What are the intraoperative complications of cataract surgery, specifically posterior capsule (PC) rent?

From the Guidelines

When a posterior capsule (PC) rent occurs during cataract surgery, the surgeon should immediately stabilize the anterior chamber with a cohesive viscoelastic device and remove any prolapsed vitreous with anterior vitrectomy to prevent complications like retinal detachment, which has an overall risk of approximately 1% after cataract surgery 1. The management of a PC rent is crucial to prevent further complications. The first step is to stabilize the anterior chamber with a cohesive viscoelastic device to prevent vitreous prolapse. Any remaining lens material should be carefully removed using either irrigation/aspiration or a vitrectomy probe, depending on the extent of the rent. Some key points to consider in the management of PC rent include:

• The risk of retinal detachment (RD) after cataract surgery is increased in certain conditions, such as axial myopia, pre-existing vitreoretinal disease, male gender, younger age, vitreous prolapse into the anterior chamber, vitreous loss, and spontaneous extension of the capsulotomy at the time of surgery 1.
• The absence of a posterior vitreous detachment (PVD) at the time of cataract surgery is a major risk factor for RD later, especially in higher risk eyes such as those with myopia and lattice 1.
• Patients with a history of nontraumatic detachment in one eye have a 10% increased risk of developing RD in the fellow eye, since pathologic vitreoretinal changes are frequently bilateral 1.
• Postoperatively, patients typically require more intensive anti-inflammatory treatment with topical steroids like prednisolone acetate 1% every 2-4 hours initially, then tapered over 4-6 weeks, along with close monitoring for complications such as elevated intraocular pressure, retinal detachment, and cystoid macular edema. The surgeon should then assess whether sufficient capsular support remains for in-the-bag intraocular lens (IOL) placement. If adequate support exists, a foldable IOL can be placed in the bag or sulcus. With insufficient support, alternative IOL options include sulcus fixation with optic capture, iris fixation, or scleral fixation. Miosis should be induced with acetylcholine or pilocarpine to prevent vitreous prolapse.

From the Research

Intraoperative Complications of Cataract Surgery - PC Rent

• Posterior capsular rent (PCR) is a potentially sight-threatening complication that can occur during cataract surgery, even in the hands of experienced surgeons 2.
• Certain types of cataracts are prone to PCR, and improper management can lead to serious complications with a higher incidence of permanent visual disability 2.
• To manage PCR, surgeons can use techniques such as suturing the haptics of a posterior chamber intraocular lens (IOL) to the sclera or iris 3.
• Flexible open-loop anterior chamber IOL implantation can be used after posterior capsule rupture and vitreous loss, with results showing that 72% of patients achieved a best-corrected visual acuity of 6/9 (20/30) 4.
• Anterior chamber and sutured posterior chamber IOLs can be used in eyes with poor capsular support, with similar outcomes and complication rates 5.
• Anterior capsule tears can occur during cataract surgery, with an incidence of 0.79%, and can extend to the posterior capsule, requiring anterior vitrectomy and implantation of a posterior chamber IOL 6.

Management of PC Rent

• Identifying patients at higher risk of PCR and taking measures to manage them can help minimize complications 2.
• Intraoperative management of PCR involves techniques such as anterior vitrectomy and implantation of a posterior chamber IOL 2, 4, 6.
• Suturing the haptics of a posterior chamber IOL to the sclera or iris can help secure the lens in place 3.
• Implantation of a flexible open-loop anterior chamber IOL can be used as a primary lens in cases of posterior capsule complications 4.

Outcomes of PC Rent

• With proper management, the outcome of PCR can be similar to that of an uncomplicated case 2.
• Best-corrected visual acuity can be achieved in a significant number of patients, with 72% achieving 6/9 (20/30) in one study 4.
• Complication rates, such as elevated intraocular pressure and cystoid macular edema, can be similar between different types of IOLs used in eyes with poor capsular support 5.