This article is more than 5 years old. Information may no longer be current.
Posterior capsular fibrosis can be safely removed with manual peeling maneuvers
The procedure is a safer, easier intraoperative alternative to PCCC and Nd:YAG laser capsulotomy.
Click Here to Manage Email Alerts
PADUA, Italy – When found during cataract surgery, posterior capsular fibrosis can and should be eliminated intraoperatively with a manual peeling of the membranes, according to a surgeon here.
“I don’t think it’s advisable to leave the fibrous material there and perform a posterior Nd:YAG laser capsulotomy later. I know some surgeons do this, but the patient doesn’t get what he or she expected, is inevitably disappointed with the outcome of surgery and is difficult to reassure. Also, the fibrosis tends to consolidate after surgery and is only treatable with high laser power and a sometimes excessive high number of spots, which may damage the IOL,” said Alessandro Galan, MD, head of Padua Sant’Antonio Eye Clinic.
|
|
Primary posterior continuous curvilinear capsulorrhexis (PCCC) is another possibility, he added, but it is a difficult procedure, causing the eye an additional trauma with the aperture of the posterior capsule.
“Capsulorrhexis is far more difficult to perform posteriorly than anteriorly. There is less tension on the posterior than on the anterior capsule and the fibrosis itself makes it difficult to perform a regular, circular tear. If the opacification is large and slightly decentered, it is difficult to circumscribe it in the rhexis if we want to keep it small and symmetrical. Moreover, the procedure might create problems with the vitreous if the hyaloid membrane is not in perfect condition,” he said.
In his opinion, PCCC should be left as a last resort, in case of failure of the capsular peeling.
Lift and strip
The technique is borrowed from retinal surgery.
“You peel the fibrous membrane off the posterior capsule as you do with the epiretinal membranes in the macular pucker,” Dr. Galan said.
A small quantity of viscoelastic is injected in the anterior chamber after aspiration of cortical materials to slightly flatten and stretch the posterior capsule.
“Don’t inject too much viscoelastic, or else the capsule will be pushed too far down and become difficult to reach. Don’t inject too little, because you need the capsule to be stretched when you perform the peeling,” he said.
Capsulorrhexis forceps (Dr. Galan uses sharp-edged Corydon forceps) are used to clench and strip off the fibrous membranes. The cleavage plane between the posterior capsule and the fibrous growths may be difficult to find in some places, but there are always several areas where the membrane can be easily lifted.
“You learn it by experience,” he said. “Explore the edges of the membrane, and see where they appear more in relief. There you can usually insert the tip of the Corydon forceps, lift the edge, nip it and gently strip the membrane off. With some patience, and a lot of satisfaction, you will be able to peel it off entirely.”
The entire membrane cannot always be removed with a single maneuver. The procedure might need to be repeated at different points until the entire area is cleared. In places where the fibrous tissue is too strongly attached to the capsule, the surface can be gently scraped with the tip of the forceps. A silicon tip cannula or a ground diamond tip cannula can also be used for scraping.
No complications
The procedure is carried out under topical anesthesia. It requires high magnification and some cooperation from the patient.
“It rarely fails if it is performed with care and patience. If there is a problem, however, it can always be converted in PCCC or YAG laser capsulotomy,” Dr. Galan said. Results are very good. He said that in most cases the capsule appears almost completely transparent the day after surgery. If a slight opacification is detected, it is usually unnoticed by the patient. However, if the residuals impair good vision, a YAG laser capsulotomy can be performed at a later stage.
“The procedure should always be performed in case of posterior capsule fibrosis. It doesn’t prevent the possibility of resorting to the other two procedures and in almost all cases it resolves the problem intraoperatively, with no need for other maneuvers,” Dr. Galan said.
“It is also very safe. In case of capsule rupture, it can be converted in PCCC, but this has never happened to me in more than 3 years. Even with very thick fibrous membranes I have always performed the peeling successfully.”
For Your Information:
- Alessandro Galan, MD, can be reached at the Ospedale Civile Sant’Antonio, Via Facciolati 121, Padua, Italy; +(39) 049-821-6780; fax: +(39) 049-821-6541.