Posterior Capsule Rupture: Even With Perfect Technique, Complications Can Arise

Sumit (Sam) Garg, MD


October 13, 2022

When is the last time you broke capsule during cataract surgery? Were you able place your intended lens in the intended location? How did your patient do? Did they need additional surgery? Did another complication arise because of the posterior capsule rupture (PCR)? Did their vision improve as expected?

In experienced hands, PCR is an infrequent occurrence during cataract surgery. Early on in our careers, PCR rates are generally higher, but with experience and refinement of technique, rates generally decrease. Despite this, PCR is one of the most common complications of cataract surgery. Certainly, it is more common in complex cases, such as trauma, pseudoexfoliation, previous vitrectomy, and intraoperative floppy iris syndrome (IFIS), among others.

A group of multinational authors from Europe lead by Dr Maartje Segers reported the outcomes of cataract surgery complicated by PCR in the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO).[1] From 2008 to 2018, over 1,350,000 cataract cases were reviewed, with an incidence of 12,196 cases of PCR (0.9%).

It is no surprise that the authors reported that visual and refractive outcomes were worse in patients with PCR. Additionally, those with PCR had more complications such as corneal edema, endophthalmitis, increased intraocular pressure, and cystoid macular edema. They report a higher incidence of coexisting eye disease in 50.2% of PCR cases vs 23.4% of non-PCR cases. Despite the PCR, the majority of these patients had an improvement in vision compared with their presurgical state.

Overall, this study gives us a contemporary review of outcomes in patients with PCR. Given the large numbers reported, the 1% rate of PCR seems about right.

We all have cases of unexpected PCR. In persons with complicated eyes, the rate can be higher. I make it a point to take extra time to explain the increased risk for PCR in at-risk patients. Luckily, even in those with complex eyes, the incidence is low. Unfortunately, owing to the nature of the registry, the study only reported short-term outcomes of PCR. It would certainly be interesting to see how these patients fared over the long term. Did they have a higher incidence of retinal detachment? Did their visual outcomes stay stable? Did they have other long-term complications?

As cataract surgery technique and technologies continue to improve, I am hopeful that the rate of PCR will decrease (from an already low level). Even with perfect technique, complications such as PCR can arise. As such, it is important to discuss the possibility of PCR and the possible impact that it can have on a patient's refractive outcome and occurrence of complications with our patients.

Sumit (Sam) Garg, MD, is the vice chair of clinical ophthalmology and an associate professor in the Department of Ophthalmology at the Gavin Herbert Eye Institute, University of California, Irvine. He specializes in corneal and cataract surgery as well as laser refractive surgery.

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