Eyeworld

66 | EYEWORLD | JUNE 2022 ATARACT C References 1. Chakrabarti A, Nazm N. Pos- terior capsular rent: Prevention and management. Indian J Ophthalmol. 2017;65:1359–1369. 2. Vajpayee RB, et al. Manage- ment of posterior capsule tears. Surv Ophthalmol. 2001;45:473– 488. 3. Greenberg PB, et al. Preva- lence and predictors of ocular complications associated with cataract surgery in United States veterans. Ophthalmology. 2011;118:507–514. said. She added that if there is an intact anterior capsule despite loss of a significant amount of the posterior capsule, the best option is to per- form primary optic capture, where the surgeon places a three-piece lens in the sulcus space and tucks the optic of that lens underneath the an- terior capsule. This technique provides a secure position for the IOL and reduces the likelihood of the lens moving around in the sulcus. The refractive outcome will also be comparable to placing the lens in the capsular bag. Sometimes there may not be enough of an anterior capsule to safely perform optic capture. If the surgeon is in doubt of the lens stability in the sulcus, he or she could place a suture to secure the haptics of the lens to the iris for additional support. Dr. Venkateswaran noted that some sur- geons, in cases where the PCR is small and central, will create a primary posterior capsu- lorhexis and perform posterior optic capture, where the IOL is placed in the bag and the optic is captured in the posterior capsulorhexis. This provides additional stability for the IOL, but it's also tricky and will only work if a truly round posterior capsulorhexis can be made out of a small PCR; it will not work if there is a large radial PCR. Dr. Venkateswaran also mentioned reverse optic capture, which she said can be useful if there is a PCR particularly in the setting of a premium lens. This could provide the patient the opportunity to still get the premium tech- nology they want in a safe way. Ultimately, these lenses, when optic cap- tured, are extremely stable, Dr. Venkateswaran said. "I think there are issues when a surgeon places a three-piece lens in the sulcus, and they've lost a large portion of the anterior capsule. These lenses can move around quite a bit and can potentially dislocate, and that's why fixating these lenses to the iris is a more stable option." If the surgeon doesn't think there is enough support for a three-piece in the sulcus, Dr. Venkateswaran recommended either putting an anterior chamber lens in or staging the pro- cedure and coming back when the eye is quieter to perform a secondary lens fixation. Dr. Behshad said that timing of the PCR and residual capsular strength is what will help de- termine IOL placement. "When there is a stable residual anterior capsule remaining, placement of a three-piece IOL in the ciliary sulcus would be the most acceptable option," he said. "Re- verse optic capture can be performed in this continued from page 65 This is a preoperative photograph demonstrating existing posterior capsular weakness. The patient was referred for a cataract; YAG vitreolysis was performed for a symptomatic posterior vitreous detachment. Source: Soroosh Behshad, MD, MPH This is an intraoperative photograph of the same patient with posterior capsular tear and successful removal of all nuclear fragments by utilizing hydrodelineation instead of hydrodissection. This also allowed for intact anterior capsule support for ciliary sulcus placement of a three-piece IOL. Source: Soroosh Behshad, MD, MPH

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