Jason Jones, MD
Posterior capsule rupture (PCR) is a significant intraoperative complication of cataract surgery that is estimated to occur in approximately 1% to 2% of phacoemulsification cases.1 Even a very experienced surgeon with the best technique cannot always eliminate this unanticipated complication. Management of PCR, and in particular the selection, placement, and implantation technique of an intraocular lens (IOL) in cases of incomplete or insufficient capsule support, is an important and controversial topic. Various options, including an anterior chamber IOL (ACIOL), iris suture-fixated posterior chamber IOL (PCIOL), or scleral-fixated PCIOL are acceptable. A report by the American Academy of Ophthalmology concluded that there was insufficient evidence to demonstrate the superiority of one lens type or fixation site.2 Many alternative fixation techniques have been described and compared in the literature.3–6 One implantation technique, optic capture, was first described by Neuhann as a capsulorrhexis-fixated lens.7 With this technique, a 3-piece PCIOL is placed in the ciliary sulcus and then the optic is depressed posteriorly beneath the rim of the anterior continuous curvilinear capsulorrhexis (CCC) to achieve IOL stability. This IOL fixation technique following PCR has also been called anterior capsular support for PCIOL,8 anterior capsule rhexis fixation,9 or rhexis IOL fixation.10 This conventional 3-piece PCIOL optic capture technique (haptics in the sulcus, optic in the bag) is most often referred to as optic capture or posterior optic capture in the literature.11
In contrast, reverse optic capture (anterior optic capture or reverse rhexis fixation) is achieved by capture of the optic anteriorly through the anterior capsulorrhexis opening (haptics in the bag, optic anterior to rhexis) or both anterior and posterior capsulorrhexes (haptics behind the posterior capsule, optic anterior to rhexis). Gimbel and DeBroff proposed this technique of reverse rhexis fixation for cases where a posterior capsule tear either occurs after the IOL is placed in the bag or is noticed or extends following IOL placement.10 Jones et al evaluated outcomes and the merit of reverse optic capture of a single-piece acrylic AcrySof (Alcon Laboratories, Inc) PCIOL in 16 patients in whom PCR occurred during cataract surgery.12 Pushker et al reported a case in which a 3-piece AcrySof IOL was implanted with anterior optic capture in a patient with isolated traumatic PCR.13
Reverse optic capture has been used for other purposes in cataract patients. Akaishi et al presented the results of capturing the IOL optic through anterior CCC as a subsequent surgical method to correct residual hyperopia following multifocal IOL implantation.14 Masket and Fram reported 3 cases using reverse optic capture to successfully treat patients experiencing temporal negative dysphotopsia.15 Gimbel and Amritanand reported a case using reverse optic capture for stabilizing a rotationally unstable single-piece acrylic toric IOL.16
We prefer the term reverse optic capture because this not only accurately describes the procedure but also avoids confusion with conventional optic capture in the literature.
Topical plus intracameral anesthesia were used. A paracentesis and a 2.7-mm clear corneal incision were created. The anterior chamber was inflated with a dispersive ophthalmic viscosurgical device (OVD), and a round, well-centered CCC was fashioned with a pair of Utrata forceps. The CCC was sized about 5.0 to 5.5 mm to ensure complete overlap of the intended in-the-bag IOL optic. This was followed by hydrodissection and then nuclear removal using a phacoemulsification handpiece and second instrument. Residual cortex was removed with the irrigation/aspiration handpiece. A cohesive OVD was used for capsular bag expansion, and the IOL was implanted in the capsular bag with an injector system.
In cases where the PCR was recognized following IOL implantation into the bag, reverse optic capture was achieved by positioning a spatula or a Kuglen hook through the main incision reaching underneath the optic and vaulting the entire optic forward through the opening of intact CCC. The optic was therefore entrapped centrally in front of the bag while the haptics remained in the capsular bag. Care was taken to ensure that the optic was completely and not partially captured by inspecting the shape of the CCC. OVD was aspirated slowly from the anterior chamber using irrigation/aspiration or automated vitrector. OVD behind the IOL was left in place. The anterior chamber was restored with saline solution, and the incisions were hydrated and tested for leakage. In cases where the PCR was recognized prior to implantation of the IOL, the spatula was placed through the paracentesis and underneath the IOL as it was being injected to avoid descent into the vitreous. Either a syringe-style plunger injector or assistant activation of a screw mechanism of a traditional injector aided in this process. Filling the anterior segment with OVD temporarily suspended the IOL as the haptics slowly opened prior to entrapping the optic as described previously.
At the end of the operation, a drop of antibiotic was placed on the surface of the eye. In cases considered to be high risk for ocular hypertension, Diamox SR (acetazolamide) 500 mg can be administered after surgery. Further postoperative treatment included topical antibiotic for 1 week, steroid for 4 weeks, and nonsteroidal anti-inflammatory drops for 4 to 8 weeks.
Reverse Optic Capture Outcomes
Our retrospective study is one of the few to report reverse optic capture outcomes in the literature.12 A total of 16 eyes with reverse optic capture were compared to the control group of 12 fellow eyes that had capsular bag-IOL implantation without optic capture during the same period.12 Single-piece acrylic foldable IOLs (AcrySof IOLs) were used in this study. The IOL model has an aspheric 6.0-mm diameter optic design with a square edge, modified-L type haptic with zero-degree angulation and an overall length of 13.0 mm.
The final mean logMAR uncorrected visual acuity (UCVA) was similar in these 2 groups (P = .780). At last follow-up, 50% of eyes in each group had UCVA 20/25 or better; 81% of eyes in the reverse optic capture group and 75% in the control group had UCVA 20/40 or better.
The improvement of best corrected visual acuity (BCVA) from pre- to postoperative was significant in each group, which corresponds to 94% of eyes in the reverse optic capture group and 92% of eyes in the control group achieving a postoperative visual acuity of 20/25 or better. No eye lost BCVA in either group. There was no significant difference in BCVA at last follow-up between 2 groups (P = .717).
In the reverse optic capture group, the mean spherical equivalent (SE) decreased from 0.66 ± 2.00 diopters (D) preoperatively to -0.53 D ± 0.73 D at 1 month and -0.39 D ± 0.77 D at last follow-up. In the control group, the mean SE was 0.29 D ± 3.00 D before surgery and -0.23 D ± 0.31 D at 1 month and -0.18 D ± 0.28 D at last visit. There was no significant difference in the mean SE preoperatively (P = .690), at 1 month (P = .191), and the last follow-up visit (P = .369) between the reverse optic capture and control groups. The mean SE remained stable between 1 month and the last visit in both groups (P = .252 in reverse optic capture group and P = .210 in control, paired t test). At last visit, 88% of eyes in the reverse optic capture group and 100% of eyes in the control group achieved refraction within ±1.00 D of emmetropia.
The difference between the target refraction and predicted refractive error was not significant in the reverse optic capture group (P = .326) or the control group (P = .373). No difference of the target refraction (P = .859) and the predicted refractive error (P = .112) occurred between these 2 groups. However, there was a slight myopic shift in reverse optic capture group from predicted outcome (-0.32 D). At last follow-up, 63% of eyes in the reverse optic capture group and 100% in the control group achieved predicted refractive error within ±0.50 D, and 94% of eyes in the reverse optic capture group were within ±1.00 D from the target refraction.
Complications and Visual Quality
Reverse optic capture was performed uneventfully on all eyes in the series. No complications occurred during the reverse optic capture procedure. At the same-day or 1-day postoperative examination, no eyes in either group had hyphema or severe anterior chamber reaction (anterior chamber cells were trace or ≤ 1+ in all eyes). The intraocular pressure (IOP) was higher than 25 mm Hg in 5 eyes (31%, range: 25 to 34 mm Hg) in the study group and 1 eye (8%) in the control group. These patients were treated with oral carbonic anhydrase inhibitors, topical aqueous suppressants, or both. IOP was quickly controlled and became normal (< 21 mm Hg) without medication in all patients at the 1-week follow-up. There were no vision-threatening postoperative complications (eg, cystoid macular edema, retinal detachment, persistent uveitis), and no IOL decentration, tilt, or dislocation occurred at any time during the follow-up in both groups.
By the last postoperative visit, 3 eyes (18.8%) in the study group and 1 eye (8.3%) in the control group had undergone Nd:YAG laser posterior capsulotomy. There were no complications associated with Nd:YAG capsulotomy. All patients had a clear cornea and a clear visual axis at the last follow-up.
The patient questionnaire was received from 12 patients; all but 1 reported being satisfied with the procedure (92%). Nine patients (75%) did not need glasses for distance. One patient noted mild halos at night. No other complaints were reported.
Efficacy was evaluated by postoperative UCVA. The logMAR UCVA at last visit was similar in the reverse optic capture and control groups (P = .780). Fifty percent of eyes in each group had a UCVA of 20/25 or better, and 81% of eyes in the reverse optic capture group and 75% of control eyes had a UCVA of 20/40 or better, which corresponds to 75% of patients not wearing glasses for distance in our series. Almost all patients (92%) were satisfied with their outcomes, and this may indicate that patients not achieving a UCVA of 20/40 are still pleased with the visual improvement after surgery.
With regard to safety, no eye lost more than one line of BCVA in either group. There were no significant differences in pre- and postoperative logMAR BCVA between 2 groups. At the final visit, 94% of eyes in the reverse optic capture group and 92% in the control group had a BCVA of 20/25 or better. If eyes with coexisting ocular pathology (age-related macular degeneration in one eye of each group) are excluded, 100% of eyes in each group achieved a final BCVA of 20/25 or better. The final visual acuity results in the reverse optic capture eyes in this study compared favorably with those in other studies of phacoemulsification in the presence of PCR, with a range of 68% to 89% of patients achieving BCVA 20/40 or better.17–19 However, caution should be exercised when comparing outcomes from separate studies because of different inclusion criteria, sample size, and follow-up period.
Additional important safety issues are postoperative complications and need for further surgery. The rates of vision-threatening complications such as endophthalmitis, cystoid macular edema, and retinal detachment are higher after scleral-fixated PCIOL insertion.20 In eyes with iris suture-fixated IOLs, special concerns relate to the close proximity of the IOL to the posterior iris surface, which can result in iris chafing, pigment dispersion, chronic inflammation, and peripheral anterior synechiae.3 Currently used open-loop ACIOLs have improved visual outcomes and reduced complication rates compared to earlier-generation ACIOLs. However, the larger incision and greater potential for endothelial cell loss postoperatively are still concerns.21 A large population-based analysis found that the endophthalmitis rate was 10-fold higher in those eyes with capsule rupture compared with those without.22 In our series, there were no vision-threatening complications.
IOL stability is a major concern in patients with PCR. IOL dislocation and instability are the most common complications after scleral or iris suture fixation of IOLs, mainly due to suture degradation or breakage as well as slippage of the haptics from the suture.23 Single-piece foldable acrylic IOLs should not be placed in the ciliary sulcus because of potential complications such as pigment dispersion, secondary IOP elevation, recurrent iridocyclitis, and IOL decentration requiring surgical intervention.24–26 In this study, the postoperative slit-lamp examination did not show IOL decentration, tilting, or dislocation in any of the reverse optic capture eyes. Also, no additional surgery was performed in our series beside YAG posterior capsulotomy.
Transient ocular hypertension was common in reverse optic capture eyes (31%) compared to the control group (8.3%). The IOP was readily reduced with hypotensive medications and became normal in all patients at 1-week follow-up. The potential causes of early postoperative ocular hypertension include retained OVD, residual lens debris, and increased inflammatory mediators caused by extra surgical manipulation and prolonged procedure duration.27 The early anterior chamber reaction was similar in the 2 groups. Therefore, the greater tendency to increased IOP in the reverse optic capture eyes was most likely a result of retained OVD. In our series, the same OVD was used in both groups. The only difference was that OVD was removed from the anterior chamber as well as behind the IOL in the control eyes but only anterior to the IOL in the reverse optic capture eyes, which could result in an IOP elevation due to retained OVD. The use of shorter chain dispersive OVD and the use of additional topical aqueous suppressants in combination with oral acetazolamide (Diamox) may be effective to prevent IOP elevation in reverse optic capture eyes.
The axial IOL position is a major parameter influencing postoperative refractive outcome after cataract surgery.28 A significant myopic refraction (-0.8 D) was observed in eyes in which the entire PCIOL was placed in the sulcus in 2 separate studies with different lens designs.29,30 The mean difference of 0.44 D between the sulcus IOL used and the in-the-bag IOL that would provide the same refraction was reported in a study of sulcus implantation in patients with PCR.31 A 0.5 D to 1.0 D reduction in IOL power has been recommended to compensate for the axial change in the position of the optic from bag to sulcus.29 With conventional optic capture (haptics in the sulcus, optic in the bag), the same IOL power calculated for bag fixation can be used without adjustment since minimal change of the optic axial position occurs. In this study, the reverse optic capture eyes had a more myopic mean SE refraction than control eyes with uneventful surgery. A slight myopic-predicted refractive error (-0.32 D) was observed in the reverse optic capture eyes. This myopic shift was less than that in a study by Akaishi et al, in which the reverse optic capture technique was performed in a subsequent surgery to correct the residual hyperopia after previous cataract surgery with multifocal IOL implantation.14 The mean difference in refraction from before to after reverse optic capture was -0.81 D in their study. The discrepancy between these 2 study outcomes may be due to differences in the IOLs used. Our study used the single-piece AcrySof IOL with zero-degree haptic angulation, whereas the other study used the 3-piece silicone multifocal with 6 degrees of haptic angulation IOL (Tecnis ZM900). In addition, reverse optic capture was performed following PCR in all of our cases but as a secondary surgery without PCR in their study and the follow-up periods were different (mean 19 months in our study compared to 6.5 months in theirs).
Contact between the IOL and the iris is one of the major concerns when IOLs are not placed completely in the bag. This concern applies to the reverse optic capture technique where the CCC-captured optic is located within the sulcus and therefore closer to the iris. Although this could increase the risk of iris chafing and pigment dispersion as noted in typical sulcus fixation of single-piece acrylic IOLs, no such complications occurred in our series. This lack of iris chafing may occur because the optic position does not seem to be as anterior with reverse optic capture as it is in conventional sulcus fixation. The haptics are also sealed behind the anterior capsule, and reverse optic capture fixation prevents any movement of the IOL within even the largest anterior segments. The minimal amount of induced myopia from the reverse optic capture IOL position supports our observation that the IOL optic is located more posterior than with total sulcus fixation, and the zero-degree angulation of the haptics may further contribute to the apparent reduced axial position change. It was also reassuring that no cases of uveitis-glaucoma-hyphema syndrome were noted in our series.
The postoperative refraction was stable between 1 month and the final follow-up visit, and the deviation of the postoperative refraction from the targeted refraction was small. The refractive stability is a result of secure positioning, centration, and minimal axial shift of the captured IOL optic, which are all advantages of reverse optic capture with a single-piece acrylic foldable IOL. We generally do not recommend IOL power adjustment for most cases of reverse optic capture. However, in select cases where emmetropia is crucial, such as multifocal IOL implantation, a slight power adjustment could be entertained. The surgeon should consider the power of the original in-the-bag lens and the refractive target of the original lens power; if the original lens for in-the-bag is a lower power or the target is close to plano or slightly hyperopic, then no adjustment is reasonable. Additionally, if the original lens power is used for reverse optic capture, the result is more likely to be slightly myopic, which is generally well tolerated and is also more amenable to corneal refractive surgical enhancement compared to a hyperopic error.
We believe that reverse optic capture with a single-piece acrylic PCIOL is a viable and safe option when the posterior capsule is torn. When the IOL has already been placed into the capsular bag and then a PCR is recognized, the single-piece acrylic IOL should not be placed in the sulcus. Reverse optic capture becomes a reasonable option compared to exchanging the single-piece acrylic IOL for a suitable 3-piece IOL in the sulcus.24 For cases where the PCR occurs prior to IOL placement, a surgeon may choose to gently place a single-piece acrylic IOL with reverse optic capture as an alternative to the more standard placement of a 3-piece IOL in the sulcus.
Reverse optic capture may have some benefits over a sulcus 3-piece IOL implantation with optic capture. The incision size need not be enlarged, which may reduce postoperative astigmatism change and ensure a routine wound closure. The low profile of the optic and haptics during injection provides greater control and reduced manipulation. Finally, reverse optic capture using the single-piece acrylic IOL platform can preserve certain lens-based technologies that can benefit specific patients, such as presbyopia correction, asphericity, and toricity. In the end, the experience and judgment of the surgeon will determine whether reverse optic capture with a single-piece lens is selected over alternate choices.
Whether to implant an IOL and at what location depends on multiple factors. These include the size, location, and timing of the PCR; the visibility of the remaining capsular margins; the extent of zonular support; available facilities; and the surgeon’s experience and preferences. Vajpayee et al recommended that if the PCR is small (< 6 mm) or if the margins are visible with no vitreous prolapsed, a PCIOL could be inserted in the capsular bag; otherwise, an ACIOL or sutured PCIOL should be used.32 Hao et al recommended PCIOL implantation in eyes with peripheral PCRs of less than 120 degrees or with a central PCR less than 4.0 mm in diameter.33 The reverse optic capture technique was originally proposed by Gimbel and DeBroff for eyes where the PCR occurred after the IOL is implanted in the bag or is noticed after IOL placement.10 In our cases, 46% had large PCR 6 mm or greater, and among them, half had PCR 180 degrees or greater; 69% of cases were peripheral and in 46% of eyes, the edge of the PCR was not visualized. In 85% of eyes, PCR occurred before IOL implantation. Therefore, the reverse optic capture technique provides an option of implantation of a PCIOL in a variety of PCR conditions and is an optimal method for the implantation of a single-piece acrylic IOL in patients with posterior capsule compromise.
Reverse optic capture provides an alternative method in dealing with posterior polar cataract (PPC) eyes complicated with PCR. PPC presents a special challenge to the surgeon due to adhesion of the lens opacity to the posterior capsule and the extreme thinness and fragility of the posterior capsule. The incidence of PCR has been reported to be 26% to 36%,34,35 and PCR can occur at any stage of surgery. Various approaches have been suggested to obtain stable IOL implantation in cases of PPC with PCR. A technique using an oval capsulorrhexis with optic capture was described for PPC patients with full-length preexisting PCR.5 The authors suggested that the smaller axis of the oval capsulorrhexis facilitates optic capture of a sulcus-fixated 3-piece PCIOL. In our series, reverse optic capture was successfully performed in a 68-year-old patient with PPC where a total PCR occurred before IOL implantation. At last follow-up, the UCVA was 20/20 and manifest refraction was -0.25 sph. The single-piece IOL was well centered with both haptics posterior to the anterior capsule and the optic in the sulcus. The patient was very satisfied with the results.
This reverse optic capture technique requires skillfully manipulating an instrument posterior to the IOL to pull the optic forward to achieve capture. Care must be taken not to lose control of the IOL into the vitreous space. There are several key points for successfully achieving reverse optic capture. The CCC diameter is important because the anterior capsule opening must be smaller than the size of the planned optic of a single-piece IOL. The optic cannot be safely captured through the CCC if the diameter is too small or too large. In our series, all CCCs were 5.0 to 5.5 mm in diameter. In addition to being well centered, the CCC rim should be intact for the full 360 degrees to ensure stable IOL centration. Zonular support is an important consideration when contemplating reverse optic capture, and if there is enough zonular damage to require a capsular tension ring, then a different IOL fixation technique must be used. Finally, all vitreous must be removed from the plane of the anterior capsule to avoid vitreous entanglement and potential complications such as cystoid macular edema, inflammation, and retinal detachment.
Reverse optic capture is a safe and effective method of PCIOL implantation in eyes with PCR. In our series, the rates of postoperative complications were low, and there were no vision-threatening complications throughout the follow-up period. The main advantage of reverse optic capture is that the surgeon can use a single-piece acrylic lens, which is the most commonly used IOL design and is therefore readily available in most operating rooms today. The technique of reverse optic capture is relatively less complex and less time-consuming than conversion to a 3-piece IOL in the sulcus in case of PCR during IOL placement in the bag. The disadvantage is that reverse optic capture cannot be achieved in every patient, such as patients with irregular, decentered, or large CCC or with zonular damage requiring a capsular tension ring. Future studies with larger numbers and longer follow-up are necessary to assess the frequency of late-onset complications, to monitor the long-term IOL stability, and to merit wider adoption of reverse optic capture.
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31. Spokes DM, Norris JH, Ball JL. Refinement of lens power selection for sulcus placement of intraocular lens. J Cataract Refract Surg. 2010;36:1436-1437.
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34. Osher RH, Yu BC, Koch DD. Posterior polar cataracts: a predisposition to intraoperative posterior capsular rupture. J Cataract Refract Surg. 1990;16:157-162.
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