Anterior Segment Oct–Guided Strategy For Posterior Polar Cataract In Down Syndrome: Surgical Video And Management Of Late Posterior Capsular Rupture After Iol Implantation

To report bilateral posterior polar cataract surgery under general anaesthesia in a patient with Down syndrome and very poor preoperative vision, highlighting the value of intraoperative anterior segment OCT (AS-OCT) to support surgical planning, and demonstrating management of a late posterior capsular rupture (PCR) occurring after in-the-bag IOL implantation in the second eye.

Tertiary eye clinic; cataract surgery performed under general anaesthesia with phacoemulsification, intraoperative AS-OCT imaging, and video recording.

A patient with Down syndrome presented with bilateral posterior polar cataract and light perception in both eyes. She had esotropia and moderate amblyopia in the right eye (OD). Biometry and IOL power selection for OD were based on the left eye (OS) due to poor fixation with OD. Surgery was performed under general anaesthesia. The first procedure (OS) was uneventful and a 1-piece hydrophobic acrylic IOL (DIB00, +21.50 D) was implanted in the capsular bag. Intraoperative AS-OCT supported the suspicion that the posterior capsule could be involved/closely adherent to the polar opacity. The second procedure (OD) was uncomplicated until the final steps. After implantation of an in-the-bag IOL, a longitudinal posterior capsular rupture was identified. Irrigation was stopped, the anterior chamber was stabilised with cohesive OVD, the IOL was explanted, and an anterior vitrectomy was performed. A 3-piece posterior chamber IOL (AR40, +21.50 D) was then implanted in the sulcus. At 1-week follow-up, uncorrected distance visual acuity was 0.25 in OD (limited by amblyopia) and 0.5 in OS, with stable pseudophakia in both eyes. The next review is scheduled at 1 month to allow refractive stabilisation and resolution of postoperative inflammation.

In posterior polar cataract, even when surgery is uncomplicated until late stages, posterior capsular rupture can occur after IOL implantation. Prompt recognition, chamber tamponade with OVD, IOL explantation when required, meticulous anterior vitrectomy, and sulcus implantation of a 3-piece IOL can safely rescue the case. Intraoperative AS-OCT may add useful confirmation of posterior capsule involvement and help justify a low-stress strategy.