In-the-bag intraocular lens placement via secondary capsulorhexis with radiofrequency diathermy in pediatric aphakic eyes

Abstract

Pediatric ophthalmologists increasingly recognize that the ideal site for intraocular lens (IOL) implantation is in the bag for aphakic eyes, but it is always very difficult via conventional technique. We conducted a prospective case series study to investigate the success rate and clinical outcomes of capsular bag reestablishment and in-the-bag IOL implantation via secondary capsulorhexis with radiofrequency diathermy (RFD) in pediatric aphakic eyes, in which twenty-two consecutive aphakic pediatric patients (43 aphakic eyes) enrolled in the Childhood Cataract Program of the Chinese Ministry of Health were included. The included children underwent either our novel technique for secondary IOL implantation (with RFD) or the conventional technique (with a bent needle or forceps), depending on the type of preoperative proliferative capsular bag present. In total, secondary capsulorhexis with RFD was successfully applied in 32 eyes (32/43, 74.4%, age 5.6±2.3 years), of which capsular bag reestablishment and in-the-bag IOL implantation were both achieved in 30 eyes (30/43, 70.0%), but in the remaining 2 eyes (2/32, 6.2%) the IOLs were implanted in the sulcus with a capsular bag that was too small. Secondary capsulorhexis with conventional technique was applied in the other 11 eyes (11/43, 25.6%, age 6.9±2.3 years), of which capsular bag reestablishment and in-the-bag IOL implantation were both achieved only in 3 eyes(3/43, 7.0%), and the IOLs were implanted in the sulcus in the remaining 8 eyes. A doughnut-like proliferative capsular bag with an extensive Soemmering ring (32/43, 74.4%) was the main success factor for secondary capsulorhexis with RFD, and a sufficient capsular bag size (33/43, 76.7%) was an additional factor in successful in-the-bag IOL implantation. In conclusion, RFD secondary capsulorhexis technique has 70% success rate in the capsular bag reestablishment and in-the-bag IOL implantation in pediatric aphakic eyes, particularly effective in cases with a doughnut-like, extensively proliferative Soemmering ring.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Schematic diagrams of the surgical techniques of capsular bag reestablishment and in-the-bag IOL implantation via secondary capsulorhexis with RFD.

A, We used sodium hyaluronate to maintain the anterior chamber of an aphakic eye with a doughnut-like, extensive Soemmering ring. B, The RF tip was inserted into the anterior chamber to cut the anterior fibrotic capsule with coagulation energy, and the appearance of a visible bubble line indicates the cutting site. C, The cortical material was removed via I/A or a phaco tip using a divide-and-conquer approach. D, The capsular bag was reestablished with sodium hyaluronate. E, An IOL was implanted into the peripheral capsular bag. F, The RF tip was inserted into the anterior chamber again through the tilted IOL to cut the posterior fibrotic capsule. G, The IOL was dialed centrally after secondary capsulorhexis of the posterior capsule. H, The IOL was well-centered and implanted in the bag after the sodium hyaluronate was cleared. Notes: RFD = radiofrequency diathermy, IOL = intraocular lens, I/A = irrigation/aspiration.

Figure 2. The relationships between different types of proliferative capsular bags, secondary capsulorhexis with/without RFD and the IOL implantation site in two groups.

The number of cases is shown in different columns. Proliferative capsular bag Type 1 was included in Group A, and proliferative capsular bag Types 2 and 3 were included in Group B. Notes: RFD = radiofrequency diathermy, IOL = intraocular lenses.

Figure 3. Photograph of an aphakic eye with a proliferative capsular bag.

A, The capsular bag was completely closed with anterior-posterior synechia, was filled with proliferative cortical material and had an extensive Soemmering ring. B, The capsular bag was completely closed with anterior-posterior synechia, but it had little cortical material and a sparse and focal Soemmering ring.

Figure 4. Postoperative photographs of secondary IOL implantation 1 week after surgery.

A, The in-the-bag IOL was centered in the peripheral capsular bag with clear anterior (small arrow) and posterior (large arrow) secondary capsulorhexis relative to the smooth edge in one of the eyes underwent our novel surgical technique. B, In-the-bag IOL was accompanied by epithelium proliferation (small arrow) scattered in the visual axis and a relatively rough posterior edge (large arrow) after secondary capsulorhexis in one of the eyes underwent the traditional surgical technique. Notes: IOL = intraocular lenses.

Figure 5. Postoperative photograph of secondary IOL implantation 3 months after surgery.

A, The in-the-bag IOL was well-centered in the peripheral capsular bag without any epithelium proliferation in the visual axis in one of the eyes underwent our novel surgical technique. B, Apparent epithelium proliferation and shrinkage of the residual capsular bag was identified in one of the eyes underwent the traditional surgical technique. Notes: IOL = intraocular lenses.