Posterior Polar Cataract with Central Capsule Defect

We have highlighted multiple different posterior polar cataract cases, which warrant reviewing. These include:

• Soft Posterior Polar in a younger patient
• a resident-performed Posterior Polar cataract
• a tough, dense cataract, floppy iris, small pupil Posterior Polar case
• a surprise Posterior Polar case
• general background knowledge about Posterior Polar cataract surgery
• we have even had a guest surgeon show his bowl technique for Posterior Polar cataract

The case presented here is different. This patient was referred to us by another ophthalmologist in a different city because of the nature of this posterior polar cataract. There is a large, dense, central opacity which involves the posterior capsule and there is a very high suspicion that the central posterior capsule is absent. This pre-existing defect means that we will certainly face many challenges during surgery.

With an open posterior capsule, we will need to plan for implantation of a sulcus IOL. The ideal way of implanting this is to have the haptics of the three-piece IOL in the sulcus while the optic is captured through the capsulorhexis. This technique, much like putting a button through a buttonhole, provides great long-term stability and it creates a barrier to separate the anterior segment from the vitreous cavity. Because the optic is behind the capsulorhexis, the IOL power calculation is much the same for in-the-bag placement of the IOL. And we have the added benefit of avoiding touch between the back surface of the iris and the optic edge. This method of securing the IOL should last for many decades (my goal is 50 years).

Let’s review the basics for a posterior polar cataract surgery:

• make a great, well-centered, 5-mm capsulorhexis since we will need this to optic capture the IOL
• do NOT perform hydro-dissection since that could lead to displacement of the entire nucleus into the vitreous cavity.
• perform a gentle hydro-delineation to separate the endo-nucleus from the epi-nucleus
• remove the endo-nucleus with the phaco probe
• use a dispersive viscoelastic to perform visco-dissection between the capsule and the cortex and epi-nuclear shell in all quadrants
• use the I/A probe to gently aspirate all of this epi-nucleus and cortex
• in this case, keep the epi-nuclear shell intact and in one piece which will help prevent losing lens fragments through the open posterior capsule
• perform a minimal, conservative anterior vitrectomy to ensure that the anterior segment is free from vitreous. Using triamcinolone can help stain vitreous to aid in visualization.
• place the three-piece IOL in the eye with the haptics in the sulcus and then carefully place the 6-mm optic through the 5-mm capsulorhexis to capture and secure it
• remove the viscoelastic, seal the incisions, and finish the case

The key in this case is to remove all of the cataract material without extensive vitreous prolapse and without having retained lens material in the vitreous cavity. You must be able to do this type of surgery while staying calm and focused. The end result is great vision for our patient.

Click below to learn from this highly challenging case: