Cases of Lens Capsular Enlargement Case conference 2013.3.7 R4 백지원/St.이용은/Pf. 주천기

AC rupture during incision or CTR ins. Classification Accidental Intentional Radial tear uneven CCC Incomplete/ Small CCC AC rupture during incision or CTR ins. 2 stage CCC in mature cat or congenital cat in PC rupture PCCC or PC opacity Small CCC Incomplete/uneven CCC AC rupture during incision or CTR ins. 2 stage CCC in mature cat PCCC in PC rupture or congenital cat or PC opacity Anterior Posterior Radial tear

Case 1 : AC rupture F 56 Dec VA(OS) onset) several yrs History VA DM/HBP (-/+) for 7rys, po medi. Ocular op/trauma(-/-) Gls (+) Eye drop (-) VA OS 0.2 (0.8 x +4.00Ds -1.00Dc Ax85) MR OD +4.25Ds -1.00Dc Ax105 / OS +4.00Ds -1.00Dc Ax85 IOP 17/18mmHg LOCS : OS 2233 Axial length OS 21.63(IOLm) ACD 2.39 K 43.50/43.25 2011.7.18 Phaco+PCL(OS) <MI60, 30.0D, -2.35DT (IOL m, SRK-T), -1.2DT (IOL m, Hoffer Q) >

Case 2 : 2 stage CCC in mature cat F 57 Dec VA(OS) History DM/HBP (+/+)(3yr po medi/3yr po medi) Ocular op/trauma(+/-) 2011.3.10 Phaco+PCL(OD) <Miniflex ,+23.0 D, -0.16 DT(A-scan, SRK-T)> VA OD 1.0 / OS FC30 (n-c) MR OD +0.50Ds -1.00Dc Ax100 OS error IOP 14/17mmHg LOCS : OS 5555 Axial length OS 22.78(Ascan) K 44.50/45.00 2013.01.31 Phaco+PCL(OS) <NY60, +21.50D, -0.17DT(A scan, SRK-T)> SMI : 0 (autoK와 topoK 불일치)(Topo K) Combo-Prechopper 사용안함 ORGC 5.3 mm 사용함 ICG dye 사용함 hypermature cat 으로 ICG dye 사용 후 small CCC 시행하고 I&A 하여 lenticular pressure & intraocular pressure 를 낮추고 ORGC 넣고 CCC 시행함

Case 3 : Uneven CCC M 87 Dec VA(OD) History DM/HBP (-/+) for 4 month po medi Ocular op/trauma(-/-) VA OD 0.16(0.25) / OS 0.2(0.32) MR OD +2.50Ds -0.50Dc Ax90 OS -0.50Ds -1.25Dc Ax55 IOP 17/20 mmHg LOCS : OD 3343 Axial length OD 23.71(Ascan) K 43.75/44.25 2012.03.19 Phaco+PCL(OD) <Asphina, +19.0D, -0.26DT(IOLm, SRK-T)> CCC후 roundability 좋음. centering 9시 방향으로 치우쳐서 3시방향 CCC 넓힘./OD

Case 4 : PCCC in PC rupture M 51 Dec VA(OD) for 10 yrs History DM/HBP (-/-) Ocular op/trauma(-/-) VA OD 0.5 (n-c) / OS 0.63 (n-c) MR OD -4.50Ds -1.00Dc Ax120 OS -3.75Ds -1.00Dc Ax50 IOP 16/15 mmHg LOCS : OD 2221 Axial length OD 24.55 (Ascan) K 43.50/44.50 2012.02.27 Phaco+PCL(OD) <ZA9003, +18.0D, -0.23DT(IOLm, SRK-T)> Polishing 도중 Post. capsule tear가 발견됨 --> Incomplete PCCC가 됨 --> PC가 intact 부분으로 haptic이 가게 (12시, 6시방향) 위치시킴 (IOL in the bag)/OD

Case 5 : PCCC in congenital cataract M 33 Dec VA(OS) onset) at birth History DM/HBP (-/-), Ocular op/trauma(-/-) VA OD 1.0 / OS 0.63(n-c) MR OD -0.75Ds -0.25Dc Ax 124 OS error IOP 20/19 mmHg LOCS : OD 1123 Axial length OD 23.88(Ascan) K 44.00/43.25 2012.12.20 Phaco+PCL(OS) <EC-1PAL, +17.50D, -2.05 DT(IOLm, SRK-T)>

Lens Capsular enlargement References 1. Cataract Surgery, 3rd Edition Cataract Surgery, 3rd Edition 2. Essentials of Cataract Surgery 3. Posterior capsule staining and posterior continuous curvilinear capsulorhexis in congenital cataract. J Cataract Refract Surg 2002 4. Intraoperative Management of Posterior Capsule Tears in Phacoemulsification and Intraocular Lens Implantation. Ophthalmology 2001;108:2186–2192. Review Lens Capsular enlargement

Capsulorrhexis Using lens capsule's shearing property Gives mechanical and structural integrity Advantages No tags or flaps of anterior capsule remnants Mechanical forces exerted onto the zonules are minimized Closed-system approach: the posterior capsule is ballooned posteriorly No risk of extending radial tears in the anterior capsule into the posterior capsule Even in the case of a PC defect, an intact anterior capsulorrhexis provides the possibility of implanting an IOL safely into the ciliary sulcus After cataract manage Thus, successful round & proper sized CCC is important

Challenge requiring enlargement Radial tear AC deeping with viscoelastics puncture the capsule again with a 30-gauge needle or vannas scissors Pull leading edge flap to backward &centrally Small CCC Incomplete/uneven CCC AC rupture during incision or CTR ins. In congenital cataract or PC opacity or PC rupture PCCC is required

Posterior CCC Indication congenital cataract prevent extension of inadvertant PC tear For in the bag lens implantation in small PC tear Removal of PC plaque Prevent PCO

PCCC in congenital cataract To prevent PCO or secondary membrane formation Difficulty thin, transparent, elastic pediatric posterior capsule. Primary PCCC : up to 6–8 yo. Procedure A 26-gauge needle puncture PCCC accomplished aiming at a size of 3.5–4mm by using the ACCC principles and strategies Additional viscoelastic material can be placed through the central puncture of the posterior capsule to push the vitreous face away PCCC should be concentric to and smaller than the ACCC

PCCC in PC rupture A CCC made in the PC thus behaves like a CCC and is resistant to radial tears PCCC technique allows safe and secure in-the-bag IOL Placement Small tears in the PC at the end of phaco or during I/A can be converted to a PCCC -> in the bag Large tears in the PC can be converted to a PCCC ->anterior rhexis fixation Sustaining the integrity of the capsular bag when a vitrectomy is required.

Summary CCC gives mechanical and structural integrity during phacoemulsification Proper enlargemnet of CCC should be done if required in situations like Radial tear Small CCC Incomplete/uneven CCC AC rupture during incision or CTR ins. PCCC is required In congenital cataract or PC opacity PCCC enables IOL in the bag insertion in cases of PC rupture

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