Implantation of foldable intraocular lens with anterior optic capture in isolated posterior capsule rupture

Abstract

We would like to raise several pertinent points regarding isolated posterior capsule rupture occurrence and its management described in the article by Pushker et al.1 Isolated posterior capsule rupture is a well-recognized clinical entity. In our literature review, we came across 22 cases reported prior to the authors' case.2–9 Previous authors suggest that the absence of a formed nucleus in young patients allows contrecoup forces to be transmitted through the lens substance.3 We theorize that its occurrence in young patients following blunt trauma is due to localized pressure buckling the cornea and deforming the soft nucleus (with posterior bulging against the posterior capsule). In addition, zonular tension pulls the posterior capsule centrifugally. This combination results in a blow-out rupture of the posterior capsule. We recently managed a similar case. Two months following blunt ocular trauma, a 19-year-old man had lens aspiration with implantation of an Alcon MA60BM intraocular lens (IOL) in the capsular bag. We aspirated the lens through a superior 2.75 mm clear corneal incision using automated irrigation/aspiration with an anterior chamber maintainer (ACM). With low-flow settings and the ACM, no vitreous prolapsed and anterior vitrectomy was not required. The posterior chamber IOL was placed in the capsular bag, with no optic capture, and has remained stable with over 1 year of follow-up. Even without grossly fibrotic edges, these posterior capsular defects are relatively stable and resistant to enlargement like posterior capsulorhexis. In essence, we feel that vitreous loss should be avoided with the attendant reduction in the risk for retinal detachments and cystoid macular edema. Plain capsular bag fixation is also possible in most cases and is ideal because prolapsing the optic anteriorly brings it closer to the iris and increases the risk for iris chafing and pigment dispersion. If the defect is extremely large or the edges of the posterior capsule defect are not visualized, the posterior chamber IOL haptics should be placed in the ciliary sulcus (with posterior optic capture through an intact anterior capsulorhexis). In fact, anterior optic capture was recommended by Gimbel and DeBroff10 in cases in which the posterior capsule tear occurred during or after posterior chamber IOL insertion rather than in cases with preexisting breaks. In cases of posterior capsule tear during or after posterior chamber IOL insertion, leaving the haptics in the capsular bag, rather than trying to dial them out into the sulcus, minimizes vitreous disturbance. Finally, we would like to point out that the Alcon MA30BA has polymethyl(methacrylate) haptics not polypropylene haptics as mentioned by the authors.