August 13, 2017
A posterior capsular tear during phacoemulsification can be surgically challenging, and the surgical difficulty is inversely proportional to the timing of the tear during the phaco procedure. When a tear occurs in the early phases of nuclear sculpting and fragmentation, it can be more difficult for the surgeon as compared with this mishap happening toward the end of the procedure. Regardless of when the tear occurs, the primary surgical objectives are prevention of posterior vitreous cavity migration of the nuclear remnants, management of anterior vitreous, prevention of iatrogenic iris tissue damage, and retention of the anatomic integrity of the zonular-capsular complex.
The posterior capsule with intact zonular circumferential support of the capsular bag acts as a partially protective divisional screen between the anterior and posterior chambers. An opening in the posterior capsule somewhat unifies the two chambers into one, with the opening serving as the communicating channel through which the nuclear fragments can often gravitate toward the posterior pole and retina. To artificially re-establish the protective screen, various methods have been used intraoperatively after anterior transfer of the sinking nucleus into the anterior chamber, such as the Sheets glide, the IOL scaffold technique and other devices. After removal of the lens material, a three-piece IOL can often be placed in the ciliary sulcus. However, when the posterior capsular compromise is coupled with inadequate or deficient ciliary sulcus tissue support for the IOL, then alternative techniques need to be utilized in which the IOL is suspended from the sclera.