CATARACT 32 EWAP SEPTEMBER 2022 considered to help identifying prolapsed vitreous, and the surgical approach, whether anterior or posterior, should be based on surgeon experience. Dr. Al-Mohtaseb also highlighted lens options that are available if a posterior capsular tear or rupture does occur. Typically, if there is a small, circular tear that is centrally located, the surgeon could still do a one-piece in the bag, but for most posterior capsular tears, you typically want to put a three-piece lens in the sulcus. “I’m a firm believer that you need to also optic capture that three-piece lens to avoid decentration in the future and 1G syndrome, especially in patients with long axial lengths,” Dr. Al-Mohtaseb said. “I don’t like putting three-piece lenses in the sulcus without optic capture.” Another benefit of doing optic capture is the surgeon doesn’t have to change the power of the IOL because the position of the IOL is theoretically the same as if they’d put a one-piece lens in. Additionally, if the anterior capsule is too large or the surgeon can’t get a good optic capture, Dr. Al-Mohtaseb said she likes to make the posterior capsular tear round and circular and capture the lens into the posterior capsulotomy. In a complex case where there is a large posterior capsular tear, zonular loss, etc., Dr. Al-Mohtaseb said surgeons might want to choose another technique, like getting rid of the capsule altogether and doing Yamane intrascleral fiÝation. Dr. Behshad added that in cases where the surgeon is planning for astigmatism management with a toric IOL, 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 capsule support for ciliary sulcus placement of a three-piece IOL. Source: Soroosh Behshad, MD, MPH there currently are no toric IOL options FDA approved for placement in the ciliary sulcus. There has been some movement in developing a toric IOL that is stable in the sulcus and not a one-piece IOL, but currently none are available in the U.S., he said, adding that astigmatism management can be completed with placement of corneal LRIs or subsequent laser vision correction. Both Drs. Al-Mohtaseb and Behshad again stressed the importance of early recognition of PCR and having a plan in place if it occurs. They said to not chase lens material that falls posteriorly. Dr. Al-Mohtaseb said that this can potentially cause traction or retinal tears. Dr. Behshad added that in this case, risks increase exponentially for retinal damage that can lead to permanent vision loss. Remove as much of the cataract that is present anteriorly and complete a thorough vitrectomy, he said. If possible, place a three-piece IOL in the sulcus, and if there are retina services available, consider same-day lens fragment removal by a retina colleague. Otherwise, plan to involve retina early in the postop course. EWAP References 1. Chakrabarti A, Nazm N. Posterior capsular rent: Prevention and management. Indian J Ophthalmol. Ó0£ÇÆÈx\£Îxq£ÎÈ. 2. Vajpayee RB, et al. Management of posterior capsule tears. Surv Ophthalmol. Ó00£Æ4x\4ÇÎq4nn. Î. Greenberg PB, et al. Prevalence and predictors of ocular complications associated with cataract surgery in United States veterans. Ophthalmology. Ó0££Æ££n\x0Çqx£4. Editors’ note: Dr. Al-Mohtaseb is Associate Professor, Baylor College of Medicine, Houston, Texas. Dr. Behshad is Associate Professor of Cataract, Corneal, and Refractive Surgery, Emory University School of Medicine, Atlanta, Georgia. Dr. Venkateswaran is a cornea, cataract, and refractive surgeon at Massachusetts Eye and Ear, Waltham, Waltham, Massachusetts. None of the doctors disclosed any relevant financial interests.
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