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Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 12

Rate and risk factors for posterior capsular rent in small incision cataract surgery in a teaching hospital

Department of Ophthalmology, Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India

Date of Submission03-Sep-2021
Date of Decision25-Dec-2021
Date of Acceptance18-Jan-2022
Date of Web Publication23-Mar-2022

Correspondence Address:
Dr. Devappa Namrata
Plot No. 11, Devi Colony, Bidar, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_109_21

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Purpose: The purpose was to study the proportion and risk factors for posterior capsular rent (PCR) in small incision cataract surgery in a teaching hospital.
Methods: We conducted a retrospective observational study of all cases with PCR in small incision cataract surgery performed between November 2015 and May 2018. The medical records were analyzed and data were collected.
Results: There were a total of 63 cases of PCR out of 4206 cases who underwent small incision cataract surgery with a 1.68% PCR rate. The mean age was 65.5 years and the male-to-female ratio was 2.15:1. There was no association between nuclear sclerosis, pupil dilatation, and pseudoexfoliation. Resident operated surgeries had a PCR rate of 1.96 compared to faculty operated surgeries which was 1.46. Three faculty surgeons accounted for 54.3% of the cases while the remaining ten surgeons accounted for 45.7% of the cases. Postoperative day 1 vision was low, with only 19% achieving >6/18 vision, and 54% of the individuals needed more than one topical drug and 61.5% were started on oral steroids.
Conclusion: Surgeon- and patient-related factors are equally important in avoiding posterior capsule rent in cataract surgeries. Patient-related factors should be carefully assessed preoperatively on slit-lamp biomicroscope, so that surgeons are prepared for all the complications and visual morbidity limited. Surgeon factors also need to be looked into and efforts have to be made to limit them and thus ensure the right to vision to each patient.

Keywords: Posterior capsular rent, small incision cataract surgery, teaching hospital

How to cite this article:
Pradeep TG, Namrata D, Thomas AM. Rate and risk factors for posterior capsular rent in small incision cataract surgery in a teaching hospital. Pan Am J Ophthalmol 2022;4:12

How to cite this URL:
Pradeep TG, Namrata D, Thomas AM. Rate and risk factors for posterior capsular rent in small incision cataract surgery in a teaching hospital. Pan Am J Ophthalmol [serial online] 2022 [cited 2023 May 29];4:12. Available from: https://www.thepajo.org/text.asp?2022/4/1/12/340382

  Introduction Top

The prevalence of blindness in India is 1.99% according to the National Blindness and Visual Impairment Survey, 2019.[1] The survey further reports that cataract is the leading cause of blindness above 50 years of age, but the third cause of blindness is cataract surgery-related complication which accounts for 7.2% of blindness. 8.2% from postcataract surgery individuals had vision <6/60. In our bid to reduce blindness due to cataract, we are increasing the number of cataract surgeries performed, but we need to be cautious to not increase the surgery-related complication and associated blindness.

The cataract surgery has evolved over the years from intracapsular cataract extraction to extracapsular cataract extraction with placement of intraocular lens (IOL). With evolvement of surgeries, the rate of complications and ocular morbidities has also reduced with early visual rehabilitation.[2] The two most common cataract surgeries done among extracapsular surgeries are manual small incision cataract surgery (SICS) and phacoemulsification. The manual SICS is the most common surgery performed in developing countries owing to its cost-effectiveness and less steeper learning curve, when compared to phacoemulsification.[3],[4],[5] Even though the rate of complications has decreased, many of the complications are still significant and result in visual morbidities. Posterior capsular rent (PCR) is one of the most common complications of cataract surgery which causes significant visual morbidity. Rohart et al. reported that in their study, only 72.4% of the patients who had PCR had a best-corrected visual acuity of 6/12 or better and those with PCR required a higher number of follow-ups (5.2 ± 2.6) and 34.5% of the patients needed additional topical and oral medications, thus emphasizing the need to identify factors associated with PCR in SICS. By identifying preoperative risk factors for PCR and better planning, we can minimize the PCR rates and ultimately improve visual outcomes.[6]

In this study, we evaluated the proportion of PCR in SICS performed in a tertiary center which included surgeons of varying surgery skill. Being a referral center, the hospital catered to varying difficulties of cases and we tried to identify the preoperative and intraoperative risk factors for PCR in SICS.

  Methods Top

We conducted an observational study of the patients who underwent manual SICS from November 2015 to May 2018. The inclusion criteria were all patients from rural camps as well as walk-in patients who had PCR with manual SICS. Both uncomplicated and complicated cases such as subluxated lens and traumatic cataract were included. All the patients who underwent phacoemulsification and those who did not have PCR were excluded from the study. The data were collected from the medical records of all the patients who had undergone cataract surgery during this period.

All the patients before surgery underwent visual acuity testing, detailed anterior segment examination with slit-lamp biomicroscope to assess the grade of cataract, maximum pupil dilatation, presence of pseudoexfoliation, grade of cataract, presence of phacodonesis, absence of zonules, and presence of anterior chamber inflammation. The intraocular pressure was measured with Goldmann applanation tonometer, and if the value was more than 21 mmHg, antiglaucoma medication was started, and only when the pressure was decreased, a patient was considered for cataract surgery. A-scan and keratometry were done to calculate IOL power. Fundus examination was done with indirect ophthalmoscopy. Patients with nonvisualization of fundus underwent B-scan to rule out other posterior segment pathologies. Preoperative medication includes systemic antibiotics and topical antibiotics, and the patient was prepared for surgery after taking informed consent. These were usually printed in a standardized template for all cataract patients in the hospital and hence collection of data was standardized.

All patients received topical antibiotics starting 1 day prior to the surgery. All patients underwent instillation of tropicamide and phenylephrine eye drops for 1 h prior to the surgery to dilate the pupil. The surgery would be done by various surgeons with varied skills, i.e., from residents, trainees to consultants with varying years of experience in the ophthalmic surgeries. All the patients were given peribulbar block. The procedure of SICS was a standard which was followed by most surgeons with minor individual variations. A scleral tunnel was done – each surgeon had a preference of superior, superotemporal, or temporal and these were recorded; capsulotomy included can-opener or capsulorrhexis which was mentioned in the case records. Following hydrodissection the nucleus was removed by sandwich technique. Cortical wash was given and rigid IOL placed after making sure posterior capsule was intact after all the steps. When PCR was noted , depending on the status of the capsular bag, a rigid lens or an iris claw lens was placed. If lens could not be placed the patient was left aphakic. If anterior hyaloid face was disturbed, manual anterior vitrectomy was done before placing the lens. If any intraoperative complications occurred, they were recorded in the operative record which were later scrutinized. The surgical step during which PCR occurred was documented in the record, and this was noted.

Postoperatively, the patient was examined on the first day:, visual acuity was noted, and anterior segment examination included slit lamp examination to look for corneal edema, anterior chamber reaction, stable IOL, and Intraocular pressure measurement. All the postoperative medications given on the 1st day were noted. All the data were entered in an Excel sheet, and were analyzed using SPSS for Windows, Version 16.0. Chicago, SPSS Inc. Released 2008.

  Results Top

A total of 4206 SICS surgeries were performed during the period of November 2015 to May 2018. Sixty-three cases had a PCR, thus the proportion of PCR in our series was 1.68%. The mean age of the patients was 65.5 years. The male-to-female ratio was 2.15:1 with higher proportion of males. The mean age group among females was 60.9 ± 7.5 years and males was 67.6 ± 10 years, which was statistically significant (P = 0.011). When the patients were grouped into greater than 65 and <65, it was seen that 42 (66.7%) of them were over 65 years of age and only 21 (33%) were below 65 years. It could not be attributed to increased nuclear sclerosis as there was no statistically significant difference in nuclear sclerosis between the different age groups (P = 0.440).

The left eye (54%) of patients had more PCRs than the right eye (46%), but this was not statistically significant.

The preoperative risk factors are studied and tabulated in [Table 1]. The senile immature cataract and pupil size >7 mm was associated with 57.1% and 76.4% of PCRs, respectively. Senile hypermature cataracts and traumatic and subluxated cataracts accounted for 23.9% of the cases. Pseudoexfoliation was seen in only 15.9% of the rents. Posterior subcapsular cataract (PSC) was seen in 49% of the individuals who had PCR. Nuclear sclerosis of >3 was seen in nearly one-third of the cases.
Table 1: Preoperative risk factors

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Intraoperative risk factors were analyzed and it was seen that resident-operated surgeries had a higher proportion of PCR (1.96) as compared to consultant (1.46), as shown in [Table 2].
Table 2: Comparison of posterior capsular rent between faculty and residents

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We analyzed PCR for each consultant and found that three consultant surgeons accounted for 54.3% of the cases and the remaining 45.7% of the cases were accounted for the remaining ten surgeons with each surgeon's proportion <5% each [Table 3].
Table 3: Comparison of posterior capsular rent proportion among consultants

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We found that in 53 (84.1%) cases, capsulorrhexis was done, and in only 10 (15.9%) cases, can-opener was done. The timing of PCR was recorded in all the case sheets, and it was seen that PCR was noted during nucleus delivery in 57.1% of the cases and during cortical wash in 41.3%.

The IOL choice was iris claw lens in 45 (71.4%), followed by PCIOL in 10 (15.9%) cases, and 8 (12.7%) were left aphakic.

postoperative day one, the vision was recorded and is shown in [Table 4], and it was shown that only 38% of the individuals had vision >6/60.
Table 4: Postoperative day 1 vision

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The postoperative complications on the first day are demonstrated in [Table 5].
Table 5: Immediate postoperative complications

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It was seen that 38 (54%) individuals required more than one drug and oral steroids were started in 45 (65.1%) patients. This is shown in [Table 6].
Table 6: Additional medications required postoperatively

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No association was seen between the grade of nuclear sclerosis, pseudoexfoliation, pupil size, PSC, and the timing of PCR.

  Discussion Top

PCR is a very important cataract surgery complication which significantly affects the postoperative vision. Recognizing the risk factors and planning the case appropriately and managing the PCR adequately minimizes the visual morbidity. It is sometimes inevitable, and only efficient management helps in preserving the vision in the patients.

Our study aimed to analyze the preoperative risk factors for PCR, and we noticed that in the age above 65 years, it was almost double than that below 65 years. Although all other factors such as pupil size, nuclear sclerosis, pseudoexfoliation, and PSC were not significantly different between the two groups, implicating increasing age itself as a risk factor for PCR. However, this is different in other studies where Bhikoo et al. in their study express that there is no association between age, gender, axial length, cataract severity, and operative complications.[7]

In our study, females were in lesser proportion than males (1:2.15), and gender rates do not seem to be significant data within this study. The mean age for females was significantly lower than males. Ryu et al. in their study of 2,237,107 cases of phacoemulsification found that male sex, preoperative diabetes, and age <40 years had a higher proportion of PCR.[8]

In SICS, hypermature cataract, hard cataract, white cataract fixed pupil, and axial length have been identified as risk factors for intraoperative complications.[9],[10] We did not find any association between these. In our study, 74.6% had a well-dilating pupil and only 23.4% of our cases had hypermature cataract, or subluxated or traumatic cataract, and 57.1% of our cases had immature cataract. This could be due to the fact that a greater number of immature cataracts were operated.

Pseudoexfoliation has been reported by many studies as a risk factor for PCR, especially in phacoemulsification,[11] but however, in our study, it was seen only in 10 (15.9%) cases and was not a risk factor for PCR in SICS. We, however, found that nearly 49% of the cases had PSC. When we tried to assess if this type of cataract was associated with timing of occurrence of PCR, we found none. When we tried to analyze if grade of nuclear sclerosis had any association with PCR, we found that 68.3% of the cases were less than Grade 2 sclerosis, implying that increased sclerosis was not a risk factor for PCR in SICS. However, it could be due to higher proportion of low-grade nuclear sclerosis being operated.

We analyzed the surgeon factors and found that resident-performed surgeries had a higher proportion of PCR (1.96%) compared to faculty (1.46%) which is similar to many studies which emphasize on the skill level of residents compared to faculty, but however, it was within the range all over the world where PCR rates vary between 0.7% and 4.7% being higher in residents.[2],[11],[12],[13]

We analyzed the PCR rates for each surgeon and found that three surgeons accounted for nearly 55% of the cases while the remaining ten surgeons accounted for 45% of the cases. Venkatesh et al. also showed in their study compared PCR rates among three surgeons and found that odds ratio of having PCR was 2.83% in one surgeon compared to other two surgeons.[14] This has not been stressed upon in other studies and thus we should lay emphasis on continued upgrading of skill even for faculty as most of the complications can be prevented with this continued training. It is very essential that the cases are allotted according to the skill level of each faculty.

Postoperative first day vision was significantly low in these individuals, with only 19% achieving >6/18 vision on postoperative day one. It is a known fact that the corneal edema and raised IOP and inflammation when controlled most of these individuals do improve with vision, but it should be noted that a significant proportion of these individuals end up with poor vision.

In our study, 54% of the individuals needed more than one topical drug and nearly 65% of the individuals were started on oral steroids to reduce inflammation. Rohart et al. also found in their study that 34.5% of the individuals needed more than two drugs in the postoperative management. These add on to the burden of management of these individuals, thus advocating the need to prevent the complication as much as possible.

Our study looked into the surgeon factor, which has not been adequately addressed by other studies. In SICS, patient factors did not show any statistical significance on PCR whereas surgeon factors seemed more important than patient factors. The need to reduce complications in cataract surgery has become the need of the hour as every patient has a right to good vision. In view of this not only identifying the patient-related factors and addressing them, even surgeon-associated factors need to be looked into and emphasis has to be laid on continued skill upgradation of surgeons.

The limitations of our study were that it was a retrospective study and hence some data collection may have been missed. As we only studied postoperative day 1 vision, we would have underestimated the number of patients who would have improved vision with medical management of the postoperative complications.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Prasad R. National Blindness and Visual Impairment Survey 2015-2019. New Delhi: Centre for Ophthalmic Sciences, AIIMS; 2020.  Back to cited text no. 1
Hashemi H, Rezvan F, Khabazkhoob M, Gilasi H, Etemad K, Mahdavi A, et al. Cataract surgical rate in Fars Province: Distribution and trend from 2006 to 2010. J Curr Ophthalmol 2016;28:43-5.  Back to cited text no. 2
Ruit S, Gurung R, Vyas S. The role of small incision suture-less cataract surgery in the developed world. Curr Opin Ophthalmol 2018;29:105-9.  Back to cited text no. 3
Gogate PM, Deshpande M, Wormald RP. Is manual small incision cataract surgery affordable in the developing countries? A cost comparison with extracapsular cataract extraction. Br J Ophthalmol 2003;87:843-6.  Back to cited text no. 4
Venkatesh R, Das M, Prashanth S, Muralikrishnan R. Manual small incision cataract surgery in eyes with white cataracts. Indian J Ophthalmol 2005;53:173-6.  Back to cited text no. 5
[PUBMED]  [Full text]  
Rohart C, Fajnkuchen F, Buffet S, Lé M, Chaine G. Visual outcome and complications after posterior capsule rupture during phacoemulsification surgery. Invest Ophthalmol Vis Sci 2008;49:380.  Back to cited text no. 6
Bhikoo R, Vellara H, Lolokabaira S, Murray N, Sikivou B, McGhee C. Short-term outcomes of small incision cataract surgery provided by a regional population in the Pacific. Clin Exp Ophthalmol 2017;45:812-9.  Back to cited text no. 7
Ryu SY, Kim J, Hong JH, Chung EJ. Incidence and characteristics of cataract surgery in South Korea from 2011 to 2015: A nationwide population-based study. Clin Exp Ophthalmol 2020;48:319-27.  Back to cited text no. 8
Gogate PM, Deshpande M, Wormald RP, Deshpande R, Kulkarni SR. Extracapsular cataract surgery compared with manual small incision cataract surgery in community eye care setting in western India: A randomised controlled trial. Br J Ophthalmol 2003;87:667-72.  Back to cited text no. 9
Day AC, Donachie PH, Sparrow JM, Johnston RL; Royal College of Ophthalmologists' National Ophthalmology Database. The royal college of ophthalmologists' national ophthalmology database study of cataract surgery: Report 1, visual outcomes and complications. Eye (Lond) 2015;29:552-60.  Back to cited text no. 10
Rutar T, Porco TC, Naseri A. Risk factors for intraoperative complications in resident-performed phacoemulsification surgery. Ophthalmology 2009;116:431-6.  Back to cited text no. 11
Hashemi H, Rezvan F, Khabazkhoob M, Gilasi H, Etemad K, Mahdavi A, et al. Trend in cataract surgical rate in iran provinces. Iran J Public Health 2014;43:961-7.  Back to cited text no. 12
Martin KR, Burton RL. The phacoemulsification learning curve: Per-operative complications in the first 3000 cases of an experienced surgeon. Eye 2000;14:190-5.  Back to cited text no. 13
Venkatesh R, Muralikrishnan R, Balent LC, Prakash SK, Prajna NV. Outcomes of high volume cataract surgeries in a developing country. Br J Ophthalmol 2005;89:1079-83.  Back to cited text no. 14


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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