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Complications from anterior capsule tears may require secondary intervention
To prevent extension of a tear to the posterior capsule, surgeons should avoid sudden changes in pressure from above and below the anterior capsule.
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Anterior capsule tears during phacoemulsification can cause intraoperative complications that sometimes require additional surgery, according to a study.
Permanent visual loss and poor refractive outcomes can also result from an anterior capsule tear, especially if the lens is implanted outside the bag.
“This complication of modern phacoemulsification cataract surgery is relatively common and important in view of the possible associated secondary complications, probably as common as the posterior capsule rupture,” Gianluca Carifi, MD, the corresponding author, told Ocular Surgery News. “Up to a fourth of cases complicated by anterior capsule tear might also experience a posterior capsule rupture. A tenth of patients in our study needed at least one additional and unplanned secondary surgical intervention.”
Patients and procedures
The retrospective study, published in the American Journal of Ophthalmology, included 239 eyes that underwent phacoemulsification and IOL implantation and incurred anterior capsule tears. A control group comprised 212 eyes that underwent uncomplicated cataract surgery.
Eyes that underwent combined surgical procedures or planned manual extracapsular cataract extraction or had a history of intraocular surgery or ocular trauma were excluded from the study.
IOLs were implanted in the capsular bag in half of cases.
“Implantation of a posterior chamber IOL was performed primarily in the vast majority of cases,” Carifi said. “However, patients might also be left aphakic if the operating surgeons are not confident to achieve a stable IOL fixation (5% of cases in our series). If possible, implantation of a [posterior chamber] IOL in the capsular bag should be preferred to the implantation in the ciliary sulcus.”
Primary outcome measures were intraoperative capsule complication rates, visual and refractive outcomes, and the incidence of short-term postoperative complications.
Refractive analysis was based on data from 187 eyes in the capsular tear group.
Outcomes and observations
A concurrent posterior capsule rupture occurred in 58 eyes (24%).
“Obviously, it depends on the experience of the operating surgeons, and it is important to highlight that close supervision of the trainees is in place at our institution. This means that often a more experienced surgeon would have taken over and completed the case. Hence, it is possible that the rate of associated secondary posterior capsule rupture might be higher in other settings,” Carifi said.
Twenty-seven eyes (11%) underwent unplanned secondary surgical procedures.
Endocapsular IOL fixation was achieved more frequently in cases of secondary tear (P = .008). Sulcus fixation was used more often in cases of primary anterior capsule tear (P = .009).
Overall, refractive outcomes were poor in 22.4% of study eyes; postoperative refraction was 1 D or more off target. Refractive outcomes were significantly worse in the study group (P < .0001).
Significant visual improvement occurred in 71% of eyes in the study group; four eyes (1.7%) had permanent visual loss.
“There are no recognized techniques to avoid the occurrence of an anterior capsule tear, while there are some maneuvers like the ‘Little technique’ to try to retrieve a rhexis that is running out,” Carifi said. “The experience of surgeons might play a role, and the advice to keep the anterior chamber always well-formed with OVD and the recommendation to pay particular attention in cases in which the anterior chamber is too shallow or too deep is given to our trainees.”
To prevent extension of an anterior capsule tear to the posterior capsule, Carifi advised surgeons to avoid sudden changes in differential pressure from above and below the anterior capsule and to avoid maneuvers that can increase tension and extend the tear further.
Additionally, if an anterior capsule tear does not extend to the posterior capsule, implantation in the capsular bag can be achieved with a one-piece or three-piece IOL, Carifi said. – by Matt Hasson
Reference:
Carifi G, et al. Am J Ophthalmol. 2015;doi:10.1016/j.ajo.2014.11.027.For more information:
Gianluca Carifi, MD, can be reached at Moorfields Eye Hospital, 162 City Road, London EC1V, United Kingdom; email: gianlucacarifi@gmail.com.Disclosure: Carifi reports no relevant financial disclosures.
Perspective
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Steve A. Arshinoff, MD, FRCSC
Once in a while, an article appears that confirms our surgical fears. Cataract surgeons regard posterior capsule rupture as a potentially disastrous complication of cataract surgery but generally do not assign anterior capsular tears similar respect, despite the recognition that a compromised anterior capsulorrhexis, at the very least, compromises the optical result of surgery (22% had a poor refractive result in this series). This large series of 239 cases of anterior capsular tears from the well-respected Moorfields Eye Hospital illustrates a surprisingly high 24% rate of subsequent posterior capsular rupture, with 5% nuclear drop and 11% requiring a secondary repair procedure at a later date. In today’s climate of expectations of flawless surgery and refractive outcomes within 0.25 D, these anterior capsular tear cases definitely significantly adversely affected results. This article serves as a sober reminder to all of us that we should not skimp on the time and effort allotted to achieve a perfect capsulorrhexis, and it should be sized to accommodate IOL capture in case the posterior capsule is compromised later in the procedure. The anterior capsulorrhexis as the life ring of cataract surgery and this article remind us to respect its importance as much as a ship’s captain respects and checks his survival gear before leaving the harbor to venture out.
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