Careful technique needed to remove posterior polar cataracts
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This patient presents to our clinic with a lifelong history of bilateral posterior polar cataracts that have progressively worsened.
With the patient’s small pupils and the central lens opacity, the visual acuity has declined to 20/200. The patient is also highly hyperopic with a shallow anterior chamber, and the planned IOL power is +27 D for a goal of emmetropia.
All these factors make this a challenging cataract surgery, particularly the posterior polar opacity because this is associated with a high risk of posterior capsule rupture. The posterior capsule is weak, fragile and often partially absent at this site, and this can result in complications leading to a poor visual outcome. For posterior polar cases, the technique that I prefer is hydrodelineation to remove the central lens endonucleus, followed by viscodissection of the remaining lens epinucleus and cortex.
Surgical technique
Creating a well-centered 5-mm round capsulorrhexis is particularly important in an eye with a posterior polar cataract because there is a significant chance that the IOL will need to be placed in the ciliary sulcus with optic capture through the anterior capsular opening.
It is important to avoid performing hydrodissection near the posterior lens opacity because the fluid wave can cause the posterior capsule to rupture and the nucleus to fall into the vitreous. While some surgeons advocate a small amount of hydrodissection, stopping just shy of the posterior pole, my advice is to avoid this step altogether.
Hydrodelineation using a small quantity of balanced salt solution in a syringe with a 27-gauge cannula can be performed because this will separate the endonucleus from the remaining epinucleus and cortex. The endonucleus can then be removed from the eye using the phaco probe.
Source: Uday Devgan, MD
At this point, all that remains in the capsular bag is the softer lens epinucleus and the cortex. With the use of a dispersive viscoelastic, which has a more liquid and syrup-like texture than the cohesive viscoelastics, the remaining lens material can be carefully dissected from the capsule. Using a viscodissection technique in all quadrants of the lens allows for a complete cleaving of all residual lens material from the capsule. This method has several benefits: The viscoelastic is slow and controlled, it pressurizes the anterior segment, it can tamponade any existing break in the capsule, and it creates a barrier between the lens material, which is brought forward, and the capsule and vitreous, which are pushed backward.
The irrigation and aspiration probe can be placed in the eye and kept centrally in the anterior segment while the lens material is aspirated. The risk of a capsular rupture is highest during attempted manipulation or cleaning of the posterior polar opacity. While the posterior polar opacity can often be removed from the capsular surface, care should be taken to avoid polishing or cleaning. It is far easier and less risky to perform a YAG laser capsulotomy to clear the visual axis in the postoperative period.
When the lens material has been removed, it is critical to not let the anterior chamber collapse. This means keeping the I&A probe in the eye in foot pedal position 1 to maintain the infusion pressure and then using the nondominant hand to inject viscoelastic via the paracentesis incision to fully inflate the capsular bag. At this point, the I&A probe can be removed from the eye, and the new IOL can be inserted.
The postoperative course for these patients tends to be straightforward, particularly if the posterior capsule remains intact. After contraction of the capsular bag has created a strong fixation for the IOL, a YAG laser capsulotomy can be performed for any residual posterior capsule opacity. Using the technique of viscodissection, posterior polar cataracts can be effectively treated while minimizing the risks.
A video of this surgery can be found at https://cataractcoach.com/ 2023/12/26/2059-opaque-posterior-polar-with-shallow-ac/.
- For more information:
- Uday Devgan, MD, in private practice at Devgan Eye Surgery and a partner at Specialty Surgical Center in Beverly Hills, California, can be reached at devgan@gmail.com; website: www.CataractCoach.com.
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