How to treat Posterior Subcapsular Cataract (PSC)?

Treatment of Posterior Subcapsular Cataract (PSC)

The definitive treatment for posterior subcapsular cataract is surgical removal through phacoemulsification with intraocular lens implantation when the cataract causes visual impairment affecting the patient's functional needs. 1

Understanding Posterior Subcapsular Cataract

Posterior subcapsular cataract (PSC) is a specific type of lens opacity located just inside the posterior lens capsule. It has distinct characteristics:

• Causes substantial visual impairment when affecting the axial region of the lens
• Often produces glare symptoms and poor vision in bright light
• Typically affects near vision more than distance vision due to miosis with near accommodation
• More common in younger patients than nuclear or cortical cataracts
• Progresses more quickly than other cataract types 1

Indications for Surgical Management

Surgery should be performed when:

1. The PSC causes visual function decline that no longer meets the patient's needs
2. The patient experiences significant glare or contrast sensitivity issues
3. The lens opacity interferes with optimal diagnosis or management of posterior segment pathology
4. The patient's quality of life is affected by visual impairment 1

Preoperative Evaluation and Planning

Before surgery, a thorough evaluation is essential:

• Anterior segment OCT can help evaluate the posterior capsule and predict potential surgical complications
• OCT-based morphological assessment has shown 98.8% sensitivity and 96.5% specificity for predicting intraoperative complications in PSC surgery 2
• Different PSC morphological types have varying risks:
  • Type 1: Low risk of complications
  • Type 2: High risk of posterior capsular plaque
  • Type 3: High risk of posterior capsular rupture 2

Surgical Approach

The standard surgical approach includes:

1. Phacoemulsification with IOL implantation:

   • Sutureless, small-incision technique
   • Foldable IOL implantation
   • Performed on an outpatient basis 1

2. Specialized techniques for PSC:

   • Rotating the IOL by at least 360° after placement in the capsular bag to clear residual lens epithelial cells
   • Using irrigation/aspiration to thoroughly remove viscoelastic and residual material 3

3. IOL selection considerations:

   • Prefer sharp-edged IOLs over round-edged designs
   • Consider hydrophobic over hydrophilic materials to reduce posterior capsule opacification (PCO) risk 4

Prevention of Posterior Capsule Opacification

PSC patients are at risk for developing PCO after surgery. Preventive measures include:

• Ensuring anterior capsulorrhexis completely overlaps the IOL optic
• Thorough cortical cleanup during surgery
• Proper IOL selection and positioning 4
• In some cases, primary posterior capsulotomy may be considered during the initial surgery, though this approach requires careful patient selection 5

Management of PCO if it Develops

If PCO develops after cataract surgery:

• Nd:YAG laser posterior capsulotomy is the definitive treatment
• Treatment is indicated when PCO causes visual impairment or interferes with fundus visualization
• The procedure creates an opening in the opacified posterior capsule using focused laser energy 4

Special Considerations

Steroid-Induced PSC

• If PSC is steroid-induced, consider discussing alternative treatments with the patient's primary care physician
• No pharmacological treatments are known to eliminate existing cataract or retard its progression 1, 6

PSC with Angle Closure

• In cases with coexisting primary angle-closure glaucoma, cataract surgery with endoscopic goniosynechialysis may be effective
• This approach can reduce IOP and decrease the need for IOP-lowering medications 7

Postoperative Care

• Provide appropriate postoperative care and visual rehabilitation
• Monitor for and treat any complications
• Schedule regular follow-up examinations to assess visual function and detect any PCO development early 1

Potential Complications

Monitor for potential complications including:

• Elevated intraocular pressure
• Retinal detachment (0.87% risk within 5 months of capsulotomy)
• Cystoid macular edema
• Posterior capsule opacification
• Inflammation 4

By following this approach, PSC can be effectively managed to improve visual function and quality of life for affected patients.