Surgical approaches to posterior polar cataract: a review
Surgical approaches to posterior polar cataract: a review
AR Vasavada 0
SM Raj 0
V Vasavada 0
S Shrivastav 0
0 Iladevi Cataract and IOL Research Centre, Raghudeep Eye Clinic , Memnagar, Ahmedabad , India
The aim of this study is to provide a comprehensive overview of surgical methods used in the emulsification of posterior polar cataracts (PPCs) that have been devised to minimize the risk of posterior capsule rupture (PCR) and its consequences. A Pubmed and Medline search of relevant literature on PPC was done. Only articles relevant to the treatment of PPC were included. The posterior capsule in eyes with PPC are known to have an abnormal adhesion to the polar opacity or a pre-existing weakness of the capsule that predisposes the eye to PCR. To circumvent the consequences of cleaving the abnormal adhesion, a majority of the surgeons use the anterior approach through the limbus, whereas some advocate the posterior approach through the pars plana. Emulsifying the nucleus and cleaving the central opacity of the PPC off the posterior capsule without disrupting its integrity provides optimal surgical outcomes. To achieve this, various modifications have been applied by surgeons during different phases of surgery. The advantages, disadvantages, complications, and results of each method have been discussed. Phacoemulsification is the preferred technique for removing PPC. This review will provide methods to avoid and /or deal with intraocular surgical difficulties that can arise during emulsification. Employing these would result in least ocular morbidity and satisfactory visual outcomes for the patient. This is particularly relevant given the major advancements in technology and refinements in surgical techniques in phacoemulsification. Eye (2012) 26, 761-770; doi:10.1038/eye.2012.33; published online 23 March 2012
posterior polar; hydrodissection; hydrodelineation
Posterior polar cataract (PPC) poses a unique
challenge to surgeons during cataract surgery.1
Depending on the clinical presentation, PPC can
be divided into three categories: (
) PPC with
imminent (eyes that are at a risk of) posterior
capsule dehiscence (Figure 1), (
) PPC with
preexisting posterior capsule dehiscence (Figures
2a and b), (
) Spontaneous dislocation. From
our clinic-based population, (unpublished data)
we examined 79 patients undergoing surgery
for PPC between 2009 and 2010. In this group,
77 of 79 (97%) eyes displayed PPC with
imminent dehiscence; 2 of 79 (3%) eyes had PPC
with pre-existing posterior capsule dehiscence.
Currently, there is no surgical technique to
eliminate the occurrence of posterior capsule
rupture (PCR). We have reviewed suggested
surgical approaches to reduce the possibility of
PCR during cataract surgery of PPC with
imminent posterior capsule dehiscence. We also
describe surgical techniques that reduce the
morbidity of the ocular tissue in eyes with
pre-existing posterior capsule dehiscence and
PPC with imminent posterior capsule dehiscence
The common symptom is glare disability in
photopic illumination conditions. The
symptoms ameliorate if there is low
illumination. Two types of PPC have been
described in literature: stationary and
progressive.1 Stationary PPC is characterized by
a central, dense, disk-shaped opacity located on
the posterior capsule with concentric rings
around the central plaque opacity that appear
like a bull?s eye (Figure 1). The opacity has a
cone-shaped projection in the subcapsular
region or central posterior cortex. This type of
PPC is compatible with good vision. In
progressive PPC (Figure 3), changes take place
in the posterior cortex in the form of radiating rider
opacities. Patients with progressive opacity become more
symptomatic as the peripheral extensions enlarge. The
average age of patients that attended our clinic was 50.67
years with patients ranging from 27 to 63 years
(unpublished data). Despite complaints of glare
disability, the corrected visual acuity was 20/20 in these
patients. It was noted that PPC was present bilaterally in
90% of the cases in our study and in 70% of cases in a
study conducted by Gavris et al.2
A suggested method to classify PPC is according to the
size and density of the opacities.3 The authors denote the
size of the opacity between 0.5 and 3 mm in increments of
0.5 mm. The density is staged from 1 ? to 4 ? and
increasing density is judged by the ability to visualize the
PPC with pre-existing posterior capsule dehiscence
A posterior capsule defect is observed as an
ellipticalshaped defect (Figure 2), which is generally vertically
oriented with a central bull?s eye-shaped opacity. It is also
described as iridescent refractile lens particles in the anterior
vitreous and onion skinning of the central dense plaque.4
Co-existing ocular association
A majority of the eyes (93.7% (74 eyes of 79)) with PPC
have emmetropia with axial length ranging between 21
and 24 mm (our unpublished data). In this data, a small
proportion of patients had an axial length of 425 mm
and none of the eyes had an axial length of o21 mm.
Co-existing anomalies have not been reported in
literature, except for a report of retinitis pigmentosa in
eyes with PPC in the Siatri and Moghini study.5 Nada
et al6 reported two children under 3 years of age with
unilateral Wilm?s tumor having sporadic aniridia along
Visual performance of the affected eye
In most eyes with PPC, vision progressively worsens in
bright light and while reading at close range. Visual
acuity does not appear to worsen until nuclear cataract
sets in. After cataract surgery, postoperative visual acuity
improves to 20/20 in a majority of the cases in adults.
Risk of PCR during surgery
The incidence of PCR cited in literature is as high as 36%
in eyes with PPC.7 Another study reports an incidence of
26%.8 More recently, the incidence has been reduced to 7
and 6%.9,10 A likely explanation for the low incidence of
PCR is an understanding of the anatomical abnormality
in the posterior capsule and perhaps the anterior vitreous
and an understanding of the surgical factors that increase
the risk of intraoperative PCR.
It was suggested that the size of the polar opacity has a
significant impact on the risk of PCR.11 Overall, 7 of 23
(30.43%) eyes with posterior polar opacities of 4 mm or
more had PCR, whereas 2 of 35 eyes (5.71%) with
posterior polar opacities of o4 mm had PCR.11 PCR was
found to be more common in patients o40 years and in
the eyes that underwent extracapsular cataract extraction
as compared with phacoemulslfication.12
Surgical management of PPC
Keeping in mind the potential risk of PCR during
surgery, the accepted strategy would be to delay the
surgery. Until the surgery is undertaken, the patient
should be periodically evaluated to note visual
deterioration, the opacity and integrity of the posterior
capsule, and development of nuclear or cortical opacities
along with PPC. If any of the above events are observed
during the follow-up evaluation, the surgeon can
consider surgical intervention counseling the patient
regarding the risks involved during surgery and possible
During the preoperative examination, the patient is
informed of the possibility of intraoperative PCR,
dropped nucleus, relatively longer surgical time,
secondary posterior segment intervention, and possibly
delayed visual outcome. The need to perform Nd: YAG
capsulotomy for residual plaque7?9 (Figure 4), and the
possibility of pre-existing amblyopia especially in
unilateral PPC is envisaged at the preliminary stage.9
Several surgical approaches have been proposed to
minimize or delay the incidence of PCR during surgery.
Depending on the stage of PPC at the time of the
presentation, the surgical approach may vary.
Surgical approach in eyes with imminent posterior capsule dehiscence
ICCE. Except for a single case, in a series of 28 eyes of 20
consecutive patients with PPC,9 there is no evidence for
or against this approach. This approach was used by the
authors in an eye with a large opacity and hard nucleus.
The posterior approach. The rationale behind using pars
plana lensectomy and vitrectomy was to eliminate the
risk of an unexpected capsular rupture and posterior
segment complications.13 This approach was investigated
in an interventional case series of 11 eyes of 8 patients.
During a mean follow-up of 13 months, 3 of 11 eyes
developed posterior segment complications. This
approach was also used in 2 of 28 eyes undergoing
surgery for PPC. The authors had used this technique as
the opacity was large and the lens soft.9
The anterior approach using phacoemulsification. The goals
of performing phacoemulsification in eyes with PPC are
to maintain the barrier of the irido-zonular-capsular
diaphragm between the anterior and posterior segments,
and to implant an intraocular lens (IOL) in the bag.
Surgical techniques that provide a closed chamber
during all the stages of phacoemulsification can maintain
the contours of the cornea and the globe. This reduces the
risk of intraoperative PCR in eyes with PPC.
A number of surgical approaches have been proposed
for emulsification of PPC14?19 (Table 1). We highlight the
subtle variations described by authors during the different
phases of this procedure (Supplementary video 1).
ee1yn )(05% i858n/ .(s814%
i s e
s e L y
leu ey IO e8
c 8 d 3
nu 4/ tea 7/
d in xfi in
) s e
se )s e y
ey ey ey e8
e 8 5
3/ 25 (1/ (9/ 5/ 17
4 / 2 /
(1 (2 .52 .55 A (1 (1
1 8 1 1 0 N 3 6
t ,on isp
o an it t
t r c o
a e c
r d s a
p la au is h
s q d p
u i o o
ay nn lt r r
u d ic
r a y
D C M h M
20/ (80 AN AN
/ e 0/ .44 A A A 40/ eey
2 s 4 %
0 y 0 8 A
2 e 2 9 N N N 2 3 N
2Z (94 .80
0 % ?7 2
A A V V
N N N N N N N
Incision. The surgery commences by creating a
paracentesis incision using the 1.1 mm dual bevel slit
knife (Alcon Surgical, Fort Worth, TX, USA). The aqueous
is exchanged with Sodium Hyaluronate (Provisc, Alcon
Laboratories, Fort Worth, TX, USA). A temporal, corneal,
single-plane, valvular incision is created. A cohesive
viscoelastic in the anterior chamber prevents chamber
collapse and forward movement of the iris-lens
diaphragm, during entry into the eye. Fine et al20 caution
against increasing the pressure in the anterior chamber as
this could cause a blow-out of the posterior capsule.
Capsulorhexis. The optimal size is approximately r5 mm.
A rhexis size of r4 mm could be detrimental in case the
need arises to prolapse the nucleus into the anterior
chamber. However, a larger opening may not provide
adequate support for a sulcus-fixated IOL in case the
posterior capsule is compromised.7,20
Hydro procedures. Cortico-cleaving hydrodissection15 can
lead to hydraulic rupture and should be avoided.7,8 It
would be logical to perform hydrodelineation to create a
mechanical cushion of the epinucleus.5,7,9,14,21 Masket,22
Hayashi et al,9 Allen and Wood,14 and Lee and Lee16
recommend hydrodelineation. In addition to
hydrodelineation, Fine et al20 also perform
hydrodissection in multiple quadrants injecting tiny
quantities of fluid gently, such that the fluid wave is not
allowed to spread across the posterior capsule.
With conventional hydrodelineation, the cannula
penetrates within the lens substance causing the fluid to
traverse from outside to inside. It is sometimes difficult
to introduce the cannula within a firm nucleus, as it can
cause stress to the capsular bag and zonules. There is also
a possibility of the fluid being injected inadvertently in
the subcapsular plane, leading to unwarranted
Inside?Out delineation. The authors propose ?Inside?Out
Delineation? as a substitute technique that can be used
instead of conventional hydro procedures as it can
precisely delineate the central core of the nucleus.10
A central trench is sculpted using the slow-motion
technique (Infinity Phacoemulsifier, Alcon Laboratories).
Care should be taken not to mechanically rock the lens. A
dispersive viscoelastic (Viscoat, Alcon Laboratories) is
injected through the side-port incision before retracting
the probe to avoid a forward movement of the iris-lens
diaphragm. A specially designed right-angled cannula,
mounted on a 2 cc syringe filled with fluid, is introduced
through the main incision and the tip is placed adjacent
to the right wall of the trench at an appropriate depth,
depending on the density of the cataract. It then
penetrates the central lens substance and fluid is injected
through the right wall of the trench (Figure 5).
Delineation is produced by the fluid traversing inside?
out. A golden ring within the lens is evidence of
successful delineation (Figure 6). Fluid injection may be
repeated in the left wall of the trench with another
rightangled cannula. The trench allows the surgeon to reach
the central core of the nucleus (Figure 7). As fluid is
injected at a desired depth, under direct vision, a desired
thickness of epinucleus cushion can be achieved. It
provides a precise epinucleus bowl that acts as a
mechanical cushion to protect the posterior capsule
during subsequent maneuvers (Figure 8). Inside?out
delineation is easy to perform, provides superior control,
reduces stress to the zonules, and precisely demarcates
the central core of the nucleus.
Figure 8 The residual epinucleus bowl provides mechanical
protection (cushion effect) to the polar opacity during
emulsification of the nucleus. This is achieved due to the precise
demarcation by inside?out delineation.
Rotation. Any attempt to rotate the nucleus can lead to
PCR and is best avoided.7
In dense nuclear sclerosis, Lim and Goh23 suggest
prechopping the anterior epinucleus before mobilizing,
segmenting, and emulsifying the dense endonucleus.
Division and fragment removal. It would be ideal to
aspirate the nucleus within the cushion of the epinucleus
to protect and tamponade the posterior capsule.
Bimanual cracking and division of the nucleus involve
outward movements and can result in distortion of the
capsular bag. In nuclear sclerosis o2, the demarcated
nucleus is emulsified by creating adjacent trenches to
create a bowl. In nuclear sclerosis of Z2, we use the
step-by-step, chop in situ, and lateral separation
technique.24 Traction of the posterior lens fibers and
posterior polar opacity during surgery are enough to
break the weak posterior capsule. Thus the slow-motion
technique is recommended to reduce turbulence in the
anterior chamber.25 The collapse of the anterior chamber
and forward bulge of the PC is prevented throughout the
procedure by injecting a viscoelastic before the
instrument is withdrawn.7
Lee and Lee16 use the lambda technique to sculpt the
nucleus, followed by the creation of a crack along both
arms, and removal of the central piece.
Epinucleus removal. Epinucleus removal is done in two
steps. The first step is to cleave the epinucleus from the
capsule 360 degrees circumferentially and the second
step is to aspirate it. For cleaving the peripheral lower
half of the epinucleus, that is, the epinucleus in the clock
hours opposite the main incision from where the probe is
introduced, it is stripped off the capsule with the probe,
leaving the central area attached (Figure 9).7,20,22 During
this step, the surgeon attempts to separate the epinucleus
and does not attempt to aspirate the epinucleus. For
cleaving the peripheral upper epinucleus (subincisional
epinucleus), focal and multi-quadrant hydrodissection
with a right-angled cannula facing right and left is done
(Figure 10). The fluid wave travels along the cleavage
formed between the capsule and the lower epinucleus
(Figure 11). It does not threaten the integrity of the
posterior capsule. Moreover, it is safe to hydrodissect as
the capsular bag is not fully occupied. Therefore, the
hydraulic pressure built-up is not sufficient to rupture
the posterior capsule. The entire epinucleus is then
aspirated, finally detaching the central area.
Allen14 and Fine20 suggest viscodissection of the
epinucleus performed by injecting a viscoelastic (Healon
5 or GV and Viscoat, respectively) under the capsular
edge to mobilize the rim of the epinucleus. It is removed
with a coaxial irrigation-aspiration (I/A) handpiece. Lee
and Lee16 perform manual dry aspiration with the
Nagappa et al19 state that rather than just cleaving the
distal epinucleus, they perform phaco-aspiration and
removal of the epinucleus in the quadrant opposite to the
section. Then hydrodissection is performed to release the
adhesion of the sub-incisional epinucleus from the
Highly dilute fluorescein dye has been used
intracamerally to stain the epinucleus and the remaining
ring-like opacity.26 The authors observe that staining the
epinucleus could aid in careful cortical aspiration
without causing damage to the intact posterior capsule.
We speculate that in the event of an unidentified breach
of the posterior capsule, injecting a dye may cause
undesirable percolation into the vitreous.
Pseudohole. At times, the posterior cortex displays a
classical appearance suggestive of a defect. If the
posterior capsule underneath this opaque ring is intact, it
is termed as a ?pseudohole? (Figure 12). Nagappa et al19
have coined the term? fish mouthing? as a sign of
posterior capsular rupture where the vitreous is seen
coming through the PPC.
Cortex removal. Bimanual automated I/A optimizes
control, ensures anterior chamber maintenance, and aids
in complete removal of the cortex. Fine et al20 use coaxial
I/A to protect the PC with ophthalmic viscoelastic
devices during cortex removal.
Posterior capsule vacuum polishing. It is avoided even if the
PC is not open, because of its potential fragility.7?9,20,22
The traction on an excessively adhered plaque as
compared with an otherwise normal posterior capsule
could eventually rupture the posterior capsule. Instead,
(Nd:YAG) laser posterior capsulotomy is preferable.
Surgical approach in eyes with a pre-existing defect in the posterior capsule
The anterior approach. In an attempt to maintain an intact
vitreous face in eyes, the authors follow the same
paradigms as those used in eyes with an intact posterior
capsule. Viscoat, which is a dispersive viscoelastic, is
injected over the area of the capsule defect before the
phaco or I/A probe is withdrawn from the eye.27 The
viscoat tamponades the vitreous face preventing it from
prolapsing. A two-port limbal anterior vitrectomy is then
performed using a maximum cut rate/min with a very
low bottle height of 20?30 cm. Once the anterior chamber
is free of vitreous, the cortex is aspirated by bimanual
I/A. A posterior continuous curvilinear capsulorhexis
(PCCC) may be performed if the rupture is confined to a
small central area.28 High-viscosity viscoelastic sodium
hyaluronate is injected around the area of the initial
puncture to achieve a flat or concave capsule.29,30 The
ends of the tear are grasped with microforceps (ASICO,
Westmont, IL, USA) and moved circumferentially to
create a circular opening in the posterior capsule. The
end result should be a PCCC concentric to and smaller
than the anterior capsulorhexis.
Vajpayee et al4 performed ?layer by layer?
phacoemulsification in eight patients with pre-existing
posterior capsule defects. Vitrectomy was not required in
any eye and the authors found a vertical posterior
capsule defect with an intact vitreous face in all eyes.
Site of IOL implantation. In eyes with a posterior capsule
defect, in-the-bag IOL implantation can be considered
only if PCCC is achieved. In eyes with a large posterior
capsule defect, the IOL could be placed in the ciliary
sulcus, provided that the lower portion of the IOL has a
circumferentially uniform capsular support. Fine et al20
have suggested optic capture through anterior
capsulorhexis. This technique was first suggested in a
case of posterior capsular tear.31 The conventional or
posterior optic capture can be achieved by capturing the
optic through anterior capsulorhexis (haptics in the ciliary
sulcus, optic in the bag).32
The technique of optic capture. A high-viscosity ophthalmic
viscosurgical device, Provisc (Alcon Laboratories), is
injected in the sulcus. The IOL is implanted into the
sulcus. The haptics are placed in the sulcus and the optic
is gently pressed backwards such that the optic gets
captured in the anterior capsulorhexis.33 The anterior
capsule assumes the shape of an elliptical opening. This
indicates a complete optic capture. The success rate of
optic capture also depends on the specific IOL design. A
haptic with a right angle at the haptic-optic junction is
preferred over a conventional three-piece C loop IOL
design as it helps in achieving complete capsule
Residual viscoelastic aspiration. After IOL implantation,
the viscoelastic is removed by two-port vitrectomy rather
than I/A, as vitrectomy aspirates in a piece-meal,
gradual manner and reduces the chances of rapid
aspiration of the vitreous.
The main valvular incision and the paracentesis
should be sutured in eyes with a posterior capsule defect.
In these eyes, a periodic evaluation for retinal break,
cystoid macular edema, and raised intraocular pressure
Posterior approach. On the basis of the theoretical
feasibility of the pars plana approach, it is possible to
perform vitrectomy and lensectomy in these eyes.
However, the options for visual rehabilitation using a
scleral-fixated, iris-fixated, or angle-supported lens, in
circumstances where the capsular barrier can be
maintained, does not seem to be a reasonable approach.
Surgical approach in eyes with a spontaneous dislocation
The clinical impression is that prolonging cataract
extraction in an eye with PPC can lead to spontaneous
rupture of the posterior capsule and subluxation of the
lens into the vitreous.34,35 It is hypothesized that an
increase in the size of the lens from nuclear sclerosis may
cause increasing pressure on the posterior capsule, which
subsequently ruptures because of its inherent abnormal
weakness and could be a risk factor for spontaneous
In such eyes, a posterior approach is preferred for
lensectomy via the pars plana. This can be followed by
either an open-loop anterior chamber, a scleral-sutured
posterior chamber, or an iris-sutured posterior chamber
IOL for the correction of aphakia in eyes without
adequate capsular support.36 The authors prefer
scleralfixated IOLs over angle-supported IOLs.37,38
PPC in children
PPC has been identified in 7% of eyes of children
undergoing congenital cataract surgery.39 The mean age
of the children in this group at the time of surgery was
6?3 years. In another study on 33 patients aged 1 week
to 8 years with lens opacities, 3 patients (9%) had PPCs.40
Unlike adult eyes, PPC occurs as unilateral cataract in a
majority of pediatric eyes (93%).39 Grading the severity of
infantile cataracts has been proposed as a clinical guide
to decide surgical intervention.40 Using this criteria, PPC
with a grade of 6 was considered for surgical removal.
The pre-existing defect seen in eyes of children with
congenital cataract is a different entity and does not
appear to be a manifestation of an association with polar
cataract. In our case series of 400 eyes that underwent
cataract surgery for congenital cataract, a defect was
present in 27 eyes (7%).41 The preoperative diagnostic
signs of a pre-existing posterior capsule defect in
children include a well-demarcated defect with thick
margins, chalky white spots in a cluster or a rough circle
on the posterior capsule, and white dots in the anterior
vitreous that move with the degenerated vitreous like a
fish tail sign (Figure 13).41?45
The surgical paradigms for cataract surgery in eyes of
children with PPC remain essentially similar to those
used in adult eyes.41 The authors prefer to adopt the
closed chamber technique. The anterior chamber is first
entered using a paracentesis incision. It is then filled with
a high-viscosity 1.4% sodium hyaluronate. A clear
corneal incision is made. An anterior capsulorhexis is
initiated by making a nick with a 26-gauge cystotome,
and thereafter completed using micro-forceps by
repeatedly grasping the flap. No hydro procedures are
performed. This is followed by bimanual I/A using a low
bottle height of 40 cm initially. The height is gradually
increased to 70?80 cm. If a thin posterior capsule with
well-demarcated margins or a capsular flutter is noticed,
posterior capsulectomy and vitrectomy are performed
with a vitrector. While carrying out vitrectomy, the goal is
to remove only the central anterior vitreous without
attempting to remove the peripheral or posterior
vitreous. This kind of limited vitrectomy is performed
typically through two limbal (corneal) ports. During this
procedure, irrigation is separated from the cutting and
aspiration. This is followed by in-the-bag implantation of
the AcrySof IOL (Alcon Laboratories). All the incisions
In eyes with PPC, an improvement in visual acuity
(20/40 or better) has been noted in 84% of children after
PPC can pose a surgical challenge to novice surgeons.
The surgical steps include performing inside?out
delineation, adhering to the closed-chamber technique,
adopting the slow-motion technique for lens removal,
and using focal and multiquadrant hydrodissection after
nucleus removal to achieve adequate cleavage of the
subincisional epinucleus from the capsule. In the event of
a breach in the posterior capsule in these eyes, a periodic
evaluation for retinal break, cystoid macular edema, and
raised intraocular pressure is necessary.
Method of literature search
Conflict of interest
The authors declare no conflict of interest.
1 Duke-Elder S . Posterior polar cataract . In: Duke-Elder S (ed). System of Ophthalmology 3, Pt 2 Normal and Abnormal Development , Congenital Deformities . CV Mosby: St Louis , MO , 1964 , pp 723 - 726 .
2 Gavris M , Popa D , Caraus C , Gusho E , Clocotan D , Horvath K et al. Phacoemulsification in posterior polar cataract . Oftalmologia 2004 ; 48 : 36 - 40 .
3 Plechaty G , Roy H . Posterior polar cataract . Medscape reference. Available at: http://emedicine.medscape.com/ article/1211609.
4 Vajpayee RB , Sinha R , Singhvi A , Sharma N , Titiyal JS , Tandon R. ' Layer by layer' phacoemulsification in posterior polar cataract with pre-existing posterior capsular rent . Eye 2008 ; 22 : 1008 - 1010 .
5 Siatiri H , Moghimi S . Posterior polar cataract: minimizing risk of posterior capsule rupture . Eye 2006 ; 20 : 814 - 816 .
6 Nada M , Rattan KN , Magu S , Parshad S. Aniridia and Wilm's tumor . Indian J Pediatr 2003 ; 70 : 837 - 838 .
7 Vasavada AR , Singh R . Phacoemulsification with posterior polar cataract . J Cataract Refract Surg 1999 ; 25 : 238 - 245 .
8 Osher RH , Yu BC , Koch DD . Posterior polar cataracts: a predisposition to intraoperative posterior capsular rupture . J Cataract Refract Surg 1990 ; 16 : 157 - 162 .
9 Hayashi K , Hayashi H , Nakao F et al. Outcomes of surgery for posterior polar cataract . J Cataract Refract Surg 2003 ; 29 : 45 - 49 .
10 Vasavada AR , Raj SM . Inside-out delineation . J Cataract Refract Surg 2004 ; 30 : 1167 - 1169 .
11 Kumar S , Ram J , Sukhija J , Severia S. Phacoemulsification in posterior polar cataract: does size of lens opacity affect surgical outcome? Clin Experiment Ophthalmol 2010 ; 38 : 857 - 861 .
12 Das S , Khanna R , Mohiuddin SM , Ramamurthy B . Surgical and visual outcomes for posterior polar cataract . Br J Ophthalmol 2008 ; 92 : 1476 - 1478 .
13 Ghosh YK , Kirkby GR . Posterior polar cataract surgery - a posterior segment approach . Eye 2008 ; 22 : 844 - 848 .
14 Allen D , Wood C . Minimizing risk to the capsule during surgery for posterior polar cataract . J Cataract Refract Surg 2002 ; 28 : 742 - 744 .
15 Fine IH . Cortico-cleaving hydrodissection . J Cataract Refract Surg 1992 ; 18 : 508 - 512 .
16 Lee MW , Lee YC . Phacoemulsification of posterior polar cataracts- a surgical challenge . Br J Ophthalmol 2003 ; 87 : 1426 - 1427 .
17 Haripriya A , Aravind S , Vadi K , Natchiar G . Bimanual microphaco for posterior polar cataracts . J Cataract Refract Surg 2006 ; 32 : 914 - 917 .
18 Chee SP . Management of the hard posterior polar cataract . Cataract Refract Surg 2007 ; 33 : 1509 - 1514 .
19 Nagappa S , Das S , Kurian M , Braganza A , Shetty R , Shetty B . Modified technique for epinucleus removal in posterior polar cataract . Ophthalmic Surg Lasers Imaging 2011 ; 42 : 78 - 80 .
20 Fine IH , Packer M , Hoffman RS . Management of posterior polar cataract . J Cataract Refract Surg 2003 ; 29 : 16 - 19 .
21 Aziz YA . Understanding hydrodelineation: The term and procedure . Doc Ophthalmol 1994 ; 87 : 123 - 137 .
22 Masket S. Consultation Section . J Cataract Refract Surg 1997 ; 23 : 819 - 824 .
23 Lim Z , Goh J . Modified epinucleus pre-chop for the dense posterior polar cataract . Ophthalmic Surg Lasers Imaging 2008 ; 39 : 171 - 173 .
24 Vasavada AR , Singh R . Step-by-step chop in situ and separation of very dense cataracts . J Cataract Refract Surg 1998 ; 24 : 156 - 159 .
25 Osher RH , Cionni R . In: Steinert RF (2nd edn) . Cataract Surgery , Technique, Complications, Management. Saunders: Philadelphia, 2004 , pp 469 - 486 .
26 Hoffer KJ , McFarland JE . Intracameral subcapsular fluorescein staining for improved visualization during capsulorhexis in mature cataracts . J Cataract Refract Surg 1993 ; 19 : 566 .
27 Gimbel HV . Posterior capsule tears using phacoemulsification: causes, prevention and management . Eur J Implant Refract Surg 1990 ; 2 : 63 - 69 .
28 Gimbel HV . Posterior continuous curvilinear capsulorhexis and optic capture of the intraocular lens to prevent secondary opacification in pediatric cataract surgery . J Cataract Refract Surg 1997 ; 23 ( Suppl 1 ): 652 - 656 .
29 Dholakia SA , Praveen MR , Vasavada AR , Nihalani B . Completion rate of primary posterior continuous curvilinear capsulorhexis and vitreous disturbance during congenital cataract surgery . J AAPOS 2006 ; 10 : 351 - 356 .
30 Praveen MR , Vasavada AR , Koul A , Trivedi RH , Vasavada VA , Vasavada VA . Subtle signs of anterior vitreous face disturbance during posterior capsulorhexis in pediatric cataract surgery . J Cataract Refract Surg 2008 ; 34 : 163 - 167 .
31 Neuhann T , Neuhann Th. The Rhexis-Fixated Lens ,' film presented at the Symposium on Cataract IOL and Refractive Surgery , Boston, MA, USA, 1991 .
32 Gimbel HV , DeBroff BM . Posterior capsulorhexis with optic capture: maintaining a clear visual axis after pediatric cataract surgery . J Cataract Refract Surg 1994 ; 20 : 658 - 664 .
33 Vasavada AR , Trivedi R . Role of optic capture in congenital cataract and IOL surgery in children . J Cataract Refract Surg 2000 ; 26 : 824 - 831 .
34 Ho SF , Ahmed S , Zaman AG . Spontaneous dislocation of posterior polar cataract . J Cataract Refract Surg 2007 ; 33 : 1471 - 1473 .
35 Ashraf H , Khalili MR , Salouti R . Bilateral spontaneous rupture of posterior capsule in posterior polar cataract . Clin Experiment Ophthalmol 2008 ; 36 : 798 - 800 .
36 Wagoner MD , Cox TA , Ariyasu RG , Jacobs DS , Karp CL . American Academy of Ophthalmology. Intraocular lens implantation in the absence of capsular support: a report by the American Academy of Ophthalmology . Ophthalmology 2003 ; 110 : 840 - 859 . Review.
37 Monteiro M , Marinho A , Borges S , Ribeiro L , Correia C . Scleral fixation in eyes with loss of capsule or zonule support . J Cataract Refract Surg 2007 ; 33 : 573 - 576 .
38 Hara T , Hara T . Ten-year results of anterior chamber fixation of the posterior chamber intraocular lens . Arch Ophthalmol 2004 ; 122 : 1112 - 1116 .
39 Mistr SK , Trivedi RH , Wilson ME . Preoperative considerations and outcomes of primary intraocular lens implantation in children with posterior polar and posterior lentiglobus cataract . J AAPOS 2008 ; 12 : 58 - 61 .
40 Forster JE , Abadi RV , Muldoon M , Lloyd IC . Grading infantile cataracts . Ophthalmic Physiol 2006 ; 26 : 372 - 379 .
41 Vasavada AR , Praveen MR , Nath V , Dave K. Diagnosis and management of congenital cataract with preexisting posterior capsule defect . J Cataract Refract Surg 2004 ; 30 : 403 - 408 .
42 Singh D , Singh R , Singh I. Cataract and IOL. Jaypee Brothers: New Delhi, 1993 , pp 160 - 167 .
43 Vajpayee RB , Angra SK , Honavar SG , Titiyal JS , Sharma YR , Sakhuja N. Pre-existing posterior capsule breaks from perforating ocular injuries . J Cataract Refract Surg 1994 ; 20 : 291 - 294 .
44 Vasavada AR , Praveen MR , Dholakia SA , Trivedi RH . Preexisting posterior capsule defect progressing to white mature cataract . J AAPOS 2007 ; 11 : 192 - 194 .
45 Vasavada AR , Praveen MR , Tassignon MJ , Shah SK , Vasavada VA , Vasavada VA et al. Posterior capsule management in congenital cataract surgery . J Cataract Refract Surg 2011 ; 37 : 173 - 193 . Review.