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Posterior capsulotomy with optic buttonholing best choice in certain cases

Issue: February 25, 2009

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WAILEA, Hawaii — While primary posterior capsulotomy with optic buttonholing can be a surgically challenging procedure with a steep learning curve, it should be considered standard of care in pediatric cataract and a worthwhile option when there is a high chance of secondary cataract, a speaker here said.

In a presentation at Hawaiian Eye 2009, Michael C. Knorz, MD, of Mannheim, Germany, said he has been able to achieve excellent results with primary posterior capsulotomy with optic buttonholing in cases of multifocal IOLs in young hyperopes.

Dr. Knorz said he was convinced to learn the technique by his colleague Rupert Menapace, MD, of Vienna, Austria, who published a study on his results with 1,000 eyes between 2004 and 2007. Dr. Menapace reported three eyes required anterior vitrectomy, eight eyes had vitreous herniation and one eye had a retinal detachment. However, he reported that no eyes had cystoid macular edema, there was no secondary cataract formation, and all IOLs were well-centered and stable, Dr. Knorz said.

In his personal experience, Dr. Knorz said, "I use it in hyperopes when implanting multifocal IOLs, and I have had no secondary cataract and no IOL decentration."

"In my hands, it's a difficult, tricky surgery with a steep learning curve, but it should be the standard of care in pediatric cataracts, and it's an interesting option if secondary cataract must be avoided or is very likely," he said.

The Menapace study and the Knorz presentation highlight the challenges of in-the-bag IOL implantation, namely posterior capsule opacification and IOL decentration. By creating a primary posterior capsulorrhexis and buttonholing the optic, stability is ensured and the visual axis remains clear because there is no central posterior capsule to become opacified. Similar techniques have been used in pediatric lensectomy surgery for years with good results, and we could reasonably expect to achieve the same outcomes in routine adult cases.

– Uday Devgan, MD, FACS
OSN SuperSite Section Editor