Today we are looking at a classic posterior polar cataract and the risk we take when we attempt to polish the posterior capsule, something that I strongly advise against! In these posterior polar cases, the central capsule is pathologically thin and often directly adherent to the lens opacity. The temptation to clean up those last few white flecks from the capsule is high, but you must resist the urge. If you touch it, you’ll turn a good surgery into a vitreous loss case instantly.
The Complication: The Split Posterior Capsule
When you attempt to polish, the weakened capsule doesn’t just stretch, it splits into a curvilinear break from lens equator to lens equator. The bag is now wide open.
How to Recover Successfully
- Step 1: Don’t Pull Out. If you suddenly withdraw the I/A tip, the AC will collapse and vitreous will prolapse. Maintain the chamber with your footpedal.
- Step 2: OVD Tamponade. Inject a dispersive viscoelastic through the paracentesis directly over the tear to tamponade the vitreous back before removing your instruments.
- Step 3: IOL Selection. If the tear is small, you can gently dial a one-piece IOL into the bag. However, the safer move is a three-piece IOL in the sulcus with optic capture through the anterior capsulorhexis for long-term stability.
The Lesson
In posterior polar cases, Perfect is the Enemy of Good. Leave the central opacity alone. Doing a 1-minute YAG laser capsulotomy a few months later is far better than a split posterior capsule.
