Posterior polar cataract surgery – a posterior segment approach
Posterior polar cataract surgery - a posterior segment approach
0 Department of Vitreo-retinal Surgery, Birmingham and Midland Eye Centre, City Hospital NHS Trust , Birmingham , UK
Purpose To suggest a surgical approach that
would pre-empt uncontrolled posterior
capsular rupture and consequent posterior
segment complications associated with
posterior polar cataract surgery.
Design An interventional case series.
Methods This was a prospective,
interventional study undertaken at a tertiary
referral ophthalmic unit. Eleven eyes of eight
patients underwent planned pars plana
vitrectomy, lensectomy and posterior chamber
sulcus fixated intra-ocular lens implantation.
Demography, presenting features, pre- and
post-operative visual acuities, complications
and length of follow-up were recorded.
A single surgical technique was performed in all the cases.
Results Five male and three female patients
with a mean age of 49.7 years, underwent this
procedure. The median-corrected
pre-operative visual acuity was 6/12 and the
same post-operatively was 6/6. The only major
per-operative complication was one case of
accidental iridectomy. Post-operatively there
were transient choroidal folds in one case,
mild posterior segment haemorrhage in
another and retinal detachment in one patient.
The mean follow-up period was 13 months.
Conclusions This surgical technique offers a
relatively controlled and predictable approach
to posterior polar cataract surgery compared to
others described in the literature. Although
this technique is not without complications,
the visual outcome is usually good.
Eye (2008) 22, 844–848; doi:10.1038/sj.eye.6702743;
published online 2 March 2007
Congenital posterior polar cataract is a localised
central sub-capsular opacification of the
YK Ghosh and GR Kirkby
crystalline lens. This particular morphology
makes cataract surgery a challenging procedure,
because the posterior capsule adjacent to the
opacity tends to be weak.1,2
Various techniques have been suggested to
minimise the risk of posterior capsular rupture
during cataract extraction.3,4 Despite these,
Osher et al5 report 26% and Vasavada et al6
report 36% incidence of capsular rupture in two
of the largest series. Recent studies with newer
techniques have reported much lower
complication rates,7,8 but the risk of posterior
capsular rupture in an uncontrolled
This prospective study looks at pre-empting
the problem of uncontrolled posterior capsular
rupture by performing planned pars plana
vitrectomy, lensectomy, and posterior chamber
intraocular lens implantation.
This was a prospective, single centre study,
which had ethical approval. Informed consent
was obtained from each patient.
Between 2001 and 2003, 11 eyes of eight patients
with congenital posterior polar cataracts were
operated on by a single surgeon. The diagnosis
of posterior polar cataract was confirmed by the
surgeon before surgery by slitlamp
biomicroscopy. The case notes of these patients
Preoperative data included presenting
symptoms and visual acuity, demography and
Operative data consisted of type of surgery
and per-operative complications. Post-operative
complications, length of follow-up and final
visual acuity were also noted.
A routine planned pars plana vitrectomy was performed.
This procedure included a limited peritomy for the entry
ports. Three self-sealing scleral ports were fashioned
with a crescent and an MVR blade. The infusion line was
secured to the lower temporal port with a 5/o Ethibond
suture and closed off. A 19-gauge winged metal infusion
canula (‘butterfly’) was then used as an infusion line
directly into the crystalline lens. The MVR blade was
then inserted into the crystalline lens and either the
vitrector cutter or the fragmatome or both (depending on
nuclear sclerosis) used to remove the lens. Efforts were
made to preserve the capsular beg intact for as long as
possible, but in all cases some lens fragments were
dislocated posteriorly. The anterior capsule was left
intact at this stage.
The infusion line was then switched on after removing
the ‘butterfly’ and a routine central vitrectomy
performed. In very young patients the posterior hyaloid
was deliberately not peeled and in older patients this was
carried out when possible. Any remaining lens fragments
were removed. Sometimes during this part of the
procedure, anterior capsular opacification would occur,
in which case the vitrector cutter was used on suction
mode to clean the posterior surface of the anterior
capsule. The retina was then inspected for presence of
retinal tears and cryotherapy applied when required.
With the infusion switched off, the anterior chamber was
then opened with a 3.5 mm keratome and filled with
viscoelastic. A foldable posterior chamber Silicone
intraocular lens was inserted and dialled so that the
haptics were vertical, thus being placed in the ciliary
sulcus anterior to the anterior capsular ledge. The
viscoelastic was then removed. A central anterior
capsulotomy was then made via the pars plana using the
The conjunctiva was sutured with 8/o vicryl and a
subconjunctival injection of steroid and antibiotic was
There were five males and three females with posterior
polar cataracts, with a mean age of 49.7 years (range,
12–68 years). Four of these patients had been noted to
have bilateral posterior polar opacities. Of these, three
had bilateral cataract surgeries. All the patients had
presented with deterioration of visual acuity.
One patient had a family history of posterior polar
cataracts, with the mother and sister suffering from the
All the eyes had pars plana vitrectomy, lensectomy,
and sulcus fixated intraocular lens implantation. Three
eyes had Pharmacia 911A Silicone IOL and eight had
Allergan S1 140NB Silicone IOL implants.
Per-operative complications included one case of
bleeding from accidental iridotomy and two cases of
small posterior segment haemorrhage, one from the
accidental iridotomy and the other from an entry site.
Three young patients required a single 10/o nylon suture
to secure the corneal wound.
Post-operative complications included one case of
retinal detachment 2 months post-operatively and one
patient had choroidal folds for 3 weeks owing to
hypotony, which resolved spontaneously. One patient
had pupillary capture with the inferior margin of the
IOL. This resolved with the use of topical miotic drops
and posturing the patient in a supine position.
The median corrected pre-operative visual acuity was
6/12 (range, 1/60 –6/9) and the median corrected
post-operative visual acuity was 6/6 (range, 6/6–6/12).
The post-operative visual acuity was significantly better.
Post-operative improvement in visual acuity was
comparatively less in one case, which had developed
The mean follow-up period was 13 months
(range, 7–24 months) Table 1.
Congenital posterior polar cataract is a localised central
sub-capsular opacification of the crystalline lens. It
consists of a very white, well-demarcated, opacity
located in the centre of the posterior capsule,9 often
looking like a pile of small white discs of decreasing size
projecting forward into the posterior lens cortex. (Figures
1 and 2) This appearance is completely different from a
localised plaque of posterior subcapsular opacity.
However, posterior sub-capsular opacity often forms
around a posterior polar cataract and is the usual cause
of presentation with decreased visual acuities.
Most of these cataracts have an autosomal-dominant
inheritance pattern,10 although occasional sporadic cases
have also been noted. Electron microscopy has shown
that there is accumulation of abnormal lens fibres and
extracellular materials. The plaque is acellular and is
strongly adherent to the posterior capsule centrally.
These cataracts show a breakdown of lens fibres,
presence of disorganised lobules and membranous
whorls and a weakness or deficiency in the posterior
capsule11 (Figure 3).
Posterior polar cataracts form a group that poses a
challenge to the cataract surgeon because of the risk of
per-operative capsule rupture potentially resulting in
vitreous loss and retained lens material. This is due to the
weakness of the capsule around the opacity.1,2 There is
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also a suggestion in the literature that the capsule may
actually be deficient in the area of polar opacity.12
Extraction of a posterior polar cataract should be
performed in a way that minimises the risks of posterior
segment complications and maximises the benefits of
posterior chamber IOL implantation.13 Various
techniques have been described previously, which
essentially aim to protect the posterior capsule around
the polar opacity by, for instance, visco-disection of
epinucleus, and cortex13 or gentle irrigation and
aspiration of epinucleus with removal of the plaque right
at the end.14
Hayashi et al15 reported two cases of pars plana
lensectomy in their series. A recent publication has
quoted 11% posterior capsular rupture rate using careful
controlled hydrodelineation and a modified ‘lambda’
technique of phacoemulsification.7 The most recent
technique advocates bimanual microphacoemulsification
as an effective way of reducing complications.8
To the best of our knowledge, our study is the first to
look prospectively at the option of routinely performing
pars plana vitrectomy and lensectomy. This eliminates
the risks of unexpected capsule rupture and posterior
segment complications, and provides a controlled
approach to posterior polar cataract surgery, although
caution should be exercised in its use in view of the
significant associated complications.
Visual improvement was significant in most cases. One
patient that comparatively did not do well had
developed a retinal detachment two month
postoperatively. He underwent retinal re-attachment surgery
and the retina remained attached at the last
In conclusion, posterior polar cataract can be operated
on by various surgical techniques, the choice of which
may depend on the surgeon. The preferred option would
be cautious conventional phacoemulsification with
careful hydrodelineation and ‘in the bag’ IOL
implantation by an experienced surgeon. However, an
individual cataract surgeon may well have a greater than
30% capsule rupture rate because of the rarity of this
condition and the lack of individual experience. Patients
having unexpected complications of this type often
require subsequent additional surgery by a posterior
segment expert, with consequent increased anxiety for all
concerned. Although the technique discussed here is not
without complications, the results are generally good and
caution should be exercised in its use in view of the
significant associated complications.
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2 Hiles DA , Chotiner B . Vitreous loss following cataract surgery . J Paediatr Ophthalmol 1977 ; 14 : 193 - 199 .
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