|Year : 1993 | Volume
| Issue : 1 | Page : 15-16
Anterior capsular support for posterior chamber intraocular lenses following vitreous loss in endocapsular surgery
Pushpa Jacob, Ravi Thomas, Subir Sen, Renu Raju
Schell Eye Hospital, Christian Medical College, Vellore, India
Schell Eye Hospital, Christian Medical College, Vellore
Source of Support: None, Conflict of Interest: None
We used anterior capsular support for posterior chamber intraocular lenses (PC IOLs) in fourteen eyes with large posterior capsular ruptures. An endocapsular technique preserved the anterior capsule and facilitated implantation. With a median follow up of 8.5 months, all patients had a visual acuity of 6/9 or better. One lens was lost in the vitreous and one patient had a clinically significant cystoid macular edema. In the event of a posterior capsular rupture we suggest this technique as an alternative to anterior chamber or scleral-fixated lenses
Keywords: Endocapsular cataract extraction; vitreous loss; posterior chamber intraocular lens; sulcus fixated; anterior capsular support
|How to cite this article:|
Jacob P, Thomas R, Sen S, Raju R. Anterior capsular support for posterior chamber intraocular lenses following vitreous loss in endocapsular surgery. Indian J Ophthalmol 1993;41:15-6
Posterior capsular rupture is a significant intraoperative complication of modern extracapsular cataract surgery. This may not only lead to vitreous loss with all its attendant problems, but may also preclude the implantation of a posterior chamber intraocular lens (PC IOL).
The endocapsular technique of cataract surgery has numerous reported advantages.  By preserving the anterior capsule until the last stages of surgery, one has the option of implanting a sulcus-fixated PC IOL in the event of a posterior capsular rupture , We present our experiences with this technique in cases of posterior capsular rupture and vitreous loss occurring during endocapsular surgery.
| Materials and methods|| |
Fourteen eyes of 14 patients developed a posterior capsular rupture during endocapsular cataract extraction between August 1990 and June 1991. Of these, 13 were male and one was female. Their median age was 52.5 years, with a range of 18 to 71 years.
Three of these cases were traumatic cataracts with pre-existing ruptures of the posterior capsule. In the remaining 11 cases, posterior capsular rupture occurred either during nucleus removal or during irrigation and aspiration.
On detection of the posterior capsular rupture, the wound was closed with two 10-0 sutures and vitreous in the anterior chamber was visualised using the light pipe of the Cooper Vision Ocutome. An automated localised anterior vitrectomy was performed using a bimanual technique with a May's illuminated infusion canula in one hand and a vitrectomy probe in the other. Using direct visualization of vitreous strands, complete removal of the vitreous from the anterior chamber was attempted. Any remaining cortical matter was then gently aspirated.
In all of our cases the posterior capsular tear was too large to attempt an "in the bag" placement of the IOL. After forming the anterior chamber with 2% methylcellulose, a V-shaped anterior capsulectomy was made in the pupillary area so as to clear the visual axis. The leading haptic of the PC IOL was then directed into the ciliary sulcus using the remaining anterior capsule as a glide. The trailing haptic was then inserted between the iris and the superior anterior capsular remnants using angled McPherson's forceps. Care was taken to ensure that the haptic did not spring into the capsular bag. Intraocular pilocarpine was used to constrict the pupil and methylcellulose was irrigated out of the anterior chamber. The wound was closed with interrupted 10-0 nylon sutures. The postoperative appearance of an IOL placed in front of the anterior capsule by this technique is shown in the [Figure - 1].
Post-operatively all eyes received topical steroid- antibiotic and cycloplegic drops for 3 to 4 weeks which were then tapered off based on anterior chamber reaction. Follow-up was performed daily for the first post operative week, and subsequently at two weeks, one month, and monthly thereafter. At each visit, vision and astigmatism were monitored by retinoscopy readings, and a complete ocular examination was performed with biomicroscopy, applanation tonometry and ophthalmoscopy through a dilated pupil.
| Results|| |
The follow up period ranged from 3 to 14 months, with a median of 8.5 months. Three patients had a best corrected visual acuity of 6/6 and eleven had 6/9. The complications are shown in [Table - 1].
A transient anterior uveitis which resolved with topical steroids was seen in all cases. Two patients had residual vitreous strands going to the wound which required YAG vitreolysis. In one patient the lens was inadvertently "posted" into the vitreous. Clinically significant CME was encountered in one patient and was treated with systemic steroids and acetazolamide.
| Discussion|| |
If the tear in the posterior capsule is small, implantation of a PC IOL in the capsular bag may still be possible . sub However, in the presence of a large posterior capsular rupture during surgery, it may be impossible to proceed with the surgical plan of implanting a PC IOL. In this situation, the options available include the use of an anterior chamber intraocular lens (AC IOL) or a scleral fixated lens. 
However, early-model rigid AC IOL designs have been associated with significant ocular morbidity, and there have been few studies investigating the long-term results of modern flexible AC IOLs. Likewise, the technique of scleral-fixated lenses has only recently been described and follow-up is limited. 
The endocapsular technique retains enough anterior capsule until the last stage of surgery, and in the event of vitreous loss enables PC IOL implantation with anterior capsular support. This is in effect equivalent to sulcus fixation. Clearkin and colleagues have suggested placing the PC IOL directly on the anterior capsular bag without an anterior capsulectomy in the visual axis.  All patients in Clearkin's series underwent Nd:YAG laser capsulotomy one month after surgery. The V-shaped anterior capsulectomy performed during surgery obviates the need for a laser.
Absence of vitreous from the anterior chamber is a prerequisite for the success of this technique. The use of a light pipe permits a meticulous vitrectomy even in relatively inexperienced hands. The infusion can be kept separate if desired by using a May's illuminating infusion needle. Alternatively, the surgeon's assistant can hold the light pipe. Even with this technique, however, it is possible to miss the occasional vitreous strand as happened in two of our cases.
The technique of PC IOL implantation with anterior capsular support is safe, easy, and effective in the management of posterior capsular tears with vitreous loss. We recommend it in preference to other alternatives.
| Acknowledgement|| |
The authors thank Stephen C. Gieser, M.D., for editorial assistance.
| References|| |
Rosen PH, Twomey JM, Kirkness CM. Endocapsular Cataract Surgery. Eye. 3: 672-677, 1989.
Meucci G, Gini GP. The anterior capsule as a support for posterior chamber IOLs in case of posterior capsule rupture. European J Implant Refract Surg. 2: 22.9-231, 1990.
Clearkin LG, Mody CH and Jain BK. Management of zonular dehiscence and posterior capsular rupture facilitated by the intercapsular technique. European J Implant Refract Surg. 2: 119-121, 1990.
Osher RH and Cionni RJ. The torn posterior capsule: its intraoperative behaviour, surgical management, and long-term consequences J Cat Refract Surg. 16: 490-494, 1990.
Hu BV, Slim DH, Gibbs KA and Hong YJ. Implantation of posterior chamber lens in the absence of capsular and zonular support. Arch Ophthalmol. 106: 416-420, 1988.
[Figure - 1]
[Table - 1]