This article is funded by Beijing Haidian Innovation and Transformation Project, HDCXZHKC2021212.

This study adhered to the tenets of the Declaration of Helsinki. The study protocol was approved by the Institutional Review Board of Peking University Third Hospital. It should be noted that the novel procedure here is the step of rotating the IOL. The inclusion criteria are cataract patients over 50 years of age willing to undergo cataract surgery in Peking University Third Hospital. The exclusion criteria are the presence of eye diseases that may affect the stability of the suspensorium and capsular bag, such as pathologic myopia, glaucoma, pseudoexfoliation syndrome, uveitis, subluxation of the lens including Marfan syndrome, Marchesani syndrome, and homocystinuria.
1. Surgery preparation
<ol>
	<li>Patient preparation
	<ol>
		<li>Use 0.5% levofloxacin eye drops four times per day 3 days before surgery. Administer topical anesthetic eye drops of 0.4% oxybuprocaine hydrochloride three times per 5 min before the surgery (see Table of Materials). 
		NOTE: Patients&#39; pupils become dilated with compound tropicamide eye drops (0.5% tropicamide and 0.5% phenylephrine hydrochloride) 1 h before surgery.</li>
	</ol>
	</li>
	<li>Equipment settings
	<ol>
		<li>Ensure the following settings for the phacoemulsification device system (see Table of Materials): 30%-95% torsional nucleus chop, 90 cm bottle height, 260-450 mm Hg vacuum, and 36 cc/min aspiration flow rate.</li>
	</ol>
	</li>
</ol>
2. Rotating using the irrigation and aspiration (I/A) system
<ol>
	<li>Corneal incision
	<ol>
		<li>Make a 3.2 mm limbal incision at the steepest meridian using a 3.2 mm slit blade (see Table of Materials). A &#34;Z&#34;-shaped multiplanar corneal incision is preferred. First, create a 0.3 mm deep groove perpendicular to the corneal surface and insert the blade into the groove with its tip tangentially directed to the corneal surface, thereby creating a tunnel through the clear cornea into the anterior chamber.</li>
		<li>Create a 0.8 mm subsidiary incision 90&#176; anti-clockwise using a 20 G side port microvitreoretinal (MVR) knife (see Table of Materials).</li>
	</ol>
	</li>
	<li>Phacoemulsification
	<ol>
		<li>Open the capsule with a continuous curvilinear capsulorhexis using Utrata capsulorhexis forceps (see Table of Materials) under viscoelastic conditions.</li>
		<li>Perform cortical-cleaving hydrodissection by placing a blunt-tipped cannula with balanced salt solution (BSS) under the anterior capsule flap, carefully lifting the capsular, and injecting BSS in a radial direction, to separate the cortex from the posterior capsule.</li>
		<li>Perform hydrodelineation by injecting BSS into the substance of the nucleus to separate the harder nucleus from the peripheral softer nucleus.</li>
		<li>Under the mode of &#34;chop&#34;, bury the phaco tip into the center of the nucleus and insert the phaco tip (see Table of Materials) under the anterior capsule flap, cracking the nucleus into two pieces using Sinskey hook (see Table of Materials). Repeat this step to create multiple small wedges of the nucleus for phacoemulsification.</li>
	</ol>
	</li>
	<li>Irrigation and Aspiration (I/A)
	<ol>
		<li>Modulate the machine in &#34;cortex&#34; mode. Use the I/A tip (see Table of Materials) to accomplish cortical cleanup. Remove the soft epinucleus and peripheral cortical material.</li>
	</ol>
	</li>
	<li>IOL insertion
	<ol>
		<li>Fill the capsule bag and anterior chamber with viscoelastics (see Table of Materials). Load a foldable single-piece IOL (see Table of Materials) into an injector cartridge prefilled with viscoelastic.</li>
		<li>Introduce the tip of the injector through the incision and insert the IOL by pushing the tail of the injector, with the anterior haptic spreading into the capsular bag. Place the posterior haptic under the anterior capsule using the tip of the injector.</li>
	</ol>
	</li>
	<li>Rotating the IOL and removing the viscoelastic
	<ol>
		<li>Use the I/A tip to remove the viscoelastic from the anterior chamber. During this procedure, rotate the IOL clockwise at least 360&#176; using the I/A tip with slight posterior pressure.</li>
		<li>Aspirate the residual fragments and viscoelastic in the capsular bag by inserting the I/A tip behind the optic part of the IOL.</li>
	</ol>
	</li>
</ol>
3. Rotating using IOL hooks
<ol>
	<li>The steps before insertion of the IOL are the same as the first four steps (2.1-2.4) above. In this method, after the IOL is inserted into the capsular bag, use a Fenzl hook (see Table of Materials) to rotate the IOL clockwise at least 360&#176; and slide the IOL in the capsular bag from side to side, putting slight pressure on the posterior capsule at the same time.</li>
</ol>
4. Follow-up procedures
<ol>
	<li>Instill BSS from the paracentesis incision using a blunt-tipped cannula to reform the anterior chamber.</li>
	<li>Inject BSS into both sides of the corneal tunnel incision. If the incision leaks, the wound should be sutured with a 10-0 nylon suture.</li>
</ol>

Preventing Posterior Capsular Opacification Through IOL Rotation in Cataract Surgeries

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C., Hadayer, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Continuous+curvilinear+capsulorhexis+-+a+practical+review.">Continuous curvilinear capsulorhexis - a practical review.</a> Seminars in Ophthalmology. 37 (5), 583-592 (2022).</li><li>Wormstone, I. M., Wormstone, Y. M., Smith, A. J. O., Eldred, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Posterior+capsule+opacification:+What's+in+the+bag.">Posterior capsule opacification: What's in the bag.</a> Progress in Retinal and Eye Research. 82, 100905 (2021).</li><li>Wu, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+importance+of+the+epithelial+fibre+cell+interface+to+lens+regeneration+in+an+in+vivo+rat+model+and+in+a+human+bag-in-the-lens+(BiL)+sample.">The importance of the epithelial fibre cell interface to lens regeneration in an in vivo rat model and in a human bag-in-the-lens (BiL) sample.</a> Experimental Eye Research. 213, 108808 (2021).</li><li>Darian-Smith, E., Safran, S. G., Coroneo, M. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lens+epithelial+cell+removal+in+routine+phacoemulsification:+is+it+worth+the+bother.">Lens epithelial cell removal in routine phacoemulsification: is it worth the bother.</a> American Journal of Ophthalmology. 239, 1-10 (2022).</li><li>Leydolt, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Posterior+capsule+opacification+with+two+hydrophobic+acrylic+intraocular+lenses:+3-year+results+of+a+randomized+trial.">Posterior capsule opacification with two hydrophobic acrylic intraocular lenses: 3-year results of a randomized trial.</a> American Journal of Ophthalmology. 217, 224-231 (2020).</li><li>Ursell, P. G., Dhariwal, M., O'Boyle, D., Khan, J., Venerus, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=5+year+incidence+of+YAG+capsulotomy+and+PCO+after+cataract+surgery+with+single-piece+monofocal+intraocular+lenses:+a+real-world+evidence+study+of+20,763+eyes.">5 year incidence of YAG capsulotomy and PCO after cataract surgery with single-piece monofocal intraocular lenses: a real-world evidence study of 20,763 eyes.</a> Eye. 34 (5), 960-968 (2020).</li><li>Apple, D. 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A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rotation+versus+non-rotation+of+intraocular+lens+for+prevention+of+posterior+capsular+opacification.">Rotation versus non-rotation of intraocular lens for prevention of posterior capsular opacification.</a> Indian Journal of Ophthalmology. 67 (9), 1428-1432 (2019).</li><li>Liu, X., Cheng, B., Zheng, D., Liu, Y., Liu, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Role+of+anterior+capsule+polishing+in+residual+lens+epithelial+cell+proliferation.">Role of anterior capsule polishing in residual lens epithelial cell proliferation.</a> Journal of Cataract and Refractive Surgery. 36 (2), 208-214 (2010).</li><li>Boyce, J. F., Bhermi, G. S., Spalton, D. J., El-Osta, A. 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L., Tian, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cytoskeletal+drugs+prevent+posterior+capsular+opacification+in+human+lens+capsule+in+vitro.">Cytoskeletal drugs prevent posterior capsular opacification in human lens capsule in vitro.</a> Graefes Archive for Clinical and Experimental Ophthalmology. 250 (4), 507-514 (2012).</li><li>Eid, A. M., Abd-Elhamid Mehany Elwan, S., Sabry, A. M., Moharram, H. M., Bakhsh, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+technique+of+pneumatic+posterior+capsulorhexis+for+treatment+and+prevention+of+posterior+capsular+opacification.">Novel technique of pneumatic posterior capsulorhexis for treatment and prevention of posterior capsular opacification.</a> Journal of Ophthalmology. 2019, 3174709 (2019).</li><li>Hollick, E. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effect+of+polymethylmethacrylate,+silicone,+and+polyacrylic+intraocular+lenses+on+posterior+capsular+opacification+3+years+after+cataract+surgery.">The effect of polymethylmethacrylate, silicone, and polyacrylic intraocular lenses on posterior capsular opacification 3 years after cataract surgery.</a> Ophthalmology. 106 (1), 49-54 (1999).</li><li>Ursell, P. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Relationship+between+intraocular+lens+biomaterials+and+posterior+capsule+opacification.">Relationship between intraocular lens biomaterials and posterior capsule opacification.</a> Journal of Cataract and Refractive Surgery. 24 (3), 352-360 (1998).</li><li>Nishi, O., Nishi, K., Wickstrom, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preventing+lens+epithelial+cell+migration+using+intraocular+lenses+with+sharp+rectangular+edges.">Preventing lens epithelial cell migration using intraocular lenses with sharp rectangular edges.</a> Journal of Cataract and Refractive Surgery. 26 (10), 1543-1549 (2000).</li><li>Li, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+AcrySof+versus+silicone+or+polymethyl+methacrylate+intraocular+lens+on+posterior+capsule+opacification.">Effect of AcrySof versus silicone or polymethyl methacrylate intraocular lens on posterior capsule opacification.</a> Ophthalmology. 115 (5), 830-838 (2008).</li><li>Maedel, S., Evans, J. R., Harrer-Seely, A., Findl, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraocular+lens+optic+edge+design+for+the+prevention+of+posterior+capsule+opacification+after+cataract+surgery.">Intraocular lens optic edge design for the prevention of posterior capsule opacification after cataract surgery.</a> The Cochrane Database of Systematic Reviews. 8 (8), (2021).</li><li>Schartmuller, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Posterior+capsule+opacification+and+Nd:YAG+laser+rates+with+two+hydrophobic+acrylic+single-piece+IOLs.">Posterior capsule opacification and Nd:YAG laser rates with two hydrophobic acrylic single-piece IOLs.</a> Eye. 34 (5), 857-863 (2020).</li><li>Patel, C. K., Ormonde, S., Rosen, P. H., Bron, A. 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All authors have no conflict of interest.

There are some benefits to this method. Firstly, residual LECs in the capsule bag were reduced further, especially those in the equatorial area, and the possibility of PCO occurrence was reduced rationally. Secondly, a reduced possibility of PCO means a lower rate of Nd:YAG laser treatment, providing the opportunity to maintain the integrity of the capsule bag and effective lens positions and functions. Thirdly, this method can be achieved with available instruments in cataract surgery without additional preparation. In ...

Cataracts are the most common cause of blindness worldwide, characterized by a clouding of the lens. The only means of treating cataracts is surgical intervention by removing the opaque lens, which restores high visual quality. However, a secondary reduction of visual quality, termed posterior capsule opacification (PCO), develops in 20%-40% of patients within 2 to 5 years after surgery1. This article introduces a method to further remove residual lens epithelial cells (LECs) left in the capsular bag in cataract surgery by rotating the intraocular lens (IOL) to prevent PCO.
PCO is a process caused by LECs, which are inevitably left in the capsular bag following cataract surgery and then begin to proliferate and migrate2. During phacoemulsification, a capsular bag is generated by continuous curvilinear capsulorhexis in the anterior capsule, which comprises a part of the anterior capsule, the equatorial capsule, and the entire posterior capsule2,3. In most patients, an IOL is implanted into the capsular bag. A transparent capsular bag, especially the posterior capsule, permits the light to transmit into the eyes, which is necessary for good postoperative visual quality4. A proportion of LECs are usually still attached to the capsular bag. As a reaction to the surgical trauma and a foreign body response toward IOLs, the residual epithelial cells start to proliferate and occupy first the remaining part of the anterior capsule, and then all available surfaces, including the surface of IOL and, most importantly, the previously acellular posterior capsule4. Subsequently, cells continue to divide, ultimately covering the entire posterior capsule and affecting the visual axis. The following changes, including fibrosis and regenerative form5, can cause significant visual impairment6. 
PCO that affects visual acuity can be treated with capsulotomy of the posterior capsule, usually by a neodymium-doped yttrium aluminum garnet (Nd:YAG) laser and sometimes a surgical procedure4. Recent studies report that the incidence of Nd:YAG capsulotomy for treating PCO 3 years after surgery is between 5% and 20%7,8. However, this procedure can break the normal posterior capsular morphology and wrinkle the posterior capsule, thus likely affecting the position of IOLs, which is unfavorable to the long-term visual outcome of IOLs, especially multifocal IOLs, and toric IOLs6. Advances in surgical procedures, IOL design, the pharmacological inhibition of LEC proliferation, and the induction of LEC apoptosis have been confirmed useful in preventing PCO, most of which target the LECs9. 
LECs are normally distributed over the inner side of the anterior lens capsule in single-layer form1. LECs distributed in the area around the equatorial lens are the natural site of division, which is known as the germinative zone, while the dividing cells are also observed on the anterior capsule10,11. It has also been shown that equatorial cells can proliferate and migrate in the posterior capsule12. Residual LECs in the capsular bag are responsible for PCO. If LECs in the germinative zone are cleared as much as possible during cataract surgery, the possibility of PCO occurring postoperatively decreases as a consequence. As far as it is known, routine phacoemulsification does not include a procedure to remove equatorial LECs. In a study in India, the author proposed that rotation of the IOL by a Sinskey hook13 in the capsular bag decreases PCO and Nd:YAG capsulotomy rate.
Here, we introduced a method by rotating the IOL using an irrigation/aspiration (I/A) tip in the capsular bag to prevent PCO in cataract surgeries. The rationale of this method relies on the mechanical contact between the IOL and the capsular bag, especially the equatorial area, to remove residual LECs. Compared with treating PCO using Nd:YAG capsulotomy, the prevention of PCO maintains the integrity of the posterior capsule and the correct position of IOLs. Additionally, this method is cost-effective and requires no extra tools, which applies to cataract phacoemulsification and IOL implantation. Different from anterior capsule polishing, which is conducted using an I/A tip in the polishing mode of the phaco system6,14, the rotation of the IOL is conducted after the IOL implantation and is supposed to further remove visible lens matter (cortex) and cells.

<table><tbody><tr><td>20 G Sideport MVR Knife</td><td>BVI</td><td>378231</td><td>To make corneal incision</td></tr><tr><td>3.2 mm Slit Blade</td><td>BVI</td><td>378232</td><td>To make corneal incision</td></tr><tr><td>Balanced salt solution</td><td>Xingqi</td><td>H19991142</td><td>Compound electrolyte intraocular irrigating solution</td></tr><tr><td>Centurion vision system&amp;nbsp;</td><td>Alcon Laboratories</td><td>8065753057</td><td>The Centurion Vision System is indicated for emulsification, separation, irrigation, and aspiration of cataracts, residual cortical material and lens epithelial cells, vitreous aspiration and cutting associated with anterior vitrectomy, bipolar coagulation, and intraocular lens injection.</td></tr><tr><td>Compound tropicamide eye drops</td><td>Xingqi</td><td>Zhuobian</td><td>To dilate the pupils before the surgery</td></tr><tr><td>Disposable sterile irrigator</td><td>WEGO</td><td>100038404339</td><td>To complete hydrodissection and hydrodelineation&amp;nbsp;</td></tr><tr><td>Fenzl lens insertion hook and manipulator</td><td>Belleif</td><td>IF-8100</td><td>IOL positioning hook</td></tr><tr><td>Levofloxacin eye drops</td><td>Santen</td><td>Cravit</td><td>To prevent ocular infection before the surgery</td></tr><tr><td>Mini-flared Kelman tip 30DG</td><td>Alcon Laboratories</td><td>8065750852</td><td>To complete phacoemulsification</td></tr><tr><td>One piece intraocular Lens</td><td>Zeiss</td><td>AT TORBI 709M</td><td>Intraocular lens</td></tr><tr><td>Oxybuprocaine hydrochloride</td><td>Santen</td><td>Benoxil</td><td>Topical anesthesia</td></tr><tr><td>Phaco handpiece</td><td>Alcon Laboratories</td><td>8065751761</td><td>To complete phacoemulsification&amp;nbsp;</td></tr><tr><td>Sinskey hook</td><td>Belleif</td><td>IF-8013</td><td>For chop</td></tr><tr><td>Ultraflow II I/A tip</td><td>Alcon Laboratories</td><td>8065751795</td><td>To complete irrigation and aspiration&amp;nbsp;</td></tr><tr><td>Utrata capsulorhexis forceps</td><td>Belleif</td><td>IF-3003C</td><td>To complete continuous circular capsulorhexis</td></tr><tr><td>Viscoelastics/Medical sodium hyaluronate gel</td><td>Bausch&amp;amp;lomb</td><td>iviz</td><td>Maintaining the anterior chamber and capsular bag</td></tr></tbody></table>

rotating the intraocular lens to prevent posterior capsular opacification in cataract surgeries

Posterior capsule opacification (PCO) is a common postoperative complication of extracapsular cataract surgery, which is caused by the proliferation and migration of lens epithelial cells and can affect long-term visual outcomes significantly. The most effective treatment for PCO is neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy; however, this treatment is associated with posterior segment complication and can break the stability of capsular bag, affecting the position and function of trifocal or toric intraocular lenses (IOLs). Advances in surgical procedures, IOL design, and pharmacy have reduced the rate of PCO in recent years, concentrating on the inhibition of proliferative lens epithelial cells (LECs). This protocol aimed to clear LECs more thoroughly during phacoemulsification and IOL implantation. The first several steps, including clear corneal incision, continuous circular capsulorhexis, hydrodissection, hydrodelineation, and phacoemulsification, were completed as conventional procedures. After placing the IOL into the capsular bag, rotation of the IOL by at least 360&#176; was performed using an irrigation/aspiration tip or a hook, with slight stress on the posterior capsule. Some residuals occurred in the originally transparent capsular bag after rotation of the IOLs. Then, these materials and the viscoelastic were cleared completely using an irrigation/aspiration system. A clear posterior capsule was observed after the surgery in patients undergoing this method. This method of rotating IOLs is a simple, effective, and safe way to prevent PCO by clearing residual LECs and can be carried out without extra tools or skills.

A clear capsular bag was formed after the I/A step (Figure 1A). However, some cortical fragments were observed in the capsular bag after rotating and polishing the IOL (Figure 1B).
This process can also be performed using a hook. Similarly, the posterior capsule was clear after capsular polishing by the I/A tip (Figure 2A). Through fast rotation and movement of the IOL, some residuals appeared in the caps...

Watch this Scientific Journal Video about Enhancing Visual Outcomes in Cataract Surgery: A Novel Technique to Prevent Posterior Capsular Opacification Through IOL Rotation at JoVE.com

Author Spotlight: Enhancing Visual Outcomes in Cataract Surgery: A Novel Technique to Prevent Posterior Capsular Opacification Through IOL Rotation 

The present protocol describes removing residual epithelial cells by rotating the intraocular lens in extracapsular cataract surgery without extra tools for preventing posterior capsular opacification.

Rotating the Intraocular Lens to Prevent Posterior Capsular Opacification in Cataract Surgeries

Posterior capsule opacification (PCO) is a common postoperative complication of extracapsular cataract surgery, which is caused by the proliferation and ...

rotating-intraocular-lens-to-prevent-posterior-capsular-opacification

Research

JoVE Journal

Medicine

2.2K Views.  Peking University Third Hospital. The present protocol describes removing residual epithelial cells by rotating the intraocular lens in extracapsular cataract surgery without extra tools for preventing posterior capsular opacification.

Video: Author Spotlight: Enhancing Visual Outcomes in Cataract Surgery: A Novel Technique to Prevent Posterior Capsular Opacification Through IOL Rotation 

A Novel Capsulorhexis Technique Using Shearing Forces with Cystotome

Purpose:
To demonstrate a capsulorhexis technique using predominantly shearing forces with a cystotome on a virtual reality simulator and on a human eye.
Method:
Our technique involves creating the initial anterior capsular tear with a cystotome to raise a flap. The flap left unfolded on the lens surface. The cystotome tip is tilted horizontally and is engaged on the flap near the leading edge of the tear. The cystotome is moved in a circular fashion to direct the vector forces. The loose flap is constantly swept towards the centre so that it does not obscure the view on the tearing edge.
Results:
Our technique has the advantage of reducing corneal wound distortion and subsequent anterior chamber collapse. The capsulorhexis flap is moved away from the tear leading edge allowing better visualisation of the direction of tear. This technique offers superior control of the capsulorhexis by allowing the surgeon to change the direction of the tear to achieve the desired capsulorhexis size.
Conclusions:
The EYESI Surgical Simulator is a realistic training platform for surgeons to practice complex capsulorhexis techniques. The shearing forces technique is a suitable alternative and in some cases a far better technique in achieving the desired capsulorhexis.

This video demonstrates a novel capsulorhexis technique in modern cataract surgery. Capsulorhexis is the most difficult and important part of phacoemulsification surgery.

Purpose:
To demonstrate a capsulorhexis technique using predominantly shearing forces with a cystotome on a virtual reality simulator and on a human eye....

A Novel Technique of Rescuing Capsulorhexis Radial Tear-out using a Cystotome

Part 1 : Purpose: To demonstrate a capsulorhexis radial tear out rescue technique using a cystotome on a virtual reality cataract surgery simulator and in a human eye. Part 2 : Method: Steps: When a capsulorhexis begins to veer radially towards the periphery beyond the pupillary margin the following steps should be applied without delay. 2.1) Stop further capsulorhexis manoeuvre and reassess the situation. 2.2) Fill the anterior chamber with ophthalmic viscosurgical device (OVD). We recommend mounting the cystotome to a syringe containing OVD so that the anterior chamber can be reinflated rapidly. 2.3) The capsulorhexis flap is then left unfolded on the lens surface. 2.4) The cystotome tip is tilted horizontally to avoid cutting or puncturing the flap and is engaged on the flap near the leading edge of the tear but not too close to the point of tear. 2.5) Gently push or pull the leading edge of tear opposite to the direction of tear. 2.6) The leading tearing edge will start to do a 'U-Turn'. Maintain the tension on the flap until the tearing edge returns to the desired trajectory. Part 3 : Results: Using our technique, a surgeon can respond instantly to radial tear out without having to change surgical instruments. Changing surgical instruments at this critical stage runs a risk of further radial tear due to sudden shallowing of anterior chamber as a result of forward pressure from the vitreous. Our technique also has the advantage of reducing corneal wound distortion and subsequent anterior chamber collapse. Part 4 : Discussion The EYESI Surgical Simulator is a realistic training platform for surgeons to practice complex capsulorhexis tear-out techniques. Capsulorhexis is the most important and complex part of phacoemulsification and endocapsular intraocular lens implantation procedure. A successful cataract surgery depends on achieving a good capsulorhexis. During capsulorhexis, surgeons may face a challenging situation like a capsulorhexis radial tear-out. A surgeon must learn to tackle the problem promptly without making the situation worse. Some other methods of rescuing the situation have been described using a capsulorhexis forceps. However, we believe our method is quicker, more effective and easier to manipulate as demonstrated on the EYESi surgical simulator and on a human eye. Acknowledgments: List acknowledgements and funding sources. We would like to thank Dr. Wael El Gendy, for video clip. Disclosures: describe potential conflicting interests or state We have nothing to disclose. References: 1. Brian C. Little, Jennifer H. Smith, Mark Packer. J Cataract Refract Surg 2006; 32:1420 1422, Issue-9. 2. Neuhann T. Theorie und Operationstechnik der Kapsulorhexis. Klin Monatsbl Augenheilkd. 1987; 1990: 542-545. 3. Gimbel HV, Neuhann T. Development, advantages and methods of the continuous circular capsulorhexis technique. J Cataract Refract Surg. 1990; 16: 31-37. 4. Gimbel HV, Neuhann T. Continuous curvilinear capsulorhexis. (letter) J Cataract Refract Sur. 1991; 17: 110-111.

Capsulorhexis is an important step in phacoemulsification surgery. A surgeon creates a continous curvilinear tear on the anterior lens capsule by controlling the tearing vector forces. A peripherally extended tear is a serious complication. This video demonstrates a novel technique of rescuing capsular radial tear out using a cystotome.

Part 1 : Purpose:   To demonstrate a capsulorhexis radial tear out rescue technique using a cystotome on a virtual reality cataract surgery simulator and ...

Ultrasound Cyclo Plasty in Eyes with Glaucoma

Glaucoma is a chronic disease caused by the progressive degeneration of the optical nerve fibers, resulting in decreased visual field that can lead to severe visual impairment, and eventually blindness. This manuscript describes a simple, surgeon-friendly, non-incisional technique, named Ultrasound Cyclo Plasty (UCP), for reducing intraocular pressure (IOP) in glaucoma patients. The technique determines a selective coagulation necrosis of the ciliary body; in addition, the stimulation of supra-choroidal and trans-scleral portions of the uveo-scleral outflow pathway has been recently proposed. UCP shows several technical improvements in ultrasound technology compared to previous techniques, providing more precise focusing on the target zone. The procedure is performed in the operating room under peribulbar anesthesia. Briefly, the coupling cone is put in contact with the eye and the ring probe, that contains six piezoelectric transducers which produce the ultrasound beams, is inserted inside it. Their proper centering over the ocular surface represents a crucial step for the correct targeting of the ciliary body. Sterile balanced salt solution is used to fill the empty spaces to ensure ultrasound acoustic propagation. Surgical treatment consists in the sequential automatic activation of each of the six transducers, for a total duration of less than 3 min. The patient leaves the hospital 1 h after the procedure with the treated eye patched. In the present study, 10 patients with open-angle glaucoma were followed-up during at least 12 months after the procedure. IOP was reduced at each interval compared to pre-operative, as well as the number of hypotensive medications. Twenty percent of patients did not respond to the treatment, and needed subsequent surgery to better control IOP. Treatment tolerability was good, with no cases of hypotony or phthisis. The UCP procedure is simpler, faster, safer, and less invasive than traditional cyclodestructive procedures with similar results in reducing IOP.

Glaucoma is a chronic disease with progressive degeneration of optic nerve fibers resulting in decreased visual field. Elevated intraocular pressure is considered the most important and the only treatable risk factor. This manuscript describes a simple, surgeon-friendly, non-incisional technique, named Ultrasound Cyclo Plasty, for reducing intraocular pressure in glaucoma patients.

Glaucoma is a chronic disease caused by the progressive degeneration of the optical nerve fibers, resulting in decreased visual field that can lead to ...

Behavior

Synthesis of Soft Polysiloxane-urea Elastomers for Intraocular Lens Application

This study discusses a synthesis route for soft polysiloxane-based urea (PSU) elastomers for their applications as accommodating intraocular lenses (a-IOLs). Aminopropyl-terminated polydimethylsiloxanes (PDMS) were previously prepared via the ring-chain equilibration of the cyclic siloxane octamethylcyclotetrasiloxane (D4) and 1,3-bis(3-aminopropyl)-tetramethyldisiloxane (APTMDS). Phenyl groups were introduced into the siloxane backbone via the copolymerization of D4 and 2,4,6,8-tetramethyl-2,4,6,8-tetraphenyl-cyclotetrasiloxane (D4Me,Ph). These polydimethyl-methyl-phenyl-siloxane-block copolymers were synthesized for increasing the refractive indices of polysiloxanes. For applications as an a-IOL, the refractive index of the polysiloxanes must be equivalent to that of a young human eye lens. The polysiloxane molecular weight is controlled by the ratio of the cyclic siloxane to the endblocker APTMDS. The transparency of the PSU elastomers is examined by the transmittance measurement of films between 200 and 750 nm, using a UV-Vis spectrophotometer. Transmittance values at 750 nm (upper end of the visible spectrum) are plotted against the PDMS molecular weight, and &#62; 90% of the transmittance is observed until a molecular weight of 18,000 g&#183;mol&#8722;1. Mechanical properties of the PSU elastomers are investigated using stress-strain tests on die-cut dog-bone-shaped specimens. For evaluating mechanical stability, mechanical hysteresis is measured by repeatedly stretching (10x) the specimens to 5% and 100% elongation. Hysteresis considerably decreases with the increase in the PDMS molecular weight. In vitro cytotoxicity of some selected PSU elastomers is evaluated using an MTS cell viability assay. The methods described herein permit the synthesis of a soft, transparent, and noncytotoxic PSU elastomer with a refractive index approximately equal to that of a young human eye lens.

This study describes synthetic routes for aminopropyl-terminated polydimethylsiloxanes and polydimethyl-methyl-phenyl-siloxane-block copolymers and for soft polysiloxane-based urea (PSU) elastomers. It presents the application of PSUs as accommodating an intraocular lens. An evaluation method for in vitro cytotoxicity is also described.

This study discusses a synthesis route for soft polysiloxane-based urea (PSU) elastomers for their applications as accommodating intraocular lenses ...

Chemistry

Translaminar Autonomous System Model for the Modulation of Intraocular and Intracranial Pressure in Human Donor Posterior Segments

There is a current unmet need for a new preclinical human model that can target disease etiology ex vivo using intracranial pressure (ICP) and intraocular pressure (IOP) which&#160;can identify various pathogenic paradigms related to the glaucoma pathogenesis. Ex vivo human anterior segment perfusion organ culture models have previously been successfully utilized and applied as effective technologies for the discovery of glaucoma pathogenesis and testing of therapeutics. Preclinical drug screening and research performed on ex vivo human organ systems can be more translatable to clinical research. This article describes in detail the generation and operation of a novel ex vivo human translaminar pressure model called the translaminar autonomous system (TAS). The TAS model can independently regulate ICP and IOP using human donor posterior segments. The model allows for studying pathogenesis in a preclinical manner. It can reduce the use of living animals in ophthalmic research. In contrast to in vitro experimental models, optic nerve head (ONH) tissue structure, complexity, and integrity can also be maintained within the ex vivo TAS model.

We describe and detail the use of the translaminar autonomous system. This system utilizes the human posterior segment to independently regulate the pressure inside the segment (intraocular) and surrounding the optic nerve (intracranial) to generate a translaminar pressure gradient that mimics features of glaucomatous optic neuropathy.

There is a current unmet need for a new preclinical human model that can target disease etiology ex vivo using intracranial pressure (ICP) and intraocular ...

Neuroscience

Full-Circle Cauterization of Limbal Vascular Plexus for Surgically Induced Glaucoma in Rodents

Glaucoma, the second leading cause of blindness worldwide, is a heterogeneous group of ocular disorders characterized by structural damage to the optic nerve and retinal ganglion cell (RGC) degeneration, resulting in visual dysfunction by interrupting the transmission of visual information from the eye to the brain. Elevated intraocular pressure is the most important risk factor; thus, several models of ocular hypertension have been developed in rodents by either genetic or experimental approaches to investigate the causes and effects of the disease. Among those, some limitations have been reported such as surgical invasiveness, inadequate functional assessment, requirement of extensive training, and highly variable extension of retinal damage. The present work characterizes a simple, low-cost, and efficient method to induce ocular hypertension in rodents, based on low-temperature, full-circle cauterization of the limbal vascular plexus, a major component of aqueous humor drainage. The new model provides a technically easy, noninvasive, and reproducible subacute ocular hypertension, associated with progressive RGC and optic nerve degeneration, and a unique post-operative clinical recovery rate that allows in vivo functional studies by both electrophysiological and behavioral methods.

The goal of this protocol is to characterize a novel model of glaucomatous neurodegeneration based on 360&#176; thermic cauterization of limbal vascular plexus, inducing subacute ocular hypertension.

Glaucoma, the second leading cause of blindness worldwide, is a heterogeneous group of ocular disorders characterized by structural damage to the optic ...

Iris Fixation via External Pentagram Suturing

Extensive anterior synechia of the iris can result in the gradual disappearance of the anterior chamber. It is one of the most common outcomes of both oculopathy and complicated post anterior segment surgery. This can impact visual function and lead to bullous keratopathy, making it one of the most complex clinical problems. Conventional anterior chamber plasty will partially create the anterior chamber, but the anterior chamber disappears again in some cases. The main reasons are: (1) the iris lens diaphragm is loose with atrophied and tension-free iris so that the aqueous humor circulation will push and squeeze the iris forward; (2) the effect of "roller" formed in the process of inflammation or restoration will change the iris structure from peripheral anterior synechia (PAS) to extensive anterior synechia again; (3) the fibration will result in synechia from iris to the cornea. In such cases, corneal endothelium deficiency can't stop the aqueous humor from entering the cornea. This results in persistent corneal edema post-conventional anterior chamber plasty, resulting in progressive rubbing and lachrymation. Therefore, anterior chamber plasty is not the first choice for patients without surgical indications of Descemet's stripping automated endothelial keratoplasty (DSAEK). However, this can be performed in patients with surgical indications who plan to receive DSAEK. A unique method of iris fixation via external pentagram suturing anterior chamber plasty (PSACP) is described here. The present technique is also compared with the conventional anterior chamber plasty. PSACP and DSAEK might be an effective way to cure the bullous keratopathy with extensive anterior synechia of the iris and disappeared anterior chamber.

Iris Fixation via External Pentagram Suturing

The present protocol describes how a 10-0 polypropylene suture crosses the anterior surface of the iris, forming a pentagram to prevent both iris and pupil from moving toward the cornea. This can be combined with subsequent keratoplasty to cure bullous keratopathy with extensive anterior synechia of the iris.

Extensive anterior synechia of the iris can result in the gradual disappearance of the anterior chamber. It is one of the most common outcomes of both ...

Replicating Cataract Surgical Techniques in a Mouse Model Through LEC Extraction

Modeling Cataract Surgery in Mice

Cataract surgery (CS) is an effective treatment for cataracts, a major cause of visual disability worldwide. However, CS leads to ocular inflammation, and in the long term, it can result in posterior capsular opacification (PCO) and/or lens dislocation driven by the post-surgical overgrowth of lens epithelial cells (LECs) and their conversion to myofibroblasts and/or aberrant fiber cells. However, the molecular mechanisms by which CS results in inflammation and PCO are still obscure because most in vitro models do not recapitulate the wound healing response of LECs seen in vivo, while traditional animal models of cataract surgery, such as rabbits, do not allow the genetic manipulation of gene expression to test mechanisms. Recently, our laboratory and others have successfully used genetically modified mice to study the molecular mechanisms that drive the induction of proinflammatory signaling and LEC epithelial to mesenchymal transition, leading to new insight into PCO pathogenesis. Here, we report the established protocol for modeling cataract surgery in mice, which allows for robust transcriptional profiling of the response of LECs to lens fiber cell removal via RNAseq, the evaluation of protein expression by semi-quantitative immunofluorescence, and the use of modern mouse genetics tools to test the function of genes that are hypothesized to participate in the pathogenesis of acute sequelae like inflammation as well as the later conversion of LECs to myofibroblasts and/or aberrant lens fiber cells.

Author Spotlight: Unraveling the Molecular Mechanisms in PCO and Fibrosis Following Cataract Surgery

This method models cataract surgery in vivo by removing lens fiber cells from adult mice and leaving behind the capsular bag with attached lens epithelial cells (LECs). The injury response is then assessed at various times post-surgery using molecular and morphological criteria.

Cataract surgery (CS) is an effective treatment for cataracts, a major cause of visual disability worldwide. However, CS leads to ocular inflammation, and ...

Biology

Optimized Rat Intracameral Injection Technique for Reduced Tissue Damage

Intracameral Injection in Rats with Low Risk of Adverse Effects

Intracameral injection is a standard administration routine in ophthalmology. The application of intracameral injection in rodents for research is challenging due to the limiting dimensions and anatomy of the eye, including the small aqueous humor volume, the lens curvature, and lens thickness. Potential damage during intracameral injections introduces adverse effects and experimental variability. This protocol describes a procedure for intracameral injection in rats, allowing precision and reproducibility.
Sprague-Dawley rats were used as experimental models. Since the lens position in rats protrudes into the anterior chamber, injecting from the periphery, as done in humans, is unfavorable. Therefore, an incision is created in the central corneal region using a 31 gauge 0.8 mm stiletto blade to form a self-sealing tunnel into the anterior chamber. An incision at&#160;an angle close to the flat allows to create a long tunnel, which minimizes the loss of aqueous humor and shallowing of the anterior chamber. A 34 gauge nanoneedle is inserted into the tunnel for injection. This enables penetration with minimal friction resistance and avoids touching the lens. Injection of trypan-blue allows&#160;visualization&#160;by slit microscopy the presence of the dye in the anterior chamber and exclude leakage. Bioavailability to the corneal endothelial layer is demonstrated by injection of Hoechst dye, which stained the nuclei of corneal endothelial cells after injection.
In conclusion, this protocol implements a procedure for accurate intracameral injection in rats. This procedure may be used for intracameral delivery of various drugs and compounds in experimental rat models, increasing the efficiency and reproducibility of ophthalmic research.

Author Spotlight: A Novel Protocol for Intracameral Injections to Enhance Precision in Rodent Ophthalmology

This protocol describes a technique for intracameral injection in rats using a central corneal incision and a long tunnel into the anterior chamber. This injection method minimizes the risk of inducing inadvertent tissue damage and thereby improves precision and reproducibility.

Intracameral injection is a standard administration routine in ophthalmology. The application of intracameral injection in rodents for research is ...

Cultivation and Characterization of Lens Epithelial Cells

Optimizing Mouse Primary Lens Epithelial Cell Culture: A Comprehensive Guide to Trypsinization

Lens epithelial cells (LECs) play multiple important roles in maintaining the homeostasis and normal function of the lens. LECs determine lens growth, development, size, and transparency. Conversely, dysfunctional LECs can lead to cataract formation and posterior capsule opacification (PCO). Consequently, establishing a robust primary LEC culture system is important to researchers engaged in lens development, biochemistry, cataract therapeutics, and PCO prevention. However, cultivating primary LECs has long presented challenges due to their limited availability, slow proliferation rate, and delicate nature. 
This study addresses these hurdles by presenting a comprehensive protocol for primary LEC culture. The protocol encompasses essential steps such as the formulation of an optimized culture medium, precise isolation of lens capsules, trypsinization techniques, subculture procedures, harvest protocols, and guidelines for storage and shipment. Throughout the culture process, cell morphology was monitored using phase-contrast microscopy. 
To confirm the authenticity of the cultured LECs, immunofluorescence assays were conducted to detect the presence and subcellular distribution of critical lens proteins, namely &#945;A- and &#947;-crystallins. This detailed protocol equips researchers with a valuable resource for cultivating and characterizing primary LECs, enabling advancements in our comprehension of lens biology and the development of therapeutic strategies for lens-related disorders.

Author Spotlight: Unlocking the Secrets of Cataracts &#8211; Investigating Redox Repair Enzymes in Lens Epithelial Cells

This manuscript outlines a detailed video protocol for culturing primary lens epithelial cells (LECs), aiming to improve reproducibility and aid research in cataracts and posterior capsule opacification (PCO). It offers step-by-step instructions on lens dissection, LECs isolation, and validation, serving as a valuable guide, especially for newcomers in the field.

Lens epithelial cells (LECs) play multiple important roles in maintaining the homeostasis and normal function of the lens. LECs determine lens growth, ...

Rotating the Intraocular Lens to Prevent Posterior Capsular Opacification in Cataract Surgeries

Summary

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Chapters in this video

A Novel Capsulorhexis Technique Using Shearing Forces with Cystotome

A Novel Technique of Rescuing Capsulorhexis Radial Tear-out using a Cystotome

Ultrasound Cyclo Plasty in Eyes with Glaucoma

Synthesis of Soft Polysiloxane-urea Elastomers for Intraocular Lens Application

Translaminar Autonomous System Model for the Modulation of Intraocular and Intracranial Pressure in Human Donor Posterior Segments

Full-Circle Cauterization of Limbal Vascular Plexus for Surgically Induced Glaucoma in Rodents

Iris Fixation via External Pentagram Suturing

Modeling Cataract Surgery in Mice

Intracameral Injection in Rats with Low Risk of Adverse Effects

Optimizing Mouse Primary Lens Epithelial Cell Culture: A Comprehensive Guide to Trypsinization