From the Guidelines
An anterior capsular tear during cataract surgery requires immediate management to prevent extension to the posterior capsule, and the surgeon should stop phacoemulsification and inject a cohesive viscoelastic to stabilize the anterior chamber, as recommended by the most recent guidelines 1. When this complication occurs, the surgeon should redirect the tear using a cystotome or forceps to create a continuous curvilinear capsulorhexis in a different direction. If the tear extends to the equator, hydrodissection should be performed gently with minimal fluid and away from the tear. During phacoemulsification, lower vacuum settings (250-300 mmHg), reduced aspiration flow rates (20-25 cc/min), and lower bottle height should be used to minimize stress on the capsule. The surgeon should avoid engaging the nucleus near the tear and consider a divide-and-conquer technique rather than chopping methods. For lens implantation, a three-piece IOL is preferred if there's concern about posterior capsule integrity, with placement in the bag if possible or sulcus if necessary, as supported by recent studies 1. These adjustments are crucial because anterior capsular tears can lead to posterior capsule rupture, vitreous loss, and dropped nuclear fragments if not properly managed, significantly affecting visual outcomes. Key considerations in managing anterior capsular tears include:
- Stabilizing the anterior chamber with viscoelastic
- Redirecting the tear to prevent further complications
- Adjusting phacoemulsification settings to minimize capsule stress
- Selecting an appropriate IOL and placement technique
- Providing thorough preoperative evaluation and counseling, as outlined in recent guidelines 1. By following these recommendations, surgeons can minimize the risks associated with anterior capsular tears and optimize patient outcomes.
From the Research
Intraoperative Complications of Cataract Surgery: Anterior Capsular Tear
- Anterior capsular tears can occur at any stage of cataract surgery, and proper management is crucial to prevent extension into the posterior capsule and compromise the structural integrity of the capsular bag 2.
- The incidence of anterior capsule tears has been reported to be around 0.79% in a retrospective study of 2646 cases 3.
- Femtosecond laser-assisted cataract surgery can create a more consistent capsulorhexis, but may also present new challenges such as irregularities like microadhesions and tags that can lead to anterior tears if not properly treated 2.
- New technology like the Zepto pulse precision capsulotomy may produce a smoother edge and reduce the incidence of capsular tears 2.
- In cases where an anterior capsular tear occurs, novel rescue techniques can be employed to manage the tear and prevent extension into the posterior capsule 2.
Management and Outcomes of Anterior Capsular Tears
- A study comparing outcomes of primary scleral-fixated versus primary anterior chamber intraocular lens implantation in complicated cataract surgeries found that primary anterior chamber intraocular lens implantation was associated with better postoperative visual acuity 4.
- Another study comparing primary anterior chamber versus secondary scleral-fixated intraocular lens implantation in complicated cataract surgeries found no long-term differences in visual outcomes and complication profiles between the two groups 5.
- The management of anterior capsular tears can be challenging, but is compatible with implantation of a posterior chamber intraocular lens, and satisfactory results can be achieved with proper technique and technology 3, 4.
- The presence of late complications has been associated with a worse final visual outcome, highlighting the importance of proper management and follow-up in cases of anterior capsular tears 5.