Cataract

Pearls for the Management of

Posterior Polar Cataract
Jeewan S. Titiyal MD, Sana Ilyas Tinwala MD

Rajendra Prasad Centre for Ophthalmic Sciences,

All India Institute of Medical Sciences, New Delhi

posterior polar cataract is a rare form of congenital cataract with incidence ranging from 3 to 5 in
A 10001-2. It is bilateral in 65–80% of the cases with no gender predilection3. Posterior polar cataract presents a
special challenge to the surgeon because of its predisposition to posterior capsular dehiscence and possible
nucleus drop during surgery.

The high incidence of PC rupture during surgery may be due to tight adherence of the plaque to an otherwise normal
capsule, thin PC underlying the plaque that ruptures to minimal trauma and congenitally absent PC.

Classification
Duke-Elder classified it as stationary and progressive forms4. The stationary form, which is more common (about 65%),
is a well-circumscribed circular opacity, localized on the central posterior capsule. The concentric thickened rings
around the central plaque opacity give an appearance of a Bull’s-eye. Sometimes, the opacity is camouflaged by
nuclear sclerosis. Sometimes there is a smaller satellite rosette lesion adjacent to the central opacity. Progression may
begin in any decade. In the progressive type, whitish opacification take place in the posterior cortex in the form of
radiating rider opacity. It has feathery and scalloped edges but they do not involve the nucleus. Both stationary and
progressive posterior polar cataract may become symptomatic.

Singh classified posterior polar cataract into2:

Type 1: The posterior polar opacity is associated with posterior subcapsular cataract.

Type 2: Sharply defined round or oval opacity with ringed appearance like an onion with or without grayish spots at
the edge.

Type 3: Sharply defined round or oval white opacity with dense white spots at the edge often associated with thin or
absent PC. These dense white spots are a diagnostic sign (Daljit Singh sign) of posterior capsule leakage and extreme
fragility.

Type 4: Combination of the above 3 types with nuclear sclerosis.

Schroeder5 on the other hand graded posterior polar cataract in his pediatric patients according to its effect on
pupillary obstruction in the red reflex testing as follows:

Grade 1: A small opacity without any effect on the optical quality of the clear part of the lens.

Grade 2: A two-thirds obstruction without other effect.

Grade 3: The disc-like opacity in the posterior capsule is surrounded by an area of further optical distortion. Only the
dilated pupil shows a clear red reflex surrounding this zone.

Grade 4: The opacity is totally occlusive; no sufficient red reflex is obtained by dilation of the pupil.

Clinical presentation
Posterior polar cataract presents as a distinctive discoid lens opacity situated posteriorly, adjacent to the posterior
capsule. The typical symptoms are increasing glare while driving at night and difficulty in reading fine prints. The
reasons for delayed presentation may be increasing density of the opacity, age-related pupillary miosis, or increased
functional needs. If it is visually significant since childhood, it might present with strabismus indicating amblyopia in
that eye.

Slit-lamp examination and pupillary retroillumination allow good evaluation of the visual significance of the opacity.
When posterior polar cataract is fully formed, it presents as a dense, circular plaque in the central posterior part of the
lens giving rise to “bull’s-eye” appearance (concentric rings around the central opacity). It can be surrounded by
vacuoles and smaller areas of degenerated lens material. Examination of the anterior vitreous may reveal oil-like
droplets or particles6.The presence of such finding should raise the possibility of pre-existing capsular opening.

Timing of Surgery
Timing of surgery is crucial. While it should be delayed as long as the patient is able to perform his routine activities, it
must be balanced against the potential of a posterior capsule (PC) defect developing in an intact capsule, as well as
the relative technical difficulty in performing phacoemulsification in advanced cataracts. Furthermore, when it is
visually significant in childhood, it is considered amblyogenic. All these reasons emphasize the importance of early
intervention in these cases.

Counseling
During the preoperative examination, the physician should inform the patient of the possibility of a PC rupture, a
relatively long operative time, secondary posterior segment intervention, and a delayed visual recovery. In addition,
the possibility of leaving the patient aphakic should be explained. Also, the need for Nd:YAG capsulotomy for residual
plaque should be discussed and the possibility of preexisting amblyopia, especially in cases of unilateral posterior
polar cataract should be emphasized. Genetic counseling for parents in addition to screening of family members is
important.

Anesthesia
Local and topical anesthesia can be utilized. Peribulbar anesthesia may be preferred, especially for novice surgeons, as
it provides prolonged action and reduces positive vitreous pressure. This is in contrast to topical anesthesia, in which
squeezing the lids with a speculum can distort the globe. Increased eye movement and lack of hypotony would
increase the forward movement of the posterior capsule.

Phacoemulsification
The incision
A temporal clear corneal incision, as routinely performed for all patients, is preferable for topical anaesthesia surgery. It
is important to ensure that the accessories used during the procedure (i.e. phaco tip, sleeve etc) correspond to the
incision size, else this would result in an incision that is too tight or one that is leaky, resulting in an unstable anterior
chamber during the procedure.

The capsulorhexis
The capsulorhexis should be between 4.5 to 5.5mm in size (Figure 1). A larger opening may not leave adequate
support for a sulcus-fixated IOL if the posterior capsule is compromised. However, it should not be too small (<4 mm)
for several reasons. A smaller capsulorhexis may increase the hydrostatic pressure during hydrodelineation and
subsequent nuclear emulsification and may jeopardize the nuclear, epinuclear or cortical matter removal. Additionally,
if vitreous loss occurs during phacoemulsification, it is easier to manually prolapse the nucleus into the anterior
chamber in the presence of a large capsulorhexis without having to further enlarge it.

Hydrodissection and hydrodelineation

Cortical cleaving hydrodissection is considered a contraindication in eyes with Type 3 and 4 posterior polar cataracts.
However, gentle hydrodissection may be done for type 1 and 2 cases, wherein pre-operative examination has ruled
out a PC defect. Nuclear rotation is avoided in all cases. Meanwhile, hydrodelineation, which is the separation between
the nucleus and the epinucleus, is mandatory to create a mechanical cushion of epinucleus (Figure 1). Following a
continuous curvilinear capsulorhexis, multiple fluid injections are undertaken in a controlled manner to hydrodelineate
the nucleus from the epinucleus. Vigorous decompression of the capsular bag after the delineation should be avoided.

Inside-out delineation
Vasavada and Raj described a technique for posterior polar cataracts with advanced nuclear sclerosis called inside-out
delineation7. In this technique, a trench is first sculpted and a right-angled cannula is used to subsequently direct fluid
perpendicularly to the lens fibers in the desired plane through one wall of the trench. This would avoid the possibility
of inadvertent subcapsular injection and overcome the difficulty of introducing cannula to a significant depth in a
dense cataract.
Parameters of the phacoemulsification machine
We prefer a slow motion phacoemulsification with low vacuum, low aspiration and low inflow parameters to ensure a
more stable anterior chamber. Ultrasound energy 40-70%, vacuum 250-270 mmHg, aspiration flow rate (AFR) 18-20
cc/ min and bottle height of 70-80 cm is recommended. The parameters are adjusted appropriately according to the
density of cataract. The low vacuum and aspiration rates maintain a very stable chamber and the reduced infusion
drives less fluid around the lens.
Nucleotomy techniques
The technique of nuclear emulsification varies with the grade of nuclear sclerosis. During the procedure, it is important
to avoid collapse of the anterior chamber as this might cause the anterior tenting of the posterior capsule and can
lead to spontaneous rupture. This can be done by judicious injection of a dispersive viscoelastic through the side port
incision before withdrawal of the phacoemulsification tip. In addition, nuclear rotation and aggressive nuclear cracking
techniques with wide separation of fragments should be avoided.

For grade 1 nuclear sclerosis, we prefer sculpting

8
(Figure 2) followed by sequential layer-by-layer aspiration using partial segmentation technique . The wedge shaped
cortical material is gradually aspirated till the central area of the posterior polar cataract (which may or may not have a
preexisting defect) is reached. The cortical material is mechanically separated from the central plaque from
approximately 3-4 mm outside the central area with the aid of a second instrument such as a chopper or a Sinskey
hook. This maneuver avoids traction at the posterior pole, which may otherwise be generated from attempting to
directly aspirate the cortical matter. The penultimate layer is carefully aspirated leaving the posterior plaque along with
a thin layer of the cortex. This reduces undue stress on the posterior capsule. The posterior plaque is then
viscodissected and aspirated with the automated irrigation aspiration probe. The advantage of layer-by-layer
phacoemulsification10 is the availability of an adequate cushion throughout the procedure, which is available during
debulking of the nucleus. Further, the visibility of the plaque is enhanced as the subsequent layers are gradually peeled
off by aspiration.

For grade 2 and 3 nuclear sclerosis, a small central trench is made followed by quadrantic division of the nucleus. Each
nuclear piece is then pulled towards the centre and emulsified without rotation. Removal of each segment creates
adequate space for fragmenting the subsequent segments. This facilitates nuclear emulsification without undue stress
on the posterior capsule.

For advanced nuclear sclerosis, a crater and chop technique is used. In this, a central large crater is made leaving the
epinuclear plate intact, followed by chopping without nuclear rotation.

If case of a PC plaque, if it is strongly adherent to the capsule that could not be peeled off even by viscodissection, the
safest option is to leave the plaque untouched for later Nd-YAG laser capsulotomy.

Pseudohole
At times, the classic appearance suggestive of a defect may be observed in the posterior cortex when the posterior
capsule actually remains intact. This phenomenon is known as a pseudohole (Figure 2).

Posterior capsular dehiscence

If a defect is present in the posterior capsule, a dispersive viscoelastic, Viscoat, is injected over the area of defect
before withdrawing the phaco or I/A probe from the eye. If the vitreous face is intact, the cortex is aspirated with
bimanual I/A. A posterior capsulorhexis may be performed if the rupture is confined to a small central area, although
most cases of posterior polar cataract have a linear PC defect extending upto the equator, distinct from that observed
in other cases of PC rupture. This linear defect is not amenable for conversion to a PCCC in most cases. In the case of a
vitreous disturbance, a two port limbal anterior vitrectomy using a high cut rate, low vacuum and flow rates,
vitrectomy can be safely performed even close to the torn capsule. Typical parameters are cut rate 800 cuts/ min;
vacuum 200 mm Hg and AFR 20 cc/min. The vitrector is never placed behind the peripheral posterior capsule. The
infusion cannula is directed into the peripheral anterior chamber, and the fluid jet is directed toward the angle of the
chamber, away from the defect. This reduces turbulence near the tip of the cutter and avoids enlarging the capsular
tear. It also reduces hydration of the vitreous and forward movement of vitreous into the anterior chamber. Once the
anterior chamber is free of vitreous, which is confirmed by injecting preservative free triamcinolone acetonide into the
anterior chamber, the remaining cortex is aspirated.

Intraocular lens (IOL) implantation

It depends on whether or not there is a capsular tear. If there is none or the size of the PC rupture is small or it could
be converted to a round one, single piece IOL can be implanted in the bag.

In eyes where the posterior capsule is compromised, the remaining capsular support is evaluated to choose the site for
intraocular lens fixation. It is safer to compress the trailing haptic rather than subjecting the capsular bag to rotational
forces that may extend the tear. If the tear is large, a multipiece IOL has to be placed in the ciliary sulcus with or
without rhexis capture. The advantage of capturing the optic by the rhexis is to stabilize the IOL and to reduce the
contact of optic with iris. In cases in which there is a big rupture with questionable zonular integrity, it would be safer
to implant an anterior chamber IOL, suturing an IOL to the sclera, or planning an intra-scleral haptic fixation of IOL
with glue. The main valvular incision should be sutured in eyes with a PC defect. These eyes should be periodically
evaluated for retinal break, cystoid macular edema, and raised IOP.

Posterior Polar Cataract in children

Posterior Polar Cataract has been identified in 7% of eyes of children undergoing congenital cataract surgery9. Unlike
adult eyes, PPC occurs as unilateral cataract in a majority of pediatric eyes (93%). 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 sign7.

The surgical paradigms for cataract surgery in eyes of children with PPC remain essentially similar to those used in
adult eyes. 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. 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 is
followed by in-the-bag implantation of IOL. All the incisions are sutured.
Fellow eye examination
It is imperative to examine the fellow eye in all cases, particularly those with complicated surgery in one eye. In these
cases presenting with an ACIOL or sulcus IOL in one eye, one should keep in mind the possibility of a pre-existing risk
factor for PC rupture/ PC defect such as a posterior polar cataract. The subsequent eye should be thoroughly
examined to rule out this entity, though it may be difficult in cases of advanced nuclear sclerosis or mature cataracts,
and surgery should be done with all necessary precautions.

Bimanual microphacoemulsification in posterior polar cataracts

Bimanual microphacoemulsification technique with separate infusion and aspiration instruments placed through
watertight incisions 1.4 mm in width has been advocated by some authors in cases of posterior polar cataract 10.
Besides having a controlled operating environment for slow motion phacoemulsification, the advantages of this
technique lie primarily in the following: (1) allowing withdrawal of the phaco-needle first while maintaining the anterior
chamber with infusion from the separate irrigating chopper, and (2) easy injection of viscoelastic into the anterior
chamber before final withdrawal of the irrigating chopper.
Summary
• All cases of posterior polar cataract need thorough examination and pre-operative counseling
• Pre-operatively, vitrectomy equipment should be ready
• A dispersive viscoelastic (eg Viscoat) should be available
• Adequate-sized and complete CCC should be achieved
• Hydrodissection is avoided, delineation is a must
• Nucleus rotation should be avoided
• Sudden anterior chamber collapse should be avoided at all times during the surgery
• Slow motion phaco with low flow parameters are used
• Most importantly, surgeon should continue with his routine technique which he is well versed in and comfortable
with, rather than trying a new technique for these cases
References
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2. Masket S. Consultation section: Cataract surgical problem. J Cataract Refract Surg 1997; 23:819–24
3. Osher RH, Yu BC, Koch DD. Posterior polar cataracts: a predisposition to intraoperative posterior capsular rupture. J Cataract Refract Surg 1990;
16:157–62
4. Duke-Elder S. Congenital deformities. Part 2. Normal and Abnormal Development. System of Ophthalmology; vol. III. St. Louis: CV Mosby; 1964
5. Schroeder HW. The management of posterior polar cataract: the role of patching and grading. Strabismus 2005; 13(4):153–6
6. Gifford SR. Congenital anomalies of the lens as seen with the slit lamp. Am J Ophthalmol 1924;7:678–85
7. Vasavada AR, Raj SM. Inside-out delineation. J Cataract Refract Surg 2004; 30:1167–9
8. 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 (Lond) 2008; 22(8):1008–10
9. 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
10. Haripriya A, Aravind S, Vadi K, Natchiar G. Bimanual microphaco for posterior polar cataracts. J Cataract Refract Surg. 2006 Jun;32(6):914-7.