Intravitreal injections may increase risk of posterior capsule rupture in cataract surgery
When performing cataract surgery in patients treated with intravitreal injections, be aware of the increased risk for posterior capsule rupture and ready to manage it, a surgeon said.
Posterior capsule rupture (PCR) is a common complication of cataract surgery, and multiple intravitreal injections may increase that risk due to mechanical and biochemical effects not yet clarified, Oliver Findl, MD, said at the virtual European Society of Cataract and Refractive Surgeons meeting.
In a recent retrospective study of 4,047 eyes, the PCR rate was 9.3% in patients undergoing injection therapy vs. 1.9% in the control group, and an increase of 8.6% relative risk per injection was found. In a multicenter database study of 65,000 eyes, a 1.04 times higher risk for PCR per injection was found, and for patients who had 10 or more injections, the risk was more than 2.5 times higher.
“Preoperative assessment is important. Find out how many injections your patients had and inform them about the higher risk,” Findl said.
An experienced surgeon and precautions are needed to manage patients with a compromised lens capsule.
The continuous curvilinear capsulorrhexis should be near perfect in order to have the option of doing an optic capture after surgery, Findl said.
“I would not do a complete hydrodissection because you want to prevent extending a tear if it is there, so I do small local hydrodissections up to the equator. I may do a careful hydrodelineation if dealing with a strong nuclear cataract to reduce the risk of dislocating the lens,” Findl said.
Bottle height should be set at no more than 40 cm or 45 cm for minimal hydrostatic pressure, according to Findl. And, the use of ophthalmic viscosurgical device is critical, especially when removing the phaco tip or the I/A tip so as not to have a collapse of the anterior chamber.
“Ideally, you should always keep the AC filled,” he said.
Phacoemulsification should be performed carefully, with as little stress as possible to avoid pressure on the capsule, preferably using a horizontal chop technique.
“For anterior vitrectomy, I use a 23-gauge cutter, but if you have much residual cortex and nucleus, 20 gauge might be more effective. Single-piece lenses in the sulcus should be avoided. I always use a three-piece lens in the sulcus and try to do an optic capture,” Findl said.
References:
- Nagar AM, et al. J Cataract Refract Surg. 2020;doi:10.1097/j.jcrs.0000000000000047.
- Lee AY, et al. Ophthalmology 2016;doi:10.1016/j.ophtha.2016.02.014.
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Findl O. Dealing with a compromised lens capsule after intravitreal injection. Presented at: European Society of Cataract and Refractive Surgeons meeting; Oct. 2-4, 2020 (virtual meeting).
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