This patient had a long-standing cataract with a very dense 4+ posterior sub-capsular component. Pre-operative vision was barely counting fingers and the patient was so vision deprived from this eye that he developed a sensory exotropia. During cataract surgery the plaque was noted to be thick and adherent. Attempts at hydro-dissection failed because the fluid wave could not go across the posterior capsule. The nucleus was chopped into halves and removed and then the cortex was aspirated. Now comes time to address the posterior plaque. What is your technique?
The ideal situation is gently lifting the plaque off the posterior capsule using gentle vacuum suction from the irrigation/aspiration (I/A) probe. That was tried and a small edge of the posterior plaque was successfully lifted and an attempt was made to fully peel off the opacity. But it did not work and further attempts of this were thought to be too traumatic to the posterior capsule, which is just 4 microns thin.
The next option is to do a primary posterior capsulorhexis to intentionally open the posterior capsule in a controlled manner as shown in this video from 10 years ago. The risk is vitreous prolapse which is more common in older patients who have vitreous that is more liquified.
The last option, and the one that was chosen, is to implant the IOL and then plan to do a future YAG laser capsulotomy to clear the visual axis. After the cataract surgery we need to wait until the capsule has contracted, which takes a few weeks or so.
The only downside of this option is that it will take a about a month for the patient to recover sharp vision, instead of just a day in the case of the primary posterior capsulorhexis. But since this patient has lived with poor vision from this eye for many years, waiting another month is not an issue.
Click below to watch the approach to an adherent posterior capsule plaque:
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