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Frequency and intraoperative behavior of radial anterior capsular tears during phacoemulsification of cataract
Session Title: Subluxed IOLs and Scleral Fixation
Session Date/Time: Wednesday 09/10/2013 | 08:00-10:30
Paper Time: 09:07
Venue: E102 (First Floor)
First Author: : X.Corretger SPAIN
Co Author(s): : J. Keller F. Chait R. Torres
To determine the frequency of radial anterior capsule tears extending to the lens equator during cataract surgery. To ascertain the stage of the procedure at which they occur and their intraoperative behavior, particularly the risk of posterior capsular extension and the need for anterior vitrectomy. The difference in risk between cases operated on by an experienced anterior segment surgeon and by trainees was also studied, as well as predisposing intrinsic ocular factors.
Tertiary referral center in a large city in Spain
Retrospective study of consecutive cataract cases operated by phacoemulsification over five years (January 2008 - December 2012) by either an experienced anterior segment surgeon or the residents under his tutelage (mostly in their second year of training). Cases in which a radial tear of the anterior lens capsule threatening the lens equator occurred were analyzed in detail. Once a tear had been detected the remainder of the operation was finished by the senior surgeon. Surgical video recordings and case notes were reviewed. The moment when the rupture was identified, its behavior and whether it had extended to the posterior capsule were recorded. The number of cases requiring anterior vitrectomy and the type and location of the intraocular lens implant (IOL) were also recorded.
There were 14 eyes with a radial anterior capsule tear in 831 cataract operations performed during the study period (1.68%). For the anterior segment surgeon the frequency was 5/670 (0.74%) and for trainees it was 9/161 (5.59%, OR: 7.1, p=0.001). Associated factors were previous pars plana vitrectomy (PPV) (6 eyes, OR:7.5, p=0.001), intumescent cataract (4 eyes, OR:29.3, p<0.0001), proliferative diabetic retinopathy (4 eyes, OR:5.1, p=0.02), ocular hypertension or glaucoma in 2 eyes (OR:0.9, p=0.64) and narrow anterior chamber angle in 2 eyes (OR=16.9, p=0.01). The capsular tear occurred during the capsulorhexis in 6 cases, during phacoemulsification of lens fragments in 4 eyes and during placement iris hooks on the capsulorhexis, at the beginning of the nucleus phacoemulsification, during aspiration of cortical matter and during implantation of the IOL in 1 eye each. In 5/14 eyes the tear extended to the posterior capsule (35.7%) yet only one eye (7.1%) required anterior vitrectomy. A one-piece IOL was implanted in the capsular bag of 10 eyes (71.4%) and a three-piece IOL in the ciliary sulcus of 3 eyes. The remaining eye was left aphakic after an expulsive suprachoroidal hemorrhage. This case was compounded by phacogenic glaucoma with an intumescent cataract.
In our series, the frequency of anterior capsular radial tears is similar to that of other published series. The main factors associated with this complication are an intumescent cataract, narrow anterior chamber, a history of PPV, the experience of the surgeon and proliferative diabetic retinopathy. Most tears occurred during anterior capsulorhexis and a significant number during phacoemulsification of nuclear fragments. In over a third of cases the break extended to the posterior capsule. Proper management of both the anterior capsule tear and the extension to the posterior capsule may translate in a low rate of vitreous prolapse requiring vitrectomy. In nearly all patients except for one it was possible to implant a posterior chamber IOL most of which were placed in the capsular bag. It is crucial that surgeons supervising trainees are able to detect this complication in a timely fashion and manage it adequately.