August 11, 2009.Accepted: August 26, 2009.

From Brasılia Ophthalmologic Hospital, Brasılia, Brazil.

No author has a financial or proprietary interest in any material ormethod mentioned.

Corresponding author: P.F. Tzelikis, MD, PhD, SQN 203, Bloco G,Apart 405, Brasilia, DF, Brazil 70833-070. E-mail: [email protected].

Q 2009 ASCRS and ESCRS

Published by Elsevier Inc.

astigmatism, or variability in the final position of theIOL in the eye can lead to the need for spectacles post-operatively to achieve emmetropia.1,2

The incidence of residual refractive error after re-fractive IOL implantation ranges from approximately3% to 25%; at least 90%of patients should have a spher-ical equivalent (SE) refraction within G1.00 D of thetarget.3,4 When a residual refractive error occurs, thedecision the type of enhancement is based onthe type of residual refractive error. Intraocular lensexchange, piggyback IOL implantation, and refractivecorneal surgery are treatment options.5–8

In this study, we evaluated about the refractive out-comes in eyes that had cataract surgery with diffrac-tive multifocal IOL implantation and subsequentsurgery in which the IOL optic was captured throughthe continuous curvilinear capsulorhexis (CCC) ante-riorly to correct a residual refractive error. To ourknowledge, this is the first report of multifocal IOL op-tic capture through the anterior CCC to correct resid-ual refractive errors.

2078 MULTIFOCAL IOL OPTIC CAPTURE FOR RESIDUAL HYEROPIA

Figure 1. Operating microscopeviews show a cannula being intro-duced behind the IOL optic. TheIOL optic is then brought anteriorlyand captured through an intact an-terior CCC while the haptics re-main in the capsular bag.

PATIENTS AND METHODS

This prospective observational noncomparative study com-prised eyes of consecutive patients who had an anteriorIOL optic capture through the CCC from January 2007 to Oc-tober 2008. Each patient was advised that surgery would beconsidered only if the symptoms of blurry vision were re-lated to the residual refractive error. Patients were also in-formed of the potential risks of the surgical procedure. Allpatients provided written informed consent before surgeryin accordance with the Declaration of Helsinki. The Investi-gation Review Board, Hospital Oftalmologico de Brasılia,approved the study.

Exclusion criteria for cataract surgery and for anterior op-tic capture surgery were a central endothelial cell count(ECC) less than 1800 cells/mm2, glaucoma or intraocularpressure (IOP) greater than 21 mm Hg, amblyopia, retinalabnormalities, diabetes mellitus, steroid or immunosuppres-sive treatment, and connective tissue disease. Inclusion crite-ria were a residual refractive error of at least C0.75 D,previous uneventful cataract surgery, and an intact, well-centered, 5.00 to 5.25 mm anterior CCC.

Intraocular Lens

During the previous cataract surgery, all eyes had implan-tation of a Tecnis ZM900 IOL (Abbott Medical Optics, Inc.).This polysiloxane 3-piece foldable IOL has a 6.0 mm optic,6 degrees of haptic angulation (anterior angulation), andan A-constant of 119.8. Axial length was measured with anoptical biometer (IOLMaster, Carl Zeiss Meditec AG); thetargeted postoperative refractive error was 0.0 D.

Surgical Technique

The same surgeon (L.A.) performed all anterior optic cap-ture procedures using local anesthesia of lidocaine hydro-chloride 2.0% gel and intravenous sedation. The IOL was

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repositioned through 2 paracenteses. Sodium hyaluronate3.0%–chondroitin sulfate 4.0% (Viscoat) was used to reformand stabilize the surgical planes and protect the endothe-lium. With a cannula, the IOL optic was brought forwardand captured through an intact anterior CCC while the hap-tics remained in the capsular bag (Figure 1). Acetylcholinechloride was injected into the anterior chamber, and the oph-thalmic viscosurgical device was washed out. Postoperativemedication included moxifloxacin or gatifloxacin 4 timesa day for 10 days, diclofenac sodium 0.1% 3 times a dayfor 4 weeks, and prednisolone acetate eyedrops 4 timesa day for 4 weeks.

Patient Examinations

Postoperative follow-up was at 1 day and 1 and 3months.Before and after optic capture surgery, patients had a fullophthalmic examination including spherical equivalent(SE); uncorrected distance (UDVA), near (UNVA), and inter-mediate (UIVA) visual acuities; corrected distance visualacuity (CDVA); slitlamp biomicroscopy; applanation tonom-etry; fundus evaluation; B-scan biometry; specular micros-copy; and corneal topography. Visual acuities wererecorded as logMAR values. Clinical datawere collected pre-operatively and 3 months postoperatively.

Statistical Analysis

Data were analyzed using SPSS software (version 13.0,SPSS, Inc.). Comparisons were made using the Wilcoxonsigned-rank test. Differences with a P value less than 0.05(ie, at 5% level) were considered statistically significant.

RESULTS

Of the 14 patients (16 eyes) in the study, 10 were men(71.4%) and 4 were women (28.6%). The mean age of

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Table 1. Patient characteristics.

SE (D)

Pt Age (Y)/Sex AL (mm) ACD (mm) Mean K (D) IOL Power Before AOC After AOC FU (Mo)

1A 74/F 21.42 2.99 47.97 23.50 C1.00 C0.25 3.01B d 21.52 3.00 47.46 23.50 C0.75 0.00 6.02* 65/M 22,76 2.91 45.10 20.50 C1.25 C0.50 9.03 68/M 22.09 2.46 44.21 24.50 C1.50 C0.25 6.04 85/M 23.30 3.01 44.37 21.00 C1.00 0.25 7.05 54/F 21.70 3.43 42.74 30.00 C0.75 0.00 3.06 65/M 20.33 2.66 45.87 32.00 C1.00 C0.25 13.0

7A 71/M 22.70 2.85 43.37 25.00 C1.00 C0.25 10.07B d 22.95 2.94 42.77 24.00 C1.25 C0.75 11.08 65/F 22.68 3.06 44.81 22.50 C1.25 C0.50 8.09 65/M 22.83 3.43 46.49 19.50 C1.25 C0.25 6.0

10 73/M 23.29 2.35 42.86 22.00 C1.00 0.00 3.011 57/M 24.79 3.06 43.52 17.00 C1.25 C0.50 6.012 78/M 22.99 2.68 44.54 22.00 C1.25 C0.50 4.013 60/F 23.65 3.39 42.87 22.00 C0.75 �0.25 6.014 70/M 22.74 2.50 43.13 23.00 C1.25 C0.50 3.0

ACD Z anterior chamber deep; AL Z axial length; AOC Z anterior optic capture; FU Z follow-up; IOL Z intraocular lens; K Z keratometry; Pt Z patient;SE Z spherical equivalent*Developed glaucoma

the patients was 67.8 years G 8.2 (SD) (range 54 to 85years). The mean time between cataract surgery andanterior optic capture surgery was 2.4 G 2.2 months(range 1 to 10months). Anterior optic capture was per-formed within 3 months of cataract surgery in 14 eyes(87.5%), within 4 months after in 1 eye, and after 10months in 1 eye. The mean follow-up after optic cap-ture surgery was 6.50 G 3.0 months (range 3 to 13months). The postoperative results were analyzed for15 eyes; 1 eye (6.25%) developed glaucoma after theprocedure and required another surgery toreposition the IOL in the capsulorhexis. The preopera-tive results are for all 16 eyes.

Preoperative

Preoperative topography showed amean flat cornealmeridian of 44.16 G 1.7 D (range 42.11 to 47.89 D)and a mean steep corneal meridian of 44.83 G 1.7 D(range 42.90 to 48.05 D). The mean topographicastigmatism was 0.66 G 0.50 D (range 0.05 to 1.98 D).The mean preoperative ECC was 2299 G 269cells/mm2 (range 1851 to 2881 cells/mm2). The meanaxial length (AL) was 22.60 G 1.03 mm (range 20.33to 24.79 mm) and the mean anterior chamber deep(ACD), 2.92 G 0.33 mm (range 2.35 to 3.43 mm). Themean power of the implanted IOLs was C23.25 G3.63 D (range C17.0 to C32.0 D). Table 1 shows theresults by individual patient.

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After Cataract Surgery

After cataract surgery and before anterior optic cap-ture, the mean residual SE refraction was C1.09 G0.22 D (range C0.75 to C1.50 D). Themean visual acu-ities were as follows: UDVA, 0.32 G 0.07 (range 0.18 to0.48); UIVA, J3.3 (range J2 to J6); UNVA, J1.25 (range J1to J3); and CDVA, 0.03 G 0.04 (range 0.00 to 0.10). TheUDVA was 0.30 (20/40) or better in 11 eyes (68.7%)and 0.18 (20/30) or better in 2 eyes (12.5%); no eyeachieved a UDVA of 0.10 (20/25) or better.

After Anterior Optic Capture

Three months after anterior optic capture (n Z15), the mean residual SE refraction was C0.26 G0.26 D (range �0.25 to C0.75 D) (Figure 2), whichwas statistically significantly better than preopera-tively (P!.001). The mean visual acuities were asfollows: UDVA, 0.10 G 0.09 logMAR (range 0.00to 0.30 logMAR) (Figure 3); UIVA, J4 (range J3 toJ6); and CDVA, 0.02 G 0.04 logMAR (range 0.00 to0.10 logMAR) (Figure 4). All patients achieveda UNVA of J1. The mean UDVA was 0.30 (20/40)or better in 15 eyes (100.0%), 0.18 (20/30) or betterin 14 eyes (93.3%), and 0.10 (20/25) or better in 10eyes (66.70%). The mean UDVA 3 months after theanterior optic capture was statistically significantlybetter than preoperatively (P!.001). There were nostatistically significant differences in CDVA andUNVA between before anterior optic capture

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surgery and the last follow-up (PO.05). Two eyes(12.5%) gained 1 line of CDVA, and no eye lost linesof CDVA. The UIVA was statistically significantlyworse after the anterior optic capture procedure(P Z .011).

No intraoperative complications occurred. One pa-tient (6.25%) developed glaucoma after the optic cap-ture procedure. The main complaint was transientblurring of vision that interfered with daily activitiesor job functions, especially with distance activities.The mean corrected visual acuity in all patients was20/25 or better. Despite this level of acuity, all patientshad transient blurring of vision. Although no ques-tionnaire was administered at the end of the study,all patients anecdotally reported being satisfied withthe surgery. No patient reported trouble with interme-diate or near vision before or after the procedure. Atthe last follow-up, the 13 patients (92.85%) evaluatedwere spectacle independent for near and distance vi-sion. At 3 months, 5 patients (35.7%) still noted mildhalos at night with no daytime disability. No othercomplaints were reported.

DISCUSSION

Patients who have refractive surgery want to improvetheir uncorrected vision and avoid the use of glasses orcontact lenses. The loss of accommodation after cata-ract surgery and the restoration of near vision in pa-tients with IOL implantation remains a complexproblem of modern cataract surgery. Recently, multi-focal IOLs were introduced and have gained widepopularity. Studies of several multifocal IOLsmodels6–9 report excellent distance and near visualacuity. Our study evaluated and compared the refrac-tive outcomes in patients who had anterior optic IOLcapture through an intact anterior CCC after previous

Figure 2. Spherical equivalent refraction after anterior optic capture(n Z 15 eyes).

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cataract surgery with implantation of a diffractivemultifocal IOL.

After cataract surgery, patients may have a signifi-cant residual refractive error and desire additionaltreatment for the ametropia. Results of treatmentvary with the type of residual refractive error (eg, my-opia, hyperopia, mixed astigmatism). Differenttreatment techniques can also result in diverse out-comes. The technique of capturing a non-plate-hapticIOL optic through a capsulorhexis opening was firstdescribed in 1991 (T. Neuhann, MD, ‘‘The Rhexis-Fix-ated Lens,’’ film presented at the ASCRS Symposiumon Cataract, IOL and Refractive Surgery, Boston, Mas-sachusetts, USA, April 1991). To our knowledge, this isthe first study to date of the efficacy and safety of an-terior optic capture of a multifocal IOL through an in-tact anterior CCC. Our results show that this techniqueis effective and safe and has merits in treating smallhyperopic refractive errors after cataract surgery.

Figure 3.Uncorrected distance visual acuity (UDVA) over time (n Z15 eyes).

Figure 4.Corrected distance visual acuity (CDVA) over time (n Z 15eyes).

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Sulcus fixation of an IOL of a preoperativelyplanned power results in a myopic shift becausethe IOL is more anterior than an in-the-bag IOL.9

The same shift is expected to occur after anterior op-tic capture. In a study by Suto et al.,10 the mean dif-ference in the SE between preoperatively and aftersulcus IOL fixation was 0.78 G 0.47 D. This myopicshift was significant compared with the refraction incontralateral eyes with in-the-bag IOL fixation. In ourstudy, the mean difference in refraction from beforeto after anterior optic capture was 0.81 D. Hoffer11

reports that AL influences the change in IOL powerbecause the relative size of the ACD varies with AL.Errors in axial measurement are likely to cause post-operative refractive errors, particularly in eyes witha short AL in which even slight miscalculation cancause a significant error. It seems reasonable that dif-ferences in AL would affect the extent to whicha change in IOL position would influence refraction.In our study, we could not determine whether thisis the case, probably because of the small number ofpatients.

With regard to safety, no eye in our study lost morethan 1 line of CDVA. However, the UIVA was statisti-cally significantly worse after the anterior optic cap-ture procedure. This is presumably because thelocation of the distance and near foci in relation tothe retina’s plane causes visual acuity to vary gradu-ally from near to distance. However, the poorer inter-mediate vision may be outweighed by good near anddistance vision.

There were no intraoperative complications in ourstudy. After anterior optic capture surgery, 1 patientdeveloped glaucoma. Ocular inflammation resultingfrom IOL–uveal touch can lead to secondary glaucomawith multiple mechanisms.12 In our study, we werenot able to evaluate the position of the IOL and thepresence of rubbing between the iris and the IOL opticbecause we do not have ultrasound biomicroscopy(UBM). It is likely that in our patient who developedglaucoma, the IOL was touching the iris. Thus, the pa-tient had another surgery to reposition the IOL in thecapsulorhexis. Intraocular lens design should preventcontact between the iris and the IOL optic. A largerhaptic angle may prevent contact between suchcontact in cases of out-of-bag IOL fixation oranteriorization.

Another possible complication, although it did notoccur in our study, is pupillary capture that results inpupillary block glaucoma. This complication is rela-tively uncommon after phacoemulsification and in-the-bag IOL implantation, with few cases reportedin the literature.13–16 Several mechanisms for pupil-lary capture after in-the-bag IOL implantation havebeen proposed. The risk for pupillary capture can

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be lessened by using a miotic (eg, acetylcholine chlo-ride) intraoperatively and pilocarpine drops in theimmediate postoperative period and by not dilatingthe eye for 2 or more months postoperatively. Withthe data collected in our study, we were not ableto identify who is at greater risk for iris chafing orglaucoma after anterior optic capture. More informa-tion on IOL position after anterior optic captureshould be obtained using UBM or Scheimpflugimaging.

The anterior optic capture technique was usedonly with silicone multifocal IOLs. Laboratory stud-ies17–19 show that the adhesive force to the lens cap-sule differs significantly with different IOL materials,causing varying behavior of lens epithelial cells(LECs), lens fibers, or both. It is also known thatthe adhesiveness of silicone to vitronectin and colla-gen type IV is significantly higher than that of acry-late 1 week after incubation.19 In addition, siliconemay cause more anterior and posterior fibrosis thanother materials. The mechanism by which the IOLbiomaterial influences LEC behavior is not well un-derstood and requires further investigation.20,21 Wewere not able to compare how difficult the procedureand the amount of myopic shift obtained in eyes thathad the anterior optic capture earlier (!3 months)versus eyes that had the procedure later because 14eyes had the procedure before 3 months, with only2 having it later.

A potential disadvantage of the anterior opticcapture technique is the increased risk for posteriorcapsule opacification (PCO). After uneventful cataractextraction, PCO occurs more frequently when no IOLis implanted in the capsular bag than when one is.22,23

An anterior CCCwith a diameter slightly smaller thanthat of the IOL optic also seems to reduce PCO.24 Afterthe anterior optic capture procedure, the change in theIOL optic position can induce PCO. Because patientswith refractive IOLs are more sensitive to smallchanges in visual function resulting from posteriorcapsule folds, fibrosis, and cell proliferation, neody-mium:YAG laser capsulotomy remains the mostcommon treatment for clinically significant PCO.Although treatment is simple, complications includesevere IOL damage, IOL subluxation or dislocation,retinal detachment, and secondary glaucoma.25 As ofthe last follow-up in our study, there were no cases ofthe IOL shifting back into the capsular bag, which isanother possible complication of anterior opticcapture.

Methods for correcting unexpected refractive errorin cataract surgery include secondary piggyback IOLimplantation, exchange of the original IOL, and laserrefractive surgery. The piggyback method of im-planting 2 or more IOLs in the same eye has been

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expanded to successfully correct refractive error inmyopic and hyperopic pseudophakia.26 The advan-tages of secondary piggyback IOLs are fewer intrao-perative maneuvers that could lead to capsulerupture and simpler IOL power calculation. However,postoperative IOP elevation, iris chafing, pigment dis-persion syndrome, secondary glaucoma, and interlen-ticular opacification can occur after implantation ofa second IOL.27 Intraocular lens exchange is also aneffective option for treating incorrect IOL power aftercataract surgery if the source of the error is apparentand if the error is discovered early in the postopera-tive course.28 One limitation of IOL exchange is thatit is difficult to predict the power of the replacementIOL. Corneal laser refractive surgery is an effective al-ternative to piggyback IOL implantation or IOL ex-change.29 Although studies show that laser in situkeratomileusis is safe when performed beyond 3months after cataract surgery, it could create compli-cations, mostly related to wound healing and IOL sta-bility.29 In cases in which the residual refractive erroris considered to be low, we believe the best option islaser refractive surgery or anterior optic capture.

In conclusion, our results indicate that anterior opticcapture of amultifocal IOL in eyeswithmild hyperopicrefractive error is a safe and effective refractive solu-tion. Proper patient selection, preoperative measure-ments, intraoperative technique, and postoperativemanagement have resulted in excellent outcomes andimproved patient acceptance of the technique. Aswith all refractive procedures, realistic expectationsshould be established before surgical intervention.Our conclusions are based on a small number ofpatients. Further studies of a larger patient populationare needed to confirm these results.

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First author:Leonardo Akaishi, MD

Brasılia Ophthalmologic Hospital,Brasılia, Brazil

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