REVERSE OPTIC CAPTURE

Thomas A. Oetting, MS, MD

Reverse optic capture can be a very useful IOL fixation technique to salvage a case when the posterior capsule is damaged or can be planned to prevent posterior synechiae or temporal negative dysphotopsia. This technique, like every other primary capsule strategy for intraocular lens (IOL) fixation, was initially described by Gimbel and DeBroff,¹ and is a simple variation of traditional optic capture. The IOL haptics are kept in the typical intracapsular location (behind the anterior capsular plane), but the optic is prolapsed anteriorly and captured by the anterior capsulotomy. Jones et al coined the term reverse optic capture because this technique was the reverse of the traditional optic capture with the haptics in the sulcus and the optic captured posterior to the anterior capsule.²

Reverse Optic Capture With Posterior Capsule Damage

Reverse optic capture is most useful for the unusual but stressful situation where the surgeon has already implanted a single-piece acrylic IOL into the bag and then encounters a posterior capsule tear. The single-piece acrylic IOL has short and thick haptics that are not appropriate for sulcus placement where they can cause posterior iris chafe and uveitis-glaucomahyphema syndrome.³ Reverse optic capture can also be used with a 3-piece IOL, but most surgeons would likely instead use the very stable traditional optic capture method with the haptics in the sulcus and the optic in the bag. The reverse optic capture technique can also be used to fixate a specialized single-piece acrylic lens, such as a toric or multifocal IOL in the presence of a posterior capsule tear.² In a series of cases, Jones et al showed that the anterior displacement of the optic with reverse optic capture led to a small myopic refractive shift caused by the slight anterior change in the effective lens position.² The reverse optic capture IOL position was stable over time in Jones and colleagues’ series.² If the IOL has not been placed yet when the posterior capsule has been torn, traditional optic capture with a 3-piece IOL is easier and may be a more stable configuration. However, if a single-piece acrylic IOL is already in the bag and then the posterior capsule tear is discovered, reverse optic capture is an effective strategy that avoids IOL exchange.

The size of the anterior capsule opening is critical for reverse optic capture.² If the anterior capsule diameter is too large, then the optic fixation will not be stable. If the opening is not perfectly centered but of adequate size, reverse optic capture is still possible by orienting the haptics along the axis of the portion of the opening that is most centered. A single-piece acrylic IOL optic will pass through a relatively small opening more easily before it completely unfolds, and a 6-mm optic will therefore easily pass through a 4-mm diameter capsular opening. A cut with scissors in a small or irregular capsular opening can be extended and is usually sturdy enough for optic capture.

The reverse optic capture technique starts with stabilization of the posterior capsule with anterior vitrectomy, which may be difficult around the existing IOL. I typically use preservative-free triamcinolone acetonide to better identify anterior vitreous strands prior to capture of the optic. Once the optic is captured, the anterior chamber is effectively sealed off from the posterior chamber despite the posterior capsule tear. After anterior vitrectomy, I will use a dispersive and viscous viscoelastic (eg, Viscoat; Alcon Laboratories, Inc) to seal off the posterior chamber and to create a safe vitreous-free space just posterior to the optic. Then I typically use a Kuglen hook to bring the optic forward into the reverse optic capture position (Figure 24-1). The haptics are left in the capsular bag. The anterior capsule will often take on an oval or almost square shape as it is stretched in the dimension of the haptics (Figure 24-2). If the anterior capsulotomy is too large to support the optic, then the single-piece acrylic IOL should be exchanged for a 3-piece IOL better suited for the sulcus. If the capsulotomy is only slightly too large, I will typically place a larger optic IOL (eg, Alcon MA50 with a 6.5-mm optic) using traditional optic capture. Kemp and Oetting showed that with the MA50 IOL in large eyes traditional optic capture is essential to maintaining long-term IOL centration.⁴

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