AAO 2024: Quantifying risks and avoiding posterior capsular rupture in the second eye

Ahead of this year's American Academy of Ophthalmology (AAO) meeting, Abdelrahman Elhusseiny, MD, MSc, sat down to discuss his presentation, "Risk of Posterior Capsular Rupture in Fellow-Eyes Cataract Surgery." Here, he details findings from the research he presented at AAO 2024 in Chicago, Illinois.

Editor's note: The below transcript has been lightly edited for clarity.

David Hutton: I'm David Hutton of Ophthalmology Times. The American Academy of Ophthalmology is holding its annual meeting this year in Chicago. At that meeting, Dr Abdelrahman Elhusseiny is making a presentation titled "Risk of Posterior Capsular Rupture in Fellow Eyes Cataract Surgery." First, what are the key points of your presentation?

Abdelrahman Elhusseiny, MD, MSc: The main, key point is that the risks and the rates of posterior capsular rupture during cataract surgery are well documented in the literature. But what we don't know is the impact of having posterior capsular rupture [PCR] in one eye, on the risk of developing posterior capsular rupture in the second eye. And that is the main goal of our study, to quantify the risk of posterior capsular rupture in the second eye in patients who had the history of PCR in their first eye.

DH: What factors contribute to the increased risk of posterior capsular rupture in patients undergoing cataract surgery on their fellow eye?

AE: We conducted the multivariate logistic regression model to adjust for confounding factors, to see if history of PCR itself is an independent risk factor of developing PCR on the other eye. And after adjusting of all confounding factors, or non-confounding factors, we found that the risk is 1.7. We don't know the explanation for that, but there are two theories in our minds.

The first one is tissue factors. Several studies showed difference in the capsular thickness and the mechanical strength variation in the posterior capsule between different individuals. Second explanation is patient factors: patients with difficult positioning, uncooperative patients, [or patients with] deep sockets are more susceptible to complications in both eyes.

DH: Are there specific surgical techniques or preoperative assessments that can help reduce the risk of posterior capsular rupture in fellow eye surgeries?

AE: As in any pre-op planning for cataract surgery, you take a good history from the patients. Make sure that if they had the history of pars plana vitrectomy, that increased the risk of PCR more than 10 introvitreal injections. We conducted multiple studies showing that more than 10 injections increases the risk of PCR. [A] history of trauma, history of pseudoexfoliation, all of that. And these all are known risk factors.

But what we are adding in our study is taking a history from the patient, if they had PCR in their first eye, then you know, and you can counsel the patient that they are at increased risk of developing PCR in the second eye. Because, interestingly, in our study, most of the patients, about 72% of the patients, did not have an obvious risk factor for PCR intraoperatively or even during the [preoperative] planning.

DH: How do the outcomes of posterior capsular rupture in the second eye compare to the first eye?

AE: So, in terms of visual outcomes, we compared the visual outcomes of patients who had a PCR in their second eye to patients who did not have a PCR, and that visual outcome was better in the patients who did not have PCR. But comparing PCR in the second eye versus PCR in the first eye was comparible.

DH: What are the key considerations for managing these complications?

AE: The main thing is pre-op planning, counseling. Make sure that you have what you need in the room. You know, get comfortable with identifying the risk factors, identifying the capsular rupture when it first happens. You can use Kenalog [triamcinolone acetonide] and the usual technique for managing posterior capsular rupture. Kenalog, assess the capsular support, good anterior vitrectomy and evaluate if you need to proceed with the surgery, with implanting an IOL, or refer to a retina specialist, based on the situation, based on the site and the size of the rupture.

DH: Given the potential risks, how should ophthalmologists counsel patients with a history of posterior capsular rupture in one eye when planning surgery for the second eye?

AE: I think the first thing is to try to dig deep into the operative note for the patient to see if there is any red flags, like uncooperative patients or patients who are anxious during the surgery...Try to talk to the patient about how the surgical procedure goes. If the patient is completely uncooperative or has medical problems, like coughing or severe COPD, you can talk to the anesthesia team to see how [to] make this patient as comfortable as you can. That's one thing. The other thing is, counsel the patient that, given the history of the first eye, there's still an increased risk in the second eye.