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EW FEATURE 100 Headline byline goes here plus fade posterior capsule remains intact, a one-piece IOL can be implanted," she said, adding that practitioners should, however, have calculations available for a three-piece lens as well since the rate of posterior cap- sule rupture is much higher in these cases. In the event of a rupture, she advised practitioners to be prepared to implant a three-piece IOL in the sulcus, with or without optic capture. Dr. Chan also warned that premium IOLs should be avoided here. "Advanced technology IOLs may not be suitable should compli- cations arise," she said. Likewise, Dr. Safran uses a standard one-piece lenses, including torics, but stressed the importance of having a three-piece IOL on hand. He also modifies his technique. "You should make your rhexis a little smaller than the optic so that you can do optic capture," he said, adding that there is an increased chance that it may be warranted. "Some physicians might want to do a posterior rhexis, but I think that optic capture with a three-piece lens is just as good," he said. However, if the patient has a lot of astigma- tism, then the surgeon may want to consider a posterior rhexis so that a toric IOL can be placed. If the plaque is left alone or comes out without leaving a defect, he finds that usually the surgeon can put any lens in the bag. He does, however, recommend avoid- ing the Crystalens (Bausch + Lomb, Bridgewater, New Jersey) if there is a posterior capsule plaque remain- ing because that puts tension on the posterior capsule. "I don't think that's absolutely contraindicated, but personally I would avoid it in that situation," he said. Since it can be difficult getting a reading with the IOLMaster in such cases, he tends to avoid multifocal lenses as results may not be as accurate. With posterior polar cataract cases, there remains some controver- sy over whether or not femtosecond laser-assisted cataract surgery should be performed. Currently there are conflicting views on this. Dr. Safran cited a study that appeared in the December 2014 issue of the Journal of Cataract & Refractive Surgery 1 that showed there was a risk to rupturing the capsular bag due to gas from the femtosecond laser. On the other hand, a study published in the De- cember 2015 issue of the Journal of Refractive Surgery 2 indicated that with a modified program using a hybrid pattern of cylinders and chops, the laser could be used safely. Still, he urges caution. "I think one thing to keep in mind is there are reports of higher radial tear-out rates, which affects the anterior capsule with the femtosecond," Dr. Safran said, adding that if the surgeon can make a rhexis that can allow for optic capture, there will be less likelihood of experiencing a tear-out. EW References 1. Alder BD, et al. Comparison of 2 techniques for managing posterior polar cataracts: Tradi- tional phacoemulsification versus femtosec- ond laser-assisted cataract surgery. J Cataract Refract Surg. 2014;40:2148–51. 2. Titiyal JS, et al. Femtosecond laser-assisted cataract surgery technique to enhance safety in posterior polar cataract. J Refract Surg. 2015;31:826–8. Editors' note: Dr. Chan and Dr. Safran have no financial interests related to their comments. Contact information Chan: clarachanmd@gmail.com Safran: safran12@comcast.net Warming continued from page 99 Toric IOL in the bag with defect that developed adjacent to a plaque fortunately removed after the lens was in the bag Source: Steven Safran, MD

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