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Introduction
Patients and Methods
Surgical Techniques
Results
Discussion
References

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 Pediatric Ophthalmology

Enhanced Visualization of Capsulorhexis With Indocyanine Green Staining in Pediatric White Cataracts

Suqin Guo, MD · Anthony Caputo, MD · Rudolph Wagner, MD · Patrick DeRespinis, MD

Reprinted from Guo S, Caputo A, Wagner R, DeRespinis P. Enhanced Visualization of Capsulorhexis with Indocyanine Green Staining in Pediatric White Cataracts. J Pediatr Ophthalmol Strabismus. 2003;40(5)268-271.

Introduction

A continuous curvilinear capsulorhexis of the anterior lens capsule is commonly performed during surgery for cataracts to allow a safe manipulation within the capsular bag during the surgery and a stable centration of the intraocular lens postoperatively.1-3 Inadequate visualization of the anterior capsule may carry a high risk of radial capsular tears and may result in unwanted surgical complications.3,4 Visualization of the lens capsule is especially important during cataract surgery in children because elasticity of the pediatric lens capsule makes capsulorhexis difficult to perform.5,6 Capsulorhexis is even more challenging in pediatric white cataracts. Different methods of illumination and staining of the lens capsule have been described to enhance continuous curvilinear capsulorhexis in adult white cataracts, including light pipe illumination, fluorescein, trypan blue, and indocyanine green (ICG) capsular staining.7-11 We performed ICG staining of the lens capsule in 10 eyes with pediatric white cataracts and had consistently good results.

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Patients and Methods

To be included in this study, patients had to have a dense cataract with poor red reflex, normal findings on B-scan, reliable keratometry or A-scan readings, and no other significant ocular anomalies. Six patients (10 eyes) met these criteria. A preoperative evaluation consisted of cycloplegic refraction, a slit-lamp examination, a dilated fundus examination, and A-scans, B-scans, or both. All of the patients underwent an ICG-enhanced anterior capsulorhexis. In 4 eyes, light pipe illumination of the anterior lens capsule was started initially, but failed to enhance the visualization of the capsule. ICG was then used successfully to stain the lens capsules of these 4 eyes. All of the patients underwent an ICG-enhanced anterior capsulorhexis, cataract extraction, and implantation of an intraocular lens under general anesthesia. Three of these patients (4 eyes) who were younger than 6 years had a planned posterior capsulorhexis and anterior vitrectomy.

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Surgical Techniques

A side-port paracentesis incision was performed approximately 3 clock hours from the planned clear corneal incision. A large air bubble was injected into the anterior chamber using a 30-gauge cannula (Slide 1). ICG solution (0.125%) was spread onto the anterior lens capsule and under the bubble via a 30-gauge cannula (Slide 2). The air was then exchanged with viscoelastic after ICG capsular staining was complete. A clear corneal incision was performed on the meridian of the higher keratometry reading, either superiorly or temporally (Slide 3). An anterior capsulorhexis was started using a cystotome needle and completed using a capsulorhexis forceps (Slide 4 and Slide 5). After hydrodissection, a standard phaco vacuum or irrigation and aspiration procedure was performed to remove the cataract (Slide 6). The clear corneal incision was enlarged to insert the intraocular lens into the capsular bag. In young or uncooperative children, a primary posterior capsulorhexis and anterior vitrectomy were performed prior to the intracapsular insertion of the intraocular lens.

Slide 1
 		Slide 2
 		Slide 3
Slide 4
 		Slide 5
 		Slide 6

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Results

Six children (4 boys and 2 girls) were included in this study. The patients' ages ranged from 4 to 9 years. Four patients had bilateral cataracts and two had unilateral cataracts. Preoperatively, visual acuity ranged from 20/200 to hand motions. Visual acuity improved to a mean of 20/40 postoperatively. The visualization of the lens capsule was significantly enhanced with ICG staining during the anterior capsulorhexis in all 10 eyes with dense cataracts. In four eyes, light pipe illumination was attempted initially and failed to improve the capsular visualization. An ICG-enhanced capsulorhexis was then successfully completed in these eyes. A consistent and reproducible capsulorhexis had been achieved with the ICG staining technique in all 10 eyes. Centration of the intracapsular intraocular lenses was stable in all eyes. Postoperatively, there was no significant difference in corneal clarity and anterior chamber reaction between the eyes with ICG staining and the eyes without such staining. No intraoperative or other postoperative complications were noted in the group with ICG staining.

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Discussion

The insertion of intraocular lenses has become a well-accepted practice in managing pediatric cataracts. A continuous circular capsulorhexis is the best way to secure the insertion of an intraocular lens and is the gold standard procedure in experienced hands in current cataract and intraocular lens surgery for both adults and children. 5,12

A manual continuous curvilinear capsulorhexis is challenging in children due to the elastic characteristics of the immature lens capsule.5,6 Various approaches have been studied to minimize the difficulty of the manual continuous curvilinear capsulorhexis in the pediatric eye. A mechanized capsulectomy with vitrector (anterior vitrectorhexis) has been used in pediatric eyes with good results.5,12 Radiofrequency diathermy capsulotomy has been studied as an alternative technique and has been used in 14 pediatric eyes.13,14

A capsulorhexis is even more difficult to perform in white cataracts due to a poor visibility of the anterior capsule and the absence of red reflex. Different capsular staining methods have been evaluated in adult patients, including fluorescein, trypan blue, and ICG.7-11 We have used fluorescein for capsular staining in adult patients and have had variable and inconsistent results. From our experience in the management of adult mature cataracts, an ICG-enhanced continuous curvilinear capsulorhexis is superior to the fluorescein or the light pipe illumination technique. In the current study, the visualization of the ICG-stained anterior capsule against the pediatric white cataract was excellent. After comparing the ICG-enhanced capsulorhexis with fluorescein staining and light pipe illumination, we feel that an ICG-enhanced capsulorhexis provides the best visualization of the lens capsule and is the most effective method.

ICG staining also enhances the visualization of the residual lens epithelial cells on the rim of the anterior capsule, which may improve cleaning off these cells and prevent or delay posterior capsular opacification (secondary cataract).

ICG staining of the anterior lens capsule is a good technique to facilitate the performance of a continuous curvilinear capsulorhexis in the eyes of children with white cataracts. It is a safe and easy procedure with consistently excellent results.

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References

  1. Assia EI, Apple DJ, Tsai JC, et al. Mechanism of radial tear formation and extension after anterior capsulectomy. Ophthalmology. 1991;98:432-437.
  2. Assia EI, Apple DJ, Tsai JC, et al. The elastic properties of the lens capsule in capsulorhexis. Am J Ophthalmol. 1991;111:628-632.
  3. Assia EI, Legler UFC, Merrill C, et al. Clinicopathologic study of the effect of radial tears and loop fixation on intraocular lens decentration. Ophthalmology. 1993;100:153-158.
  4. Assia EI, Apple DJ, Barden A, et al. An experimental study comparing various anterior capsulotomy techniques. Arch Ophthalmol. 1991;109:642-647.
  5. Wilson ME, Bluestein EC, Wang X, et al. Comparison of mechanized anterior capsulectomy and manual continuous capsulorhexis in pediatric eyes. J Cataract Refract Surg. 1994;20:602-606.
  6. Gimble HV, Ferensowiy M, Raanan M, et al. Implantation in children. J Pediatr Ophthalmol Strabismus. 1993;30:69-79.
  7. Pandey SK, Werner L, Escolbar-Gomez M, et al. Dye-enhanced cataract surgery: Part 1. Anterior capsule staining for capsulorhexis in advanced/white cataract. J Cataract Refract Surg. 2000;26:1052-1059.
  8. Horiguchi M, Miyakek, Ohta I, et al. Staining of the lens capsule for circular continuous capsulorhexis in eye with white cataract. Arch Ophthalmol. 1998;116:533-537.
  9. Guo S, Caputo A, Wagner R, et al. Indocyanine green staining capsulorhexis in pediatric white cataract. Presented at the Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus; April 12-16, 2000; San Diego, CA. Abstract 71.
  10. Fritz WL. Fluorescein blue, light-assisted capsulorhexis for mature or hypermature cataract. J Cataract Refract Surg. 1998;24:19-20.
  11. Melles GR, deWaard PW, Pameyer JH, et al. Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J Cataract Refract Surg. 1999;25:7-9.
  12. Wilson ME, Saunders RA, Robert EL, et al. Mechanized anterior capsulectomy as an alternative to manual capsulorhexis in children undergoing intraocular lens implantation. J Pediatr Ophthalmol Strabismus. 1996;33:237-240.
  13. Morgan JE, Ellingham RB, Young RD, et al. Mechanical properties of the human lens capsule following capsulorhexis or radiofrequency diathermy capsulotomy. Arch Ophthalmol. 1996;114:1110-1115.
  14. Comer RM, Abdulla N, O'Keefe M. Radiofrequency diathermy capsulorhexis of the anterior and posterior capsule in pediatric cataract surgery: preliminary results. J Cataract Refract Surg. 1997;23:641-644.

Posted May 2004

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