Endocapsular tension ring a help in traumatic cataract

Cincinnati-Use of the Cionni endocapsular tension ring (Morcher, FCI Ophthalmics) in traumatic cataract with zonular dialysis provided improved best-corrected visual acuity (BCVA) in 95% of eyes. In addition, none of the eyes with preoperative phacodonesis or decentration had these complications postoperatively, according to Daniela Marques, MD, MBA.

"Traumatic cataract is the result of an ocular trauma that can rupture the anterior lens capsule," said Dr. Marques, affiliated with the Cincinnati Eye Institute, Cincinnati. "The zonules can be severely damaged by this trauma. Blunt trauma is the most common cause of acquired lens subluxation. The preoperative examination must be conducted carefully to identify zonular damage. In some cases in which there is vitreous prolapse, there is no question about the presence of zonular damage as a result of the extensive subluxation."

When no signs of zonular damage are present, she explained, the surgeon must look for subtleties reported by Robert Osher, MD, such as focal iridodonesis, she said.

"In such cases, a capsular tension ring that was modified by Robert Cionni, MD, is indicated to center the capsular bag and IOL complex with a scleral suture," she added.

Retrospective report

Dr. Marques and colleagues conducted a retrospective study in which they evaluated the behavior of the modified Cionni endocapsular tension ring in traumatic cataracts with zonular damage. Twenty-two eyes of 22 patients (mean age, 48 years; range, 3 to 80 years) in which a traumatic cataract had developed were included. All eyes had undergone surgery performed by the same surgeon. The mean time interval between the trauma and the surgery was 15 years. The mean follow-up was 15.8 months (range, 4 to 38 months).

Patients were included in the study if they had zonular dialysis as the result of ocular trauma, cataract, a continuous capsulorhexis, and an intact posterior capsule during surgery.

All patients underwent phacoemulsification or aspiration using the slow-motion technique. The modified Cionni tension ring type 1L was sutured to the sclera. Intraoperatively, the zonular dialysis extension and the need for vitrectomy were analyzed. Postoperatively, they evaluated the BCVA, pseudophacodonesis, and the centration of the capsular bag, Dr. Marques explained.

"Ninety-one percent of eyes achieved a BCVA of 20/40 or better. Postoperatively, no eyes had pseudophacodonesis or decentration," Dr. Marques reported. A total of 95% of the eyes had an improvement in the BCVA, and 4% did not lose any lines of vision.

"These results are similar to those published by Dr. Cionni from a study of congenitally subluxated lenses. In that study, 87% of the eyes had improved vision," she explained.

"IOL centration and the stability of the capsular bag are crucial for good postoperative visual acuity. In this study, we chose the capsular tension ring with one point at which the ring is sutured due to the large area of zonular dialysis," she said.

Preoperatively, 45% of the patients had lens decentration; postoperatively all eyes had centration. These results were similar to the results of Dr. Cionni's previous study, according to Dr. Marques.

With the use of the modified Cionni tension ring, the anatomic barrier of the capsule is restored partially, and the intraoperative vitreous prolapse is reduced or prevented, she pointed out.

"We observed vitreous prolapse in 40% of cases preoperatively and the need for vitrectomy in 50% of the eyes. In the previous Cionni study, only 15% of eyes needed vitrectomy. The transient and permanent IOP elevation might have resulted from the previous trauma with a severe inflammatory reaction," she said.

One factor that may be problematic is that it is difficult to perform a well-centered capsulorhexis in eyes with lens subluxation. This results in central and peripheral posterior capsule opacification (PCO).

"The PCO rate of 40% in this study is higher than in routine cases as a result of the difficulty in aspirating of the cortex. Of the nine eyes with PCO, seven required a posterior capsulotomy with YAG laser," she reported.