June 2008

 

CATARACT/ IOL

 

Most likely corticocapsular adhesions


by Matt Young EyeWorld Contributing Editor

   

Study takes a closer look at this surgical problem

Anterior view of a human eye obtained postmortem with advanced cataract stained with trypan blue; in one study, anterior cortical cataract increased the odds of CCA by 9.5 times, while posterior cortical cataract increased the odds of CCA by 3.3 times Source: Suresh K. Pandey, M.D.

When do corticocapsular adhesions (CCA)—which occur between the lens capsule and adjacent cortical layer—occur? Often in older patients and in females, according to new research. “Corticocapsular adhesions were strongly associated with cortical cataracts, increased age, and female gender,” wrote lead study author Abhay R. Vasavada, M.D., director, Iladevi Cataract and IOL Research Centre, Raghudeep Eye Clinic, India, and colleague Shetal M. Raj, M.S. The study was published in the March/April issue of the Indian Journal of Ophthalmology. Corticocapsular adhesions present many challenges to cataract surgery, including the fact that opacities often cannot be broken by one hydrodissection, that nucleus rotation could be impossible, and that efforts to rotate the nucleus could cause zonular damage, Dr. Vasavada noted. “In eyes with CCA, forceful rotation of the lens is likely to result in a break in the integrity of the capsular zonular complex,” Dr. Vasavada reported. “When CCA are present, we strongly recommend performing a judicious combination of multiquadrant and focal hydrodissection to cleave these adhesions apart and remove a major obstacle to phacoemulsification.”

So by zoning in on when CCA are likely to occur, surgeons can properly prepare for these more difficult cases.

CCA trends

Researchers analyzed 580 patients, 189 of which had CCA and 391 of which did not (these served as controls). Cataracts were graded as nuclear, anterior cortical, posterior cortical, or posterior subcapsular cataract. CCA was found with a slitlamp at 12´ magnification with maximum illumination, and the slit beam concentrated on the capsule at a 30-degree to 45-degree angle. “Corticocapsular adhesions appeared as an opacity in the outermost layer of the cortex with no visible area of translucence between the capsule and the underlying opaque cortical layer,” Dr. Vasavada noted. “However, during slitlamp examination, cortical cataract should be differentiated from CCA. In cortical cataract, a distinct area of translucence is always visible in the inner substance of the lens.”

Females had a higher presence of CCA than males. Of 318 male participants, 93 (29.2%) had CCA. Of 262 female patients, 96 (36.6%) did. Age also played a significant association role with CCA.

In participants 40 to 49 years, 22% had CCA while in the age group of 70 to 79 years, 70% did. “Multivariate logistic regression analysis, after adjusting for the impact of other factors, revealed that the probability of occurrence of CCA increased by 3.3% with advancing age … while the odds of CCA for females was 83% higher than that for males,” Dr. Vasavada noted. “Presence of anterior cortical cataract increased the odds of CCA by 9.5 times, while the presence of posterior cortical cataract increased the odds of CCA by 3.3 times.” Indeed, in eyes with cortical opacities, 65.5% had CCA. Although in previous research, Dr. Vasavada found the incidence of CCA to be 30.3%, which might suggest surgeons often have to be prepared for handling these cases, he also noted that the condition is infrequent in developed countries. “Corticocapsular adhesions are probably rarely seen in industrialized countries,” Dr. Vasavada noted. “This could be because surgery to remove age-related cataracts is done at a relatively early stage. We speculate that the presence of CCA could be attributed to the accumulation of secretory extracellular material due to advancing age.”

There are special circumstances when predicting CCA could help.

“While performing cataract surgery on eyes that were precluded from standardized slitlamp examination of the lens, such as eyes with small pupil and eyes allergic to dilating drops, anticipating the possible presence of CCA can avoid over-stressing the bag and zonules during rotation,” Dr. Vasavada reported. “Examination of [the] eye for extent of CCA would allow the surgeon to perform focal cortical cleaving hydrodissection in the specific clock hours/quadrants, to achieve adequate hydrodissection and successful rotation thereof. Focal hydrodissection in such eyes can prevent undesired consequences of a compromised zonular apparatus.”

Nonetheless, according to the textbook, Complications in Phacoemulsification, edited by William J. Fishkind, M.D., clinical professor of ophthalmology, University of Utah, Salt Lake City, “Hydrodissection is often unnecessary and perhaps contraindicated with white cataracts because the cortex is already hydrated, and corticocapsular adhesions are few, if any.” If the nucleus is held by corticocapsular adhesions, Dr. Fishkind noted, “Hydrodissection is necessary but must be performed slowly and with small aliquots of BSS because the capsule may be friable.”

Editors’ note: Dr. Vasavada has no financial interests related to this study. Dr. Fishkind has no financial interests related to his book.

Contact Information

Fishkind: 520-293-6740, wfishkind@earthlink.net

Vasavada: icirc@abhayvasavada.com

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