Journal ArticlePURPOSE: To evaluate the retinal detachment risks and neodymium:YAG (Nd:YAG) capsulotomy rates associated with different cataract approaches and intraocular lens (IOL) styles in a long-term,prospective clinical study. SETTING: Clinical practice of 1 ophthalmologist, Fort Collins, Colorado, USA. METHODS: Prospectively studied were surgical approach, date, and complications; IOL type; axial length; patient age and sex; Nd:YAG capsulotomy and date; and retinal detachment and date. RESULTS: Phacoemulsification had a lower risk of retinal detachment than intracapsular cataract extraction (ICCE) (0.4% versus 5.4%; P <.001) and extracapsular cataract extraction (ECCE) (0.4% versus 1.6%; P =. 002). Although retinal detachment was significantly associated with Nd:YAG for ECCE (3.1% versus 1.0%; P =.01), no patient in the phacoemulsification group had a retinal detachment after an Nd:YAG treatment. Retinal detachment was strongly associated with axial length of 24.0 mm and greater (P <.001), age of 60 years or less if axial length was 24.0 mm or greater (for ECCE, P =.001; for phacoemulsification, P =.01) and sex; that is, male (for ECCE, P =. 04; for phacoemulsification, P =.02). Regarding IOL styles the Surgidev B20/20 (P <.001) and AcrySof MA60 (P <.001) had significantly lower Nd:YAG rates, while the Cilco UPB 320 GS had a significantly higher Nd:YAG rate (P <.001). CONCLUSIONS: Cataract surgical approach and IOL style significantly affect Nd:YAG and retinal detachment rates. Being a man, being 60 years or younger, and especially having an axial length of 24.0 mm or greater were associated with detachment. Some Nd:YAG approaches may not put the patient at increased risk for retinal detachment

Olsen, Gerald

Olson, Randall J.

English

The University of Utah: J. Willard Marriott Digital Library

  Published in final edited form in: J J Cataract Refract Surg, 26(7), 1017-21                                       UU IR Author Manuscript                                                                  UU IR Author Manuscript          University of Utah Institutional Repository  Author Manuscript     Update on a long-term, prospective study of capsulotomy and  retinal detachment rates after cataract surgery  Manuscript Number 264-99 AGerald Olsen, MD BRandall J. Olson, MD  APrivate Practice, Fort Collins, Colorado B Department of Ophthalmology and Visual Sciences University of Utah Health Sciences Center  Corresponding Author: Randall J. Olson, MD Department of Ophthalmology and Visual Sciences John Moran Eye Center 50 North Medical Drive Salt Lake City, Utah  84132 Phone:  (801) 585-6622   FAX:  (801) 581-3357 Email: randall.olson@hsc.utah.edu Supported in part by a grant from Research to Prevent Blindness, Inc., New York, NY, to the Department of Ophthalmology, University of Utah. C C ~ Olsen G, Update on study of capsulotomy and retinal detachment rates Page 2 Abstract Purpose: To evaluate the retinal detachment (RD) risks and YAG capsulotomy (YAG) rates associated with different cataract approaches and intraocular (IOL) lens styles in a long-term, prospective clinical study. ~ Setting: Clinical practice of one ophthalmologist (G.O.) in Colorado. > c rt ::r"' o h Methods: A prospective cataloging of 1) surgical approach, date and complications, 2) IOL type, 3) axial length, 4) patient age and sex, 5) Y AG and date, and 5) RD and date. Results: Phacoemulsification (PE) had a lower risk of RD than intracapsular cataract extraction (ICCE)(O.4% vs. 5.4%; P < 0.001) and extracapsular cataract extraction (ECCE) (0.4% vs 1.6%; P = 0.002). While RD was significantly associated with YAG for ECCE (3.1 % vs 1.0%; P = 0.01), no patient had an RD after YAG in the PE group. RD was strongly associated with axial length of 24.0 mm and greater (P < 0.001), age of 60 or less if axial length is 24.0 mm or greater (for ECCE, P = 0.001; for PE, P = 0.01) and for maleness (for ECCE, P = 0.04; for PE, P = 0.02). Regarding IOL styles the Surgidev B20/20 (P < 0.001) and AcrySof MA60 (P < 0.001) had C C significantly reduced Y AG rates, while the Ci1co UPB 320GS had a significantly higher Y AG rate (P < ~ ~ > 0.001). c rt ::r"' o h ~ b Conclusion: Cataract surgical approach and IOL style significantly impact YAG and RD rates. C r:JJ Q Maleness, being 60 or under, and especially having an axial length of 24.0 mm or greater require special ~. rt scrutiny. Some YAG approaches may not put the patient at increased risk for RD. c c c c Olsen G, Update on study of capsulotomy and retinal detachment rates Page 3 Synopsis: Reviewing YAG and RD after cataract surgery, PE and some IOL styles were protective while maleness, axial length of 24.0mm or greater and age of 60 or less were risk factors. YAG was not a risk for RD after PE. C C Olsen G, Update on study of capsulotomy and retinal detachment rates Page 4 Cataract surgery, retinal detachment and capsulotomy are three intertwined entities that have significant impact in regard to societal financial outlay and patient outcomes. So much has been published on the subject1-11 that it may seem as though there is really little that is new to say, and reconfirming the obvious is a relatively moot point. Although this study is on the subject, it does represent an unusual twenty-two year prospective labor on the part of one ophthalmic surgeon who recorded all surgical procedures, surgical complications, axial lengths, intraocular lens (lOL) styles, caps ulotomies and retinal detachments for this period of time. We last reported results from this effort through December 31, 199212 and we feel that an update does present interesting new information on this subject. MATERIALS AND METHOD All patients operated for cataract surgery with an IOL by one surgeon (G.O.) from January 1, 1976 to December 31, 1997 were included in this study. Follow up is inclusive of all patients through June 30, 1999. The following results were prospectively recorded: 1) date of cataract surgery, 2) surgical C C approach, 3) surgical complications, 4) IOL type, 5) axial length, 6) sex of patient, 7) age of patient at the ~ ~ > time of cataract surgery, 8) capsulotomy by Y AG laser and date, and 9) retinal detachment and date. C r-t-::r" o I-t ~ b This information was tabulated and compared using chi-square analysis. C r:JJ (') I-t ~. r-t-RESULTS C C Olsen G, Update on study of capsulotomy and retinal detachment rates Page 5 With six and a half additional years of information, there was no change in the 5.4% retinal detachment rate of those patients operated with intracapsular cataract extraction (ICCE) with intraocular lens insertion. The planned extracapsular cataract extraction (ECCE) stabilized with a retinal detachment rate of 1.6% (18 of 1099), which difference in comparison to ICCE was statistically significant (P < 0.001). The group with phacoemulsification (PE) and intraocular lens insertion, had a decreased incidence of retinal detachment from 6.5 years ago of 0.8% to 0.4% (6 of 1418) presently. This difference is statistically significantly less than both ICCE (P < 0.001) and ECCE (P = 0.002; Table 1). One retinal detachment was associated with vitreous loss in 23 cases (vitreous loss rate of 0.9%). The retinal detachment rate for ECCE patients after YAG capsulotomy is 3.1 % (12 of 391) versus 1.0% (7 of 708) without a capsulotomy, which difference is significant (P = 0.01). Interestingly, in the PE group to date, with six retinal detachments, none of these had a previous capsulotomy (Table 2). Just as we previously reported, retinal detachment was strongly associated with axial length of 24.0 mm or longer. In fact, no retinal detachment occurred in a PE patient under 24.0 mm long (P < 0.001; Table 3). The male retinal detachment risk was also reconfirmed, both for ECCE (P =0.04) and for PE (P =0.02). Similarly, we reconfirmed being under the age of 60, only for axial lengths of 24.0 mm and more, as a retinal detachment risk factor. We found females significantly less likely to have eyes 24.0 C C mm or longer (males 229 of 533 or 41 % and females 165 of 885 or 19%; P < 0.001; Table 4) ~ ~ > C r-t-::r" o Regarding capsulotomy rates, the polymethylmethacrylate (PMMA) IOL styles were relatively I-t ~ b consistent across the spectrum with the exceptions of the B20/20 lens (Surgidev) which has maintained a C r:JJ Q low capsulotomy rate of 20.4% in spite of consistently using a can opener capsulotomy (P < 0.001 ~. r-t-compared to all other PMMA IOLs) and the UPB 320 GS (Ci1co) with a high capsulotomy rate of 68.1 % C C Olsen G, Update on study of capsulotomy and retinal detachment rates Page 6 in which continuous curvilinear capsulorhexis (CCC) was used (P < 0.001 compared to all other PMMA IOLs). The results with the AcrySof (Alcon Laboratories, Fort Worth, Texas) lens appear very impressive with a one-year capsulotomy rate of 5.4%, a two-year rate of 6.3% and a three-year rate of 10.3%. Comparing the three-year rate with the UPB 320 GS which is the only PMMA IOL with a similar follow-up both of which had CCC, the AcrySof is significantly better (P < 0.001; Table 5). DISCUSSION While the previous study suggested that there might be a Y AG capsulotomy effect on retinal detachment, it was noted that six of the seven most recent retinal detachments after Y AG capsulotomy and ECCE occurred when the patient was dilated at the time of capsulotomy. This prompted a change to small capsulotomies with undilated pupils (in all cases with an axial length of 24.0 mm or longer) and with minimal energy used. Amazingly, in our PE group, the evidence to date would suggest that Y AG capsulotomies are protective! While we certainly would not make this claim from this one study, what we can say is that we may have to rethink the generally accepted claim of an increased retinal detachment risk after capsulotomies. Not dilating the pupil decreases energy used, size of the capsulotomy and may C C buffer the fluid shock waves in ways that are protective. Laser instruments have also improved with ~ ~ > greater delivered accuracy and efficiency. We still want to avoid any secondary procedure simply C r-t-::r" o because of societal cost; however, if just from the medical legal standpoint and patient informed consent, I-t ~ b it would be nice to know if an increased risk of retinal detachment is still a real concern. We doubt it is c r:JJ Q for most practices today. ~. r-t-C C Olsen G, Update on study of capsulotomy and retinal detachment rates Page 7 Additionally, we had no cases of clinical cystoid macular edema or intraocular pressure problems in any patient after Y AG capsulotomy in the PE group. We, therefore, suggest the risk is, indeed, minimal with conservative Y AG capsulotomy in the vast majority of patients. The main factor that we found associated with retinal detachment is an axial length greater than 24.0 mm. For eyes greater than 24.0 mm axial length, an additional risk factor was age of 60 or under. A male under age 60 with an axial length greater than 24.0 mm long, with or without Y AG capsulotomy, had a 7.5% incidence of retinal detachment after PE compared to a zero risk for those without these three risk factors! Gender difference with a higher risk for males was only noted when looking at all patients. Interestingly, females were significantly less likely to have an axial length of 24.0 mm or greater. This alone could be the reason males are at greater risk for retinal detachment. This was all similar in degree in our previous report and, therefore, we strongly feel all three factors, especially when combined, deserve careful informed consent and meticulous retinal review and follow-up. It has long been debated whether or not intraocular lenses have specific long-term impact on the incidence of posterior capsular opacification (PCO). In this study, PMMA was relatively consistent at about a 50% capsulotomy rate with many years of follow-up with few interesting exceptions. The Surgidev B20/20, an angulated, very stiff, all-PMMA IOL had a 13+ year capsulotomy rate of 20.4%, C C which was highly significantly better than the other PMMA IOLs, even though they had shorter follow-~ ~ > Up.1 Interestingly, the Ci1co UPB320GS has had the shortest follow-up and yet has a significantly higher C r-t-::r" g caps ulotomy rate. We feel the amount of posterior pressure maintaining 3600 of capsular contact is the ~ b important differentiating factor here. Many consider CCC as important in PCO prevention. In this case, C r:JJ (") M can-opener was used with the Surgidev B20/20 and CCC with the Ci1co UPB 320GS. This indicates lens ~. r-t-design is much more important than whether CCC is used! C C Olsen G, Update on study of capsulotomy and retinal detachment rates Page 8 The AcrySof acrylic IOL with its squared-off edge has raised a lot of hope in regard to its PCO advantage. With a 3-year capsulotomy rate of 10.3% highly significantly better than the Cilco UPB 320 GS as the only PMMA lens implanted at about the same time period, it is apparent AcrySof has a definite PCO advantage. We doubt it will be any better than the B20/20 after 13+ years, however, which is consistent with the idea that the AcrySof PCO edge is also due to mechanical factors. Nishi, et al,13 for example, was able to duplicate the AcrySof effect with a squared-edge PMMA IOL. Other IOL designs will take advantage of this biomechanical advantage. Some second-generation silicone IOLs have also recently been shown to have impressive advantage over PMMA with a long-term visual acuity and PCO edge similar to AcrySof. 14 This effect was documented without a squared-off edge and certainly without the stiffness of the B20/20 suggesting a biomaterials effect. This PCO advantage certainly is not documented for all silicone IOL materials15 and it is, therefore, a mistake to lump silicones together. Unfortunately, this study does not have a silicone lens group for comparison. In conclusion, an ophthalmologist in a medium-size town with a homogeneous population can do significant clinical research with impact on our understanding of the complications associated with cataract surgery. The weakness of this study is the same as we outlined in our previous report: Complications were only known if the patient came back for follow-up; however either active files exist or the patients are deceased in over 95% of all patients operated! We feel this is not a valid concern and it C C could in no way diminish our provocative conclusion that Y AG capsulotomy done with an undilated pupil ~ ~ > for axial lengths greater than 24.0 mm and minimal energy is not a risk factor for retinal detachment. We C r-t-::r" o look forward to other studies in regard to this conclusion. I-t ~ ~ ~ C r:JJ (') I-t ~. r-t-Olsen G, Update on study of capsulotomy and retinal detachment rates Page 9 References 1. Smith PW, Start WJ, Maumenee AE, et al. Retinal detachment after extracapsular cataract extraction with posterior chamber intraocular lens. Ophthalmology 1987; 94:495-504. C 2. Kraff MC, Sanders DR. Incidence of retinal detachment following posterior chamber intraocular lens C ~ ~ surgery. J Cataract Refract Surg 1990; 16:477-480. > C & 3. Javitt JC, Vitale S, Canner JK, et al. National outcomes of cataract extraction I. Retinal detachment o h ~ after inpatient surgery. Ophthalmology 1991; 98:895-902. ~ ~ ~ 4. Coonan P, Fung WE, Webster RG Jr, et al. The incidence of retinal detachment following (") ~. "'0 rt extracapsular cataract extraction; a ten-year study. Ophthalmology 1985; 92: 1096-1101. 5. Salvesen S, Eide N, Syrdalen P. Retinal detachment after YAG-Iaser capsulotomy. Acta Ophthalmol 1991; 69:61-64. 6. Koch DD, Liu JF, Gill EP, Parke DW II. Axial myopia increases the risk of retinal complications after neodymium-YAG laser posterior capsulotomy. Arch Ophthalmol 1989; 107:986-990. 7. Javitt JC, Tielsch JM, Canner JK, et al. National outcomes of cataract extraction. Increased risk of retinal complications associated with Nd: Y AG laser capsulotomy. Ophthalmology 1992; 99: 1487-1498. 8. Van Westenbrugge JA, Gimbel HV, Soucheck J, Chow D. Incidence of retinal detachment following C C Nd:YAG capsulotomy after cataract surgery. J Cataract Refract Surg 1992; 18:351-355. ~ ~ > 9. Hurite FG, SOIT EM, Everett WG. The incidence of retinal detachment following C rt ::r" g phacoemulsification. Ophthalmology 1979; 86:2004-2006. ~ b 10. Richman-Barger L, Florine CW, Larson RS, Lindstrom RL. Retinal detachment after C r:JJ Q neodymium:YAG laser posterior capsulotomy. Am J Ophthalmol 1989; 107:531-536. ~. rt 11. Powell SK, Olson RJ. Incidence of retinal detachment after cataract surgery and neodymium:YAG laser capsulotomy. J Cataract Refract Surg 1995;21:132-135. c c c c Olsen G, Update on study of capsulotomy and retinal detachment rates Page 10 12. Olsen GM, Olson RJ. Prospective study of cataract surgery, capsulotomy and retinal detachment. J Cataract Refract Surg 1995;21:136-139. 13. Nishi 0, Nishi K. Preventing posterior capsule opacification by creating a discontinuous sharp bend in the capsule. J Cataract Refract Surg 1999; 25:521-526. 14. Hayashi H, Hayashi K, Nakao F, Hayashi F. Quantitative comparison of posterior capsule opacification after polymethylmethacrylate, silicone, and soft acrylic intraocular lens implantation. Arch Ophthalmol1998; 116:1579-1582. 15. Hollick EJ, Spalton DJ, Ursell PG, Pande MV, Barman SA, Boyce JF, Tilling K. The effect of polymethylmethacrylate, silicone, and polyacrylic intraocular lenses on posterior capsular opacification 3 years after cataract surgery. Ophthalmology 1999; 106:49-55. Olsen G, Update on study of capsulotomy and retinal detachment rates Page 11 Table 1: Retinal detachment rates for intracapsular cataract extraction (ICCE), planned ext racapsular cataract extraction (ECCE) and phacoemulsification (PE) all with intraocular lens insertion # Cases Follow up (years) # (% ) with Retinal Detachment C C ICCE 222 18-22 12 (5.4% )1,L ~ ~ ECCE 1099 8-18 18 (1.6% 1,J > C rt PE 1418 1-8 6 (0.4% ).L,J ::r"' 0 h ~ ~ ~ c 1. P = < 0.001 rJl (") ~. "'0 rt 2. P = < 0.001 3. p = < 0.002 C C ~ ~ > C rt ::r"' 0 h ~ ~ ~ C rJl (") h ....... "'0 rt Olsen G, Update on study of capsulotomy and retinal detachment rates Page 12 Table 2: Retinal detachment rates associated with Y AG laser capsulotomy (Y AG) for pati ents after planned extracapsular cataract extraction (ECCE) and phacoemulsification (PE) both with i ntraocular lens insertion C # Cases # (%) with Retinal C ~ ~ Detachment > c rt ECCE ::r"' 0 h ~ Without YAG 708 7 (1.0%)1 ~ ~ c With YAG 391 12(3.1%)1 rJl (") ~. "'0 rt PE WithoutYAG 996 6 (0.6%) With YAG 422 0(0%) 1. P = 0.01 C C ~ ~ > C rt ::r"' 0 h ~ ~ ~ C rJl (") h ....... "'0 rt Olsen G, Update on study of capsulotomy and retinal detachment rates Page 13 Table 3: Retinal detachment associated with axial length greater than 24.0 mm in patients undergoing cataract surgery by extracapsular cataract extraction (ECCE) and by phacoemulsification ( PE) both with IOL insertion. C Axial length <24.0 mm Axial length >24.0 mm C ~ ~ Number Patients Retinal Number Retinal > c Patients rt Detachment Detachment :::r" 0 h ~ #(%) #(%) ~ ~ c ECCE 784 4 (0.5%)1 315 15 (4.8%) 1 rJl (") ~. "'0 1. 6 (1.5%) 1. rt PE 1024 0 394 1. P < 0.001 2. P < 0.001 C C ~ ~ > C rt :::r" 0 h ~ ~ ~ C rJl (") h ....... "'0 rt Olsen G, Update on study of capsulotomy and retinal detachment rates Page 14 Table 4: Retinal detachment rates associated with sex and age under 60 at time of surgery for patient s undergoing cataract surgery by extracapsular cataract extraction (ECCE) and phacoemulsification (P E) both with intraocular lens insertion. C C ~ ~ Axial Length <24.0 mm Axial length > 24.0 mm > c rt ~60 >60 ~60 >60 :::r" 0 h ~ ~ 1. ECCE Male (399) 43 237 21 98 ~ C 0 4(1.7%) 2(9.5%) 5(5.1%) rJl Detachments (") ~. "'0 rt Female (651) 44 487 26 94 Detachments 0 1(0.2%) 5(19.2%) 1(1.1%) 2. PE Male (533) 24 280 40 189 Detachments 0 0 3(7.5%) 2(1.1 %) Female (885) 34 686 16 149 Detachments 0 0 0 1(0.7%) 3. All patients Male (932) 67 517 61 287 Detachments 0 4(0.8%) 5(8.2%) 7(2.4%) Female (1536) 78 1173 42 243 C C Detachments 0 1(0.09%) 5(11.9% ) 2(0.8%) ~ ~ > C rt :::r" 0 h ~ ~ 1. For gender comparison P = 0.04 for ECCE; 0.02 for PE and 0.003 for all patients. ~ C rJl (") h 2. For age of 60 and under and axial length > 24.0 mm compared with over 60 and axial length > 24. ...... "'0 o rt mm P = 0.001 for ECCE; 0.01 for PE and < 0.001 for combined. Olsen G, Update on study of capsulotomy and retinal detachment rates Page 15 Table 5: Rate of laser capsulotomy (YAG) for selected lens styles. LENS PROCEDURE YEARS TOTAL USED YAG(%) USED PMMA C (Surgidev 20B) C ECCE 1983-1985 138 40 (30%) ~ ~ PMMA > c 34 (20.4%)1 rt (Surgidev B20/20) ECCE 1984-1986 167 :::r" 0 h ~ PMMA ~ ~ c (Cilco 851) ECCE 1986-1987 226 90 (39.8%) rJl (") ~. "'0 rt PMMA ECCE except 10 (Cilco MC511251) cases of Phaco 1988-1992 483 232 (48.0%) PMMA (Alcon M220) Phaco 1991-1992 91 51 (56.0%) PMMA (Cilco UPB 350 PNS) Phaco 1992 89 45 (50.6%) PMMA (Cilco UPB 320 GS) Phaco 1992-1995 427 291 (68.1%)2 AcrySof C C MA60 Phaco 1 year results 738 40 (5.4%) ~ ~ > AcrySof C rt :::r" 0 MA60 Phaco 2 year results 490 (6.3%) h ~ ~ AcrySof ~ C rJl (") 24(10.3%)3 h MA60 Phaco 3 year results 233 ...... "'0 rt c c c c Olsen G, Update on study of capsulotomy and retinal detachment rates Page 16 1. P < 0.001 (compared to other PMMA IOL styles) 2. P < 0.001 (compared to other PMMA IOL styles) 3. P < 0.001 (compared to Cilco UPB 320 GS as the only PMMA IOL with similar follow-up) 

Update on a long-term, prospective study of capsulotomy and retinal detachment rates after cataract surgery

https://collections.lib.utah.edu/dl_files/09/c2/09c2e1c684c463dde9281d2a8c8a9c1fc6c9ed41.pdf

Update on a long-term, prospective study of capsulotomy and retinal detachment rates after cataract surgery

Abstract

Similar works

Full text

Available Versions

The University of Utah: J. Willard Marriott Digital Library