Risk factors for posterior capsule rupture in mature cataract surgery: A study of 1302 cases.

Purpose: To identify the risk factors predisposing posterior capsule rupture (PCR) during mature cataract surgery. Methods: A total of 1302 consecutive mature cataract cases were included in this retrospective study. A detailed examination was performed for each patient and risk factors including age, gender, systemic diseases, ocular comorbidities, surgeon, and surgery method were recorded. Cases with PCR during surgery were classified as complicated. Multivariate logistic regression analysis with a generalized estimating equations method was applied for statistical analysis. Results: The overall rate of PCR was 7.30% (n=95 eyes). After adjusting for confounders, factors that remained significant on multivariate analysis were strabismus (odds ratio [OR]: 5.70, 95% confidence interval [CI]: 2.17-14.97; P < 0.001), phacodonesis (OR: 4.62, 95% CI: 2.59-8.22; P < 0.001), history of trauma (OR: 4.46, 95% CI: 1.64-12.12; P = 0.003), surgery method (extracapsular cataract extraction/phacoemulsification) (OR: 2.61, 95% CI: 1.60-4.26; P < 0.001), and pseudoexfoliation (OR: 1.94, 95% CI: 1.20-3.16; P = 0. 007). Conclusion: Strabismus, phacodonesis, history of trauma, extracapsular cataract extraction method, and pseudoexfoliation were found to be important risk factors for developing PCR. Appropriate preoperative and perioperative precautions for these higher-risk cases can reduce complications.

What Is the Cost of a Posterior Capsule Rupture Complication?

BACKGROUND AND OBJECTIVE: To examine the cost of a posterior capsule rupture (PCR) in patients who underwent planned phacoemulsification. PATIENTS AND METHODS: Retrospective review of 8,113 cataract surgeries performed between January 2014 and December 2017 at one academic institution. The rate of PCR was 0.55%, and 34 patients with PCR who met inclusion criteria were identified. Investigators evaluated the added operating room time required to manage PCR, subsequent surgeon visits beyond the typical average, referrals to other specialties, further imaging, and additional required surgeries. RESULTS: Patients with PCR had an additional 2.76 (standard deviation [SD] ± 3.27) postoperative encounters and 3.06 (SD ± 3.78) visits to another subspecialty. Operating room time was found to average 61.43 minutes (range: 21 to 191 minutes) at an additional cost of $455.48 (SD ± $407.37). Additional visits, imaging, and procedures added $655.59 (SD ± $767.21). The total additional average cost was $1,111.07 (SD ± $1,021.20) per PCR. CONCLUSION: Posterior capsular ruptures impose a substantial cost burden on the health care system. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:444-447.].

Flap motility sign: not diagnostic of posterior extension of anterior capsular tears.

Flap motility sign has been recently described as an aid to guide the surgeons regarding the feasibility of continuing safe phacoemulsification in the presence of peripheral extension of anterior capsular tears. While this sign may seem to provide a safety assurance to the operating surgeon who at such times may be under considerable stress, we believe, this sign may not always hold true and this hypothesis needs further investigation. We present a case in which an everted and fluttering flap was noted in the presence of a complete posterior extension of the anterior capsular tear, thus refuting the accuracy of flap motility sign.

Visual and refractive outcomes following management of anterior capsular tears with a capsulorrhexis relaxing incision.

OBJECTIVE: To evaluate the refractive outcomes after anterior capsular tear (ACT). DESIGN: Retrospective case-control study. PARTICIPANTS: After ethics approval, the surgical operative records of 4301 consecutive patients undergoing cataract surgery by a single surgeon were reviewed for cases of ACT. METHODS: All ACTs were managed using a balancing incision of the capsulorrhexis margin 180 degrees away from the tear. If the patient's other eye had undergone cataract surgery by the same surgeon, it was included as a control. RESULTS: Fifty-one eyes of 51 patients were complicated by ACT (incidence = 1.2%). The mean age of patients in the study was 64.2 ± 12.1 years. Of the 51 patients with ACT, 34 underwent contralateral surgery. These eyes were used as the control group. There was no significant difference in preoperative visual acuity (p = 0.683) or proportion of eyes that received in-the-bag intraocular lens placement (p = 0.347) between groups (ACT = 92.2%; control = 97.1%). In 3 ACT eyes, the tear extended into the posterior capsule (5.9%), and although this did not occur in control eyes, this difference was not statistically significant (p = 0.150). There was no difference in best-corrected final logMAR visual acuity between groups (p = 0.424) or postoperative spherical equivalent between ACT (-0.23 ± 1.2D) and control (-0.15 ± 0.62D) eyes (p = 0.985). CONCLUSIONS: Cataract extraction complicated by ACT can result in equivalent visual and refractive outcomes as in uncomplicated surgery. The technique used in this study prevented extension of ACT to the posterior capsule in 94.1% of cases.

Electron microscopy of silicone irrigation/aspiration tips involved in posterior capsule rupture.

We describe 2 cases of posterior capsule rupture caused by Alcon reusable silicone irrigation/aspiration (I/A) tips. Scanning electron microscopy and reflected light microscopy of these tips revealed burring of the inner metallic shafts and tears in the silicone sleeves. A review of surgical video revealed that posterior capsule ruptures caused by the I/A tips occurred when the posterior capsule was aspirated either through the aspiration port or through a tear in the silicone sleeve. Contact of the posterior capsule with the sharp metallic burrs on the inner metal tube can result in posterior capsule rupture.

[Capsulorhexis Real-Life - Experienced Surgeon versus Femto Laser Assisted Cataract Surgery (FLACS) as Reported in Literature]. / Kapsulorhexis Real-Life ­ erfahrener Operateur versus Literaturdaten zur Femto Laser Assisted Cataract Surgery (FLACS).

BACKGROUND: Capsulorhexis is one of the most important steps in cataract surgery. Good centration, circular overlap in sufficient size and a circular edge without tears result in good centration of the intraocular lens (IOL). In this study, the capsulorhexis results of an experienced surgeon are compared with reported data in femtolaser assisted cataract surgery (FLACS). PATIENTS AND METHODS: 105 consecutive operations were photographically documented; in 81 cases size and overlap were analysed retrospectively. The surgeon's personal anterior capsular tear rate was taken from the EUREQUO database. RESULTS: Average rhexis size was 5.03 ± 0.3 mm; the difference between the two measured diameters was 0.28 ± 0.18 mm. Circular overlap was found in 88.9% of cases. No radial tears were observed in 8000 operations in EUREQUO, resulting in a rate of less than 0.0125% in manual surgery. CONCLUSIONS: The overlap rate of manual surgery was comparable to FLACS; whether the slightly 'rounder' capsulotomy is clinically relevant remains unclear. The risk of an anterior capsular tear is very low in the hands of an experienced surgeon and even lower than with FLACS.

Methods of fixation of intraocular lenses according to the anatomical structures in trauma eyes.

Ocular trauma can lead to severe visual impairment and morbidity, depending on the anatomical structures affected. The main causes of ocular trauma include foreign bodies, impact by an object, falls, and chemicals. Most ocular traumas occur in children or young male adults. A meticulous slit lamp examination is crucial for assessing all anatomical structures. Trauma to the crystalline lens can result in dislocation, an intralenticular foreign body, cataract, fragmentation, and capsular breach. An intraocular lens (IOL) can endure subluxation or luxation under the conjunctiva, into the anterior chamber or the vitreous, or can be extruded. The surgical approach depends on the condition and morphology of the lens and the anatomical structures surrounding it. If there is capsular bag support, a secondary IOL can be placed in the sulcus using remnants of the damaged capsule. If there is no capsular bag support, a secondary IOL can be fixated to the anterior chamber angle, to the iris, or to the sclera. A detailed history of injury cannot always be obtained in trauma settings. Proper education, supervision, and certified safety eye protectors could prevent up to 90% of ocular injuries. Lens trauma can be treated with various surgical procedures and fixation techniques, which nevertheless require advanced surgical skills owing to the fine anatomical structure of the anterior segment. A careful surgical strategy should be established for a globe reconstruction after trauma with secondary lens implantation. Clin. Anat. 31:6-15, 2018. © 2017 Wiley Periodicals, Inc.

Posterior capsular rupture and spontaneous posterior dislocation of lens following electrical injury.

Lenticular changes are often seen following electrical injury. We report an unusual case of electrical injury with late spontaneous posterior dislocation of lens nucleus with intact anterior capsule with ruptured posterior capsule in the right eye and anterior subcapsular cataract in the left eye. The right eye was managed with pars plana vitrectomy with cortical matter removal with multipiece intraocular lens insertion in ciliary sulcus. This report adds posterior capsular rupture and posterior dislocation of lens to the usual ocular complications of electrical injury.

Managing the posterior polar cataract: An update.

Posterior polar cataracts (PPC) have always been a challenge for cataract surgeons due to their inherently higher propensity for posterior capsule rupture. Over the years, several technical modifications have been suggested to enhance safety and reduce posterior capsule rupture rates in these polar cataracts. This review article tries to present the various techniques and strategies to published in literature to manage PPCs. It also discusses pearls for making surgery more reproducible and consistent, as well as the role of newer diagnostic and surgical technology based on the published literature on the subject.

Posterior capsular rent: Prevention and management.

This review article deals with a potentially sight threatening complication - rupture of the posterior capsule - during cataract surgery. Cataract surgery is the most commonly performed surgical procedure in ophthalmology and despite tremendous technical and technological advancements, posterior capsular rent (PCR) still occurs. PCR occurs both in the hands of experienced senior surgeons and the neophyte surgeons, although with a higher frequency in the latter group. Additionally, certain types of cataracts are prone to this development. If managed properly in a timely manner the eventual outcome may be no different from that of an uncomplicated case. However, improper management may lead to serious complications with a higher incidence of permanent visual disability. The article covers the management of posterior capsular rent from two perspectives: 1. Identifying patients at higher risk and measures to manage such patients by surgical discipline, and 2. Intraoperative management of posterior capsular rent and various case scenarios to minimize long-term complications.This review is written for experienced and not-so-experienced eye surgeons alike to understand and manage PCR.

Risk of Posterior Capsule Rupture During Cataract Surgery in Eyes With Previous Intravitreal Injections.

PURPOSE: To investigate the risk of posterior capsular rupture (PCR) during cataract surgery in eyes with previous intravitreal injection (IVI). DESIGN: Retrospective cohort study. METHODS: The Moorfields Patient Administrative System and OpenEyes electronic databases were used to study all cataract surgery procedures undertaken between January 1, 2012 and August 31, 2015 in the Moorfields main and satellite sites. Clinical data were anonymized and extracted, including prior occurrence and number of intravitreal injections. Logistic regression was performed with the Hosmer-Lemeshow test for goodness of fit to generate odds ratios for possible risk factors. RESULTS: In total, 62 994 cataract surgery procedures were undertaken over the study period, of which 1035 (1.64%) were in eyes with previous intravitreal injection(s). PCR occurred in 650 (1.04%) eyes. After logistic regression, prior intravitreal injection was associated with an increased risk of PCR (P = .037), with an odds ratio of 1.66. The number of prior injections, indication for injections, and service undertaking the surgery were not associated with increased risk of PCR (P > .1). CONCLUSIONS: Eyes with previous IVI have a higher risk of PCR. This is not affected by number of previous injections, indication for injections, or the specialty undertaking the surgery.

Previous Intravitreal Therapy Is Associated with Increased Risk of Posterior Capsule Rupture during Cataract Surgery.

PURPOSE: To investigate if previous intravitreal therapy is a predictor of posterior capsule rupture (PCR) during cataract surgery. DESIGN: Multicenter, national electronic medical record (EMR) database study with univariate and multivariate regression modeling. PARTICIPANTS: A total of 65 836 eyes of 44 635 patients undergoing cataract surgery. METHODS: Anonymized data were extracted for eyes undergoing cataract surgery from 20 hospitals using the same EMR for cases performed between 2004 and 2014. Variables included as possible risk indicators for PCR were age, sex, number of previous intravitreal injections, indication for intravitreal therapy, grade of healthcare professional administering intravitreal therapy, advanced cataract, and cataract surgeon grade. MAIN OUTCOME MEASURES: Presence or absence of posterior capsular rupture during cataract surgery. RESULTS: Data were available on 65 836 cataract operations, of which 1935 had undergone previous intravitreal therapy (2.9%). In univariate regression analyses, patient age, advanced cataract, junior cataract surgeon grade, and number of previous intravitreal injections were significant predictors of PCR. By considering the number of previous intravitreal injections as a continuous variable, the odds ratio for PCR per intravitreal injection was 1.04 (P = 0.016) after adjusting for age, advanced cataract, and cataract surgeon grade. Repeat analysis considering intravitreal injections as a categoric variable showed 10 or more previous injections were associated with a 2.59 times higher likelihood of PCR (P = 0.003) after again adjusting for other significant independent predictors. CONCLUSIONS: Previous intravitreal therapy is associated with a higher likelihood of PCR during cataract surgery. This study provides data to help inform surgeons and patients about the risk of complications when undergoing cataract surgery after multiple prior intravitreal injections. Further investigation is required to determine the cause behind the increased PCR risk.

Anterior zonulotomy: Rescue technique for capsulorhexis tear-out.

UNLABELLED: An anterior zonulotomy technique to rescue a capsulorhexis tear-out is described. The technique uses microsurgical instruments that are capable of performing microprocedures within the confines of the anterior chamber. The anterior zonulotomy releases the tractional impediment caused by the anterior zonular fibers, enabling the surgeon to use conventional rescue methods to redirect the CCC centrally. The technique demonstrates how microsurgical instruments can be used to safely perform an anterior zonulotomy for radial tear-outs that have become lodged in the zonular fibers. FINANCIAL DISCLOSURE: The author has no financial or proprietary interest in any material or method mentioned.

RATE OF POSTERIOR CAPSULAR RENT AS A COMPLICATION OF RESIDENT PERFORMED CATARACT EXTRACTION PROCEDURES.

BACKGROUND: Cataract extraction is the most commonly offered treatment for cataract. This is done surgically by a number of methods which include extracapsular cataract extraction and phacoemulsification. This study was done to assess the rate of posterior capsule rupture as a complication of resident performed cataract extraction procedures. METHODS: It is a descriptive case series conducted from 1st March to 1st April 2014 at Al Shifa Trust Eye Hospital, a tertiary care hospital. Cataract extraction procedures were done by first to fourth year residents. The surgical procedures done were extracapsular cataract extraction, phacoemulsification and lens matter aspiration. RESULTS: A total of 577 cases were operated, 307 males and 270 females. Out of which 336 were right eyes and 241 left eyes. The patients were in the age range 17-80 years. Only 61 out of 577 cases had posterior capsular rent. In phacoemulsification rate of posterior capsular rent was 29% and in extracapsular cataract extraction 69%. According to the year of residency cases done by first year were 24, second year 131, third year 231 and fourth year 191 with posterior capsular rents in 3, 23, 5 and 30 cases respectively. A total of 11 cases were left aphakic, 10 after extracapsular cataract extraction and 1 after phacoemulsification. CONCLUSION: There is a relatively high rate of posterior capsular rupture in cataract extraction procedures performed by residents. This rate is directly related to the procedure, being low for phacoemulsification and high for extracapsular cataract extraction. Rate of posterior capsular rupture is also directly related to the skill and expertise of the surgeon, being high for second year residents as compared to third and fourth year residents.

Simple approach to prevent capsule tear-out during capsulorhexis creation in hypermature cataracts.

UNLABELLED: Capsule tear-out in hypermature cataracts (Argentinean flag sign) is a common and frustrating complication during the creation of a capsulorhexis. Completing the capsulorhexis through a small side-port incision, filling the anterior chamber with a highly viscous ophthalmic viscosurgical device such as a viscoadaptive agent, and using a 23- or 25-gauge microcapsulorhexis forceps to fill the side-port incision can reliably prevent this complication. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.