Eyeworld

64 | EYEWORLD | JUNE 2022 ATARACT C by Ellen Stodola Editorial Co-Director About the physicians Zaina Al-Mohtaseb, MD Associate Professor Baylor College of Medicine Houston, Texas Soroosh Behshad, MD, MPH Associate Professor of Cataract, Corneal, and Refractive Surgery Emory University School of Medicine Atlanta, Georgia Nandini Venkateswaran, MD Cornea, Cataract, and Refractive Surgeon Massachusetts Eye and Ear, Waltham Waltham, Massachusetts P osterior capsule rupture (PCR) is one of the most dreaded complications for cataract surgeons. This complication will happen to every surgeon, no mat- ter how great their skill, said Soroosh Behshad, MD. Dr. Behshad, along with Zaina Al-Mohtaseb, MD, and Nandini Venkateswaran, MD, discussed PCR, when it can occur, how to reduce the risk, and techniques and IOL options that can be used. Rates of PCR depend on level of experience and the complexity of the case, Dr. Behshad said, with rates varying between 1–14% of cas- es. 1 When looking at a subset of surgeons who were more than 5 years out of training, these rates dropped to less than 5% of cases. 2,3 Dr. Venkateswaran agreed that percentages of PCR may be variable, depending on surgeon experience. She estimated her rate is 1–2%. She noted that certain cases will lead to a higher risk of PCR. A dense cataract, a poorly dilating pupil (from medication use, prior trauma, chronic inflammation, or posterior synechiae), pseudo- exfoliation, shallow anterior chamber, or high myopia all have very different anatomic circum- stances that can increase the chance of a PCR, she said, noting that as a corneal specialist she is often doing cataract surgery on eyes with very sick, irregular, or scarred corneas, which can in- crease risk for PCR due to a poor surgical view. "Ultimately, I think good preoperative prepara- tion helps reduce the risk of a PCR occurring," she said. "You have to go in knowing there's a higher risk for complications, and you have to take appropriate measures, whether it be changing the intracameral medications you're using, using pupil expansion devices, changing phaco settings so you're operating slower but more efficiently, using viscoelastic to protect the posterior capsule, or using alternative lighting to help improve illumination." Dr. Al-Mohtaseb said there are a number of factors that can increase risk for tears or PCR. The first thing she noted was prior surgery, especially prior retinal surgery. Additionally, if there are any zonular loss issues due to trauma or systemic diseases like pseudoexfoliation, it can be a more complicated surgery. The pres- ence of a posterior polar cataract or anything else that can cause the posterior capsule to not be normal are other scenarios that Dr. Al- Mohtaseb noted may increase the likelihood of PCR. Posterior capsular tear or rupture can hap- pen at any time during cataract surgery, Dr. Al- Mohtaseb stressed. Some might think this is just an issue when doing phacoemulsification, but she noted the importance of recognizing that it can happen at any time during a case. Dr. Behshad added that most risk factors that predispose cases to PCR can be identified Posterior capsule rupture: How to proceed and lens options This is a three-piece IOL with optic capture in a case where an anterior capsular tear had radialized posteriorly. A one-piece IOL was not able to be placed safely in the capsular bag. The haptics of the three-piece IOL were aimed away from the area of the anterior capsular tear to ensure IOL stability. Source: Nandini Venkateswaran, MD "Ultimately, I think good preoperative preparation helps reduce the risk of a PCR occurring." —Nandini Venkateswaran, MD

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