Capsule polishing may offer benefits during cataract surgery
Click Here to Manage Email Alerts
When performing cataract surgery, our goal is to remove as much of the lens material as possible to prepare the capsular bag for implantation of the IOL.
After removal of the lens cortex, some surgeons like to polish the undersurface of the anterior capsular rim in order to remove as much of the microscopic lens debris as possible. These residual lens epithelial cells may contribute to issues such as anterior capsular opacity, capsular contraction and fibrosis.
Source: Uday Devgan, MD
Believe it or not, cleaning the undersurface of the anterior lens capsule was not always considered a requirement for a beautiful cataract surgery. Years ago, our surgical microscopes did not even have a sufficient red reflex to be able to easily detect these cellular debris. Now, with microscopes with enhanced red reflex capabilities, it is easier to see the extent of the residual lens debris (Figure 1). Many surgeons do not spend any time removing this material because it is likely to be at least partially dissolved by the inflammatory cascade in the postoperative period.
Over the past couple of decades, many studies have been performed to determine if there is a benefit of capsular polishing for routine cataract cases. The results have been mixed with regards to prevention of posterior capsule opacification (PCO), which is arguably the most common complication after cataract surgery. Some studies have shown an advantage in the prevention of PCO, while many show no benefit. There are even studies that indicate that performing polishing of the anterior capsular rim may surprisingly increase the rate of PCO.
When it comes to other capsular issues such as anterior capsule opacification and contraction and fibrosis of the capsular bag, studies suggest that there is a benefit to capsular polishing. This can also affect the refractive outcome of the eye because the effective lens position is determined by the degree of capsular bag contraction. Asymmetric capsular bag contraction can also lead to the IOL optic being slightly tilted, which can induce aberrations such as lenticular astigmatism. In eyes that are more prone to anterior capsular phimosis, such as those with pseudoexfoliation syndrome, capsular polishing may reduce that risk.
Capsular polishing can be performed using a mechanical means with friction or by using vacuum from the irrigation-aspiration probe. The mechanical method uses an instrument that is rubbed against the undersurface of the anterior capsular rim while the bag is filled with viscoelastic (Figure 2). This creates friction to remove the lens epithelial cells, which are then washed out once the viscoelastic is removed. This works well, but it may not be as effective as using vacuum.
The irrigation-aspiration probe can be used with low flow and low vacuum settings to gently apply suction to the undersurface of the anterior capsular rim. Foot pedal control can be used to titrate the amount of vacuum to avoid grabbing the capsule and potentially weakening the zonular attachment (Figure 3). Even with gentle capsule polishing or vacuuming, there could be damage to the zonular support of the capsular bag, which can lead to late dislocation of the IOL with decentration of the optic.
For now, the evidence suggests that gentle anterior capsular polishing, with mechanical friction or vacuuming, is of some benefit for most patients undergoing cataract surgery. The challenge is to be gentle yet thorough, cleaning as much as possible without inadvertently damaging the delicate capsular bag and zonular support.
A video of this surgery can be found at https://cataractcoach.com/2023/01/03/1702-capsule-polishing-or-vacuuming/.
- For more information:
- Uday Devgan, MD, in private practice at Devgan Eye Surgery and a partner at Specialty Surgical Center in Beverly Hills, can be reached at devgan@gmail.com; website: www.CataractCoach.com.
Collapse
Read more about
Click Here to Manage Email Alerts