British J'ournal of Ophthalmology 1995; 79: 1133-1137

PERSPECTIVE

Effects of posterior capsular disruption on the outcome ofphacoemulsification surgery

M Mulhern, G Kelly, P Barry

The occurrence of a capsular rupture during phaco-emulsification is not an uncommon entity, with a reportedincidence of up to 5-5% when cases are performed byinexperienced residents,l as opposed to 0 9% when per-formed by an experienced phacosurgeon.2 Other predispos-ing factors to capsular rupture include: pseudoexfoliation,3poorly dilating pupils,4 posterior polar cataract,5 and canopener or linear capsulectomy techniques.6The management of a posterior capsule rupture is

probably the greatest challenge facing the cataractsurgeon. The removal of lens matter subsequent tocapsular disruption, the need for anterior vitrectomy, andthe optimum location for the intraocular lens (IOL), areall problems facing the surgeon intraoperatively, and thesolutions will of course be somewhat dependent on thesurgeon's experience.

Postoperatively, it is important to analyse the complica-tions ofthe surgeon's management ofthe capsular disruption.The visual outcome of these cases must also be determined.Finally, our study examined the prevalence ofbilateral capsu-lar disruption. This was calculated by considering patients inthis series who had a complicated outcome in two eyes.

Materials and methodsFrom a retrospective analysis of medical records, 43 casesof capsular disruption occurring during phacoemulsifica-tion over a 1 year period were identified. This cohort con-sisted of 39 patients, as four patients underwent bilateralcataract surgery in the study period and developed bilateralcapsular disruption. Fifteen of these cases (35%) in ourstudy group had background ocular pathology (see Table1), and in five cases it was felt that the visual outcomewould be suboptimal.

Fifty eight per cent of cases were carried out undergeneral anaesthesia, and the rest (42%), under local anaes-thesia. Local anaesthesia was administered via an infero-temporal peribulbar injection. A single dose of 5 ml of 4%Xylocaine (lignocaine) using a 1 inch 23 gauge needleusually provided sufficient akinesia, but sometimes thiswas supplemented by a second injection at the same site, if

Table 1 Background ocular pathology present in our study group

Diagnosis Number of eyes

Optic atrophy* 1Arteritic anterior ischaemic optic neuropathy* 1Primary angle closure glaucoma 2 (1 patient)Oculocutaneous albinism* 2 (1 patient)Dry macular degeneration 2Disciform macular degeneration* 1Myopia<6 Dioptres 2>6 Dioptres 1

Pseudoexfoliation 3 (2 patients)

*Pre-existing cause for suboptimal visual acuity.

necessary. After this a Honan balloon was applied for 15minutes in an effort to reduce vitreous volume byoculopression.7The surgeons performing the phacoemulsification were

all experienced in the technique. After a conjunctivalincision at the 11 o'clock position, a scleral tunnel wascreated. At 2 mm from the surgical limbus an angled cres-cent-shaped keratome (Alcon) was used to fashion a verti-cal linear incision of half scleral thickness measuring5*1 mm - the entrance to the scleral tunnel. This samekeratome was then used to create a two tiered scleraltunnel, which ended just distal to the limbal arcades (theso called 'golden line'). A paracentesis was created some-where between the 2 and 4 o'clock positions. A 3-2 mmkeratome was used to perforate into the anterior chamberfrom the scleral tunnel. Healon (53% of cases) or Viscoat(47% of cases), injected via the paracentesis was used todeepen the anterior chamber, and to stabilise the iris-lensdiaphragm. A continuous circular capsulorhexis wascreated; this was followed by hydrodelamination andhydrodissection using BSS (balanced salt solution).Phacoemulsification surgery proceeded in the usual way -that is, using a 'divide and conquer' technique8 for hardnucleii, and the 'chip and flip' technique for soft nucleii.9An OMS (Optical Micro Systems) device was used forphacoemulsification in all cases. Capsular dialysis, orrupture, was handled as discussed below. After irriga-tion/aspiration, the corneal aspect of the scleral tunnel wasexpanded to 5*1 mm with a keratome; this is routinelyfollowed by insertion of an intraocular lens (KabiPharmacia 809P). After removal of the viscoelastic, the selfsealing incision was closed by injection ofBSS through theparacentesis. The external lips of the tunnel were notroutinely sutured. Closure of the conjunctival wound wasby a single injection of BSS into the conjunctival stroma atthe wound site.

ResultsNot surprisingly, this study confirmed that capsular tearsare more common than capsular dialyses - with incidences

Table 2 The incidence ofcapsular disruption type, and the intraoperativestage at which disruption occurred

Incidnce ofcapsular Stage at which disruption Numberdisruption type (%/o) occurred of cases

Dialysis - 6 cases (14%) Nuclear phacoemulsification 3Irrigation/aspiration IIOL manipulation IOther I

Tear - 37 cases (86%) Nuclear phacoemulsification 18Irrigation/aspiration 4Capsule polish 4IOL manipulation INot documented 10

IOL=intraocular lens.

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Table 3 Intraocular lens (IOL) characteristics

Number of cases (%)

Sulcus fixated PC IOL 24 (56)Endocapsular PC IOL 11 (25)Primary procedure - AC IOL implanted 4 (9)Primary procedure - no IOL implanted 3 (7)Secondary procedure - AC IOL implanted 2 (5)AC IOL (total of primary and secondary procedures) 6 (14)

PC=posterior chamber; AC=anterior chamber.

of 37 cases (86%) and six cases (14%) respectively. Acomplete overview of the details relating to the timing andto the incidence of each type of capsular disruption(dialysis or tear) is given in Table 2. It is worthwhile, how-ever, to emphasise the point that the nuclear phacoemulsi-fication stage is the most dangerous stage of the procedure,as the highest proportion of posterior capsular tears anddialyses occur during this stage.A Sheet's glide was necessary in 9% of cases to allow

continued phacoemulsification of the nuclear fragment inthe presence of a capsular tear.

Anterior vitrectomy was necessary in 44% of cases.This was either a dry vitrectomy or a low flow bimanualvitrectomy.

In 25% of cases, endocapsular placement of an IOL waspossible, sulcus fixation was achieved in 56% of cases:Table 3 outlines the details relating to IOL location.During the initial procedure, 7% of cases did not have anIOL inserted. The figure for anterior chamber lenses (ACIOL), represents the total of primary and secondary ACIOL implantations. All secondary IOL insertions carriedout in this series consisted of insertion of an AC IOL.

In 56% of cases it was felt necessary to suture the scleraltunnel. This was always the case if an anterior vitrectomywas performed; however, normally in uncomplicatedsurgery no sutures are used.

Raised intraocular pressure in the immediate postopera-tive period occurred in 39% of cases; there was no casewhich resulted in chronic glaucoma.

Complications relating to lenticular debris arose in 13cases (30%) (see Table 4), 10 cases had small amounts ofresidual soft lens matter in the anterior chamber, whicheither resorbed or became quiescent; two cases had softlens matter in the vitreous, and one case had prolapse ofthe nucleus into the vitreous cavity. Associated with thislatter case was concomitant vitreous presentation in theanterior chamber, the surgeon performed a dry anteriorvitrectomy, sufficient to remove all vitreous anterior tothe iris-lens/capsular diaphragm. This was followed by alow flow irrigation/aspiration of the residual intercapsularlens material. There remained, however, insufficient cap-sular support for sulcus or endocapsular fixation of anIOL. The scleral tunnel was then closed with 10/0 nylon.The surgeon's intention was to proceed the following dayto do a pars plana vitrectomy and fragmatome removal ofthe nuclear fragment, combined with insertion of an ACIOL. The patient was, however, reluctant to have furthersurgery and so our only course was to continue to moni-tor the patient. Apart from raised intraocular pressure onthe first postoperative day, no further problems arose. Tothis day the eye remains quiet, with no evidence of retinal

Table 4 Postoperative side effects

Type Number ofcases (%)

Raised intraocular pressure 17 (39)Residual soft lens matter 10 (23)Soft lens matter in the vitreous 2 (5)Retinal detachment 2 (5)'Dropped' nucleus 1 (2)Horseshoe tear 1 (2)

Table S Visual acuity at 9 months after capsular disruption

Number of cases (%)

Hand movements 1 (2)6/24-6/60 8 (19)6/12-6/18 8 (19)6/9 11 (25)6/6 or better 15 (35)

breaks, glaucoma, or cystoid macular oedema. Correctedby a contact lens, the visual acuity is 6/9.

Retinal complications occurred in three cases (7%) -there were two eyes with retinal detachment, and one eyewith a horseshoe tear. The former were treated by threeport pars plana vitrectomy and scleral buckling (6/12 and6/18 were the respective visual outcomes) and the latterwith focal argon photocoagulation.

Table 5 details the range of visual acuities obtained. Inour series 60% of cases associated with posterior capsulardisruption achieved a visual acuity of 6/9 or better, and79% of cases obtained a final visual acuity of 6/18 orbetter.The outcome of the fellow eye with regard to capsular

disruption during phacoemulsification was examined.Forty per cent of patients in our study had an unoperatedfellow eye, while 60% had bilateral phacoemulsificationsurgery (although not necessarily in the study period). Ofthis 60%, 65% had uncomplicated surgery, but 35% hadcapsular disruption (either a tear or dialysis).

DiscussionCapsular disruption during cataract surgery has become aproblem since IOL insertion has evolved to become theideal correction of aphakia. Various groups have looked atIOL insertion after extracapsular surgery complicated bycapsular disruption, be it with an AC IOL,1013 or with aposterior chamber (PC) IOL.14-16 There are, however, fewreports2 17 in the literature on the long term outcome andcriteria for intraocular lens implantation in phacoemulsifi-cation surgery complicated by capsular disruption. Ouranalysis of 43 cases of capsular disruption (either from acapsular tear or dialysis) will highlight the contributingfactors to capsular disruption, management ofthe vitreous,criteria for IOL placement and discuss the postoperativecomplications which can ensue.Most surprisingly our study showed that general anaes-

thesia seems to be an aggravating factor for capsular dis-ruption. Perhaps the higher incidence of general versuslocal anaesthesia (58% and 42% respectively) in this serieswas related to attempts to (1) optimise patient coopera-tion, and (2) minimise the positive vitreous pressureseffects seen with peribulbar anaesthesia. Although casesconsidered difficult - for example, pseudoexfoliation ortraumatic cataract, might have undergone general anaes-thesia from the surgeon's preference, we feel patient pref-erence was overall a more likely explanation for the higherincidence of general anaesthesia, as peribulbar anaesthesiais the norm in our unit for phacoemulsification surgery.The prevalence of general versus local anaesthesia as acontributing factor in capsular disruption associated withphacoemulsification is not quantified by other authors. InClaoue and Steele's series,16 which consisted primarily ofextracapsular surgical cases associated with vitreous loss,general anaesthesia was found to be more important as arisk factor (88%) than in our series. However, the authorsdid not comment on this. All things considered, it is ouropinion that general anaesthesia is not an aggravatingfactor for capsular disruption, and the higher percentage ofcases performed under general anaesthesia in this series isrelated to (1) the surgeon's concern about the complexity

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Table 6 Overview of the cases in which zonular dialysis occurred

IOL status after Anterior Eventual visual acuity SecondaryCase Dialysis Background primary procedure vitrectomy (after lst or 2nd procedure) procedure/type1 >6 clock hours Oculocutaneous albinism Aphakic No 6/36 Yes/AC IOL2 Some nasal and temporal zonular loss Oculocutaneous albinism Endocapsular Dry 6/18 No3 5-7 o'clock Myopia (<6 dioptres) AC IOL Low flow 6/24 No4 Inferior - Sulcus No 6/12 No5 3600 Pseudoexfoliation AC IOL No 6/6 No6 3600 Pseudoexfoliation Aphakic Dry 6/12 Yes/AC IOL

AC IOL=anterior chamber intraocular lens.

of a particular case, and (2) patient specific factors - forexample, nervousness, tremor, etc.Our study showed capsular tears to be more common

(86% of cases) than dialyses (14% of cases). Osher andCionni2 and Gimbel'7 did not consider the outcome intheir series of cases in which dialysis was the aetiology ofthe capsular disruption. Table 6 gives an overview of eachcase in which capsular dialysis was encountered. One indi-vidual with oculocutaneous albinism had bilateral dialysisduring phacoemulsification. The association of zonulardialysis during phacoemulsification with albinism has notbeen previously noted in the literature. The reason thatdialysis should have occurred in this patient is not appar-ent, as no preoperative phacodonesis was noted and therewas no previous history of trauma. In cases 5 and 6 bothpatients (with pseudoexfoliation) had complete disinser-tion of the capsular bag. Of note (see Table 6), was thesuboptimal IOL location in cases of dialysis, with only twocases achieving a posterior chamber fixated IOL. On con-sideration of the group (with dialysis) as a whole, the poorvisual outcome is quite apparent, only one individual(17%) achieving 6/9 or better visual acuity. This contrastsstrongly with the fact that 70% of those getting a capsulartear had a visual acuity of 6/9 or better.The ideal location for the IOL when faced with zonular

dialysis is controversial. Endocapsular fixation is felt bysome authors18 19 to be safer, as support for the IOL is notsought directly from the zonules, and migration of the IOLis less likely, as the IOL is secured in the capsularbag. Ciliary sulcus implantation is advocated in severalarticles,4 15 20 particularly if the dialysis is less than 6 clockhours in extent. The ideal IOL for endocapsular fixationwhen dialysis has occurred, is one with a large optic and Cloops. The IOL should be inserted by pressure on thesuperior haptic rather than by dialling. The large optic willlessen the risk of glare should decentration occur, whilethe C-shaped haptics will more uniformly distributepressure over the zonular-capsular interface than J-shapedhaptics.

Concerning the stage of surgery, and the relative hazardof capsular disruption, our series suggests that nuclearphacoemulsification is the stage most likely to be associ-ated with dialyses or posterior capsular tears; 50% ofdialyses and 49% of tears occurred in this stage. Thisfigure corresponds with that of Osher and Cionni's series,2which also had nuclear phacoemulsification as the stagemost commonly associated with capsular tears. Gimbel inhis series,17 however, had the irrigation/aspiration stage asthe most hazardous stage, followed by the nuclearphacoemulsification stage. Capsular tears during nuclearphacoemulsification may be the result of sculpting toodeeply, or to the creation of tears by the sharp edges ofhard nuclear segments formed during the nucleofractistechnique. Table 2 highlights the incidence of capsular dis-ruption occurring during other stages of surgery.

In the event of a tear occurring while nuclear materialremains, the residual nucleus can be more easily removedby phacoemulsification if a Sheet's glide is placed betweenthe nucleus and the underlying cushion of cortex in a

viscoelastic medium. The glide also prevents furthernuclear material from reaching the vitreous, and to someextent may tamponade the vitreous. When the Sheet'sglide is in place, irrigation is minimised to prevent hydra-tion of the vitreous. Although not previously described inthe literature, a Sheet's glide is considered to be a usefuladjunct by the authors when faced with residual nuclearmaterial and a capsular tear; it was used in 9% of the casesin our series.

Anterior vitrectomy was carried out in 44% of our cases.Vitrectomy was not deemed necessary if the anteriorhyaloid face was intact behind the tear or dialysis. Ifvitreous presented anterior to the capsular disruption, ananterior vitrectomy was carried out, either a low flowbimanual type or a dry vitrectomy with viscoelastic - thatis, all efforts were made to prevent vitreous hydrationand thus further prolapse. Subsequent to the vitrectomy,residual lens matter can be removed by phacoemulsifica-tion over a Sheet's glide if the material is nuclear, or by lowflow irrigation/aspiration if cortical lens matter remains.The goals are to minimise vitreous hydration and anterior-posterior displacement of the zonular-capsular diaphragm(both of which can precipitate further vitreous prolapse);minimal instrumentation and constancy of the anteriorchamber depth help to achieve the latter goal.

Probably one of the most difficult decisions to makewhen capsular disruption occurs is whether or not toimplant an IOL. In our series (see Table 3), three cases didnot receive an IOL during the primary procedure; of these,two cases had a capsular dialysis. In the first (see case 1,Table 6) there was insufficient zonular support for a PCIOL; in the second (see case 6, Table 6) the capsular bagwas totally aspirated, this latter patient had pseudoexfolia-tion. Both these cases subsequently had an AC IOLimplanted as a secondary procedure. The third case, whichresulted in aphakia, was a patient with a posterior capsulartear associated with migration of the nucleus into thevitreous cavity. This case of the 'dropped' nucleus was theonly case in our series which ended up as being aphakic.Notwithstanding the patient's reluctance, our intentionhad been to combine insertion of a flexible open loop ACIOL with pars plana vitrectomy and fragmatome removalof the nuclear fragment. As already stated, this patient'svisual acuity is 6/9, but in the long term lens inducedinflammation, secondary glaucoma, and cystoid macularoedema may occur. Two interesting questions arise fromthis case: (1) what course should the phacosurgeon under-take when faced with a 'dropped' nucleus, and (2) what isthe usefulness or validity of using a scleral or iris suturedPC IOL, as opposed to an AC IOL, when insufficientcapsular support exists for the more traditional methodsof PC IOL fixation? The former question is important,especially given the increased incidence of posteriorly dis-located lens fragments since the advent of phacoemulsifi-cation.21 22 A review of the current literature23 24 wouldsuggest quite strongly that no attempts should be made bythe phacosurgeons to retrieve a lens fragment from thevitreous cavity using 'scoops, cryoprobes, saline streams',viscoelastics, or a phacoemulsifier as these are associated

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with a high rate of retinal tears. It is, however, important todo an anterior cortical clean up and an anterior vitrectomyif vitreous prolapse occurs. Concerning IOL insertion, thisis feasible unless the dislocated lens fragment is particu-larly dense (that is fragmatome removal would then beimpossible) thus making removal of the lens material viathe limbus a necessity. Postoperatively, topical and evensystemic steroids may be required to dampen the inflam-matory response. Prompt referral to a vitreoretinal surgeonis of paramount importance. The majority of authors23 25would suggest early removal of the nuclear fragment with acombined vitrectomy/fragmatome approach as being thebest course, citing reduced rates of corneal decompensa-tion, cystoid macular oedema, and secondary glaucoma.Interestingly, most authors2' 24 25 do recognise the fact thatnuclear lens material in the vitreous (particularly if small insize) may remain inert with retention of good visual acuity.The study of Gilland et al,21 however, examined the out-come of conservative management versus surgical removalof the lens fragment, and this study suggests that the longterm visual acuity was better and the incidence of compli-cations less in the operated group. As to the second issueraised, we feel that to some extent this debate is muchmore applicable to cases where a corneal graft is in situ(or where very severe endothelial disease is present), andinadequate capsular support exists for capsule supportedfixation. For these latter cases, the study by Schein et al26would suggest that insertion ofan iris sutured PC IOL maybe the best option, but as stated in a recent article byOlson,27 even for cases associated with penetratingkeratoplasty, no clear guidelines regarding the ideal IOLtype or location exist and long term data, particularlyimportant in these cases, are not available. We are of theopinion, therefore, that for eyes which have inadequatecapsular support for a PC IOL (after phacoemulsification)AC IOL insertion is a very reasonable means to correctaphakia.Four cases in our series had a primary insertion of an AC

IOL when insufficient capsular or zonular supportremained for fixation of a PC IOL. The decision to implantin the sulcus, or in the bag, is governed by several factors;the disruption type (tear or dialysis) and the extent of thedialysis, or extent of the tear. As has been mentionedabove, the ideal location for an IOL when faced withdialysis is endocapsular. If a posterior capsular tear is smallor circular endocapsular fixation is possible, but ifadequate zonular support is present, ciliary sulcus fixationremains an option, even if the tear is too large to allowendocapsular placement. One must still, however, balancethe advantages of sulcus fixation with the threat of poste-rior migration or decentration of the IOL. In our seriesanterior chamber fixation was avoided if possible, based onour own and others'"0 2829 dissatisfaction with AC IOLsequelae.

Fifty six per cent of cases had 10/0 nylon sutures used toclose the section site. This was, of course, mandatory whenan AC IOL was implanted. All cases in which an anteriorvitrectomy was warranted had the scleral tunnel closedwith 10/0 nylon. This was felt to be advantageous given therisk of a high postoperative intraocular pressure and therisk of vitreous wick syndrome.

Table 4 lists the postoperative side effects seen in thisseries. The raised intraocular pressure on the first post-operative day was felt to be the result of several factors: (1)increased instrumentation; (2) the increased amount ofviscoelastic used and the fact that it was sometimes notaspirated at the end of the procedure; (3) the fact thatresidual soft lens matter was present in the anterior cham-ber (47% of cases with raised intraocular pressure had softlens matter in the anterior chamber) or in the vitreous;

(4) the fact that anterior vitrectomy had been carried out(41% of cases with raised intraocular pressure had ananterior vitrectomy). In our series no patient developedraised intraocular pressure which persisted outside theimmediate postoperative period. Other complications seenpostoperatively included two cases of retinal detachmentand one case of a horseshoe tear. No case in our series haddocumented clinically significant cystoid macular oedema,and it was felt unjustifiable to perform fluorescein angi-ography for study purposes only. Gimbel'7 does notmention postoperative cystoid macular oedema in hisseries, and Osher and Cionni2 report only one case of clin-ically significant cystoid macular oedema. Chambless30reported the incidence of clinically significant cystoidmacular oedema as 7-6% in phacoemulsification casescomplicated by posterior capsular disruption.As can be seen from Table 5, the visual prognosis after

complicated phacoemulsification surgery can be very good- 60% of patients' corrected visual acuity was 6/9 or bet-ter and 79% of patients had a visual acuity of 6/18 or bet-ter. This compares favourably with 77% and close to100% of cases seeing 20/40 or better in Gimbel's'7 andOsher and Cionni's2 respective series. We do feel, how-ever, that the more anatomical position of the lens (in thebag or sulcus) will, in several years' time, prove to be moresatisfactory with regard to the fine visual acuity. This is incontrast with eyes receiving an AC IOL, whose ultimatevisual potential may be compromised by late onsetpseudophakic glaucoma, bullous keratopathy, and cystoidmacular oedema. The reports of Spiegelman et al 14 andClaoue and Steele'6 both affirm the poorer long termvisual prognosis of eyes with AC IOLs compared with eyeswith PC IOLs in extracapsular surgery complicated bycapsular disruption.

In our study, 60% of the patients had their fellow eyeoperated on; of these, 35% were complicated by a poste-rior capsular tear or dialysis. We do feel, therefore, that itis particularly important that the surgeon considers thisfact when planning to undertake phacoemulsificationsurgery on the second eye of a patient who had compli-cated surgery in the first eye. Our findings contrast withOsher and Cionni's series,2 which failed to show anincidence of capsular disruption in the fellow eye (39% ofcases in their series had the fellow eye operated on). Thisvariation between series may be attributable to differingcase selection.

ConclusionPosterior capsular disruption is a very important intra-operative complication but current techniques permitendocapsular or sulcus fixation of the IOL in a high per-centages of cases. Furthermore, good visual acuity andminimal long term complications ensue. Surgery on thefellow eye of a patient who has already had a posteriorcapsular disruption is associated with an appreciable risk(35%) of posterior capsular tear or dialysis in the secondeye.

M MULHERNG KELLYP BARRY

Department of Ophthalmology,St Vincent's Hospital,Dublin, Ireland

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