C L I N I C A L S C I E N C E

Reverse Optic Capture of the Single-Piece

Acrylic Intraocular Lens in Eyes With
Posterior Capsule Rupture
Jason J. Jones, MD; Thomas A. Oetting, MD; Gina M. Rogers, MD; George J. C. Jin, MD, PhD

 BACKGROUND AND OBJECTIVE: To evalu-
ate the clinical results of reverse optic capture (ROC)
with single-piece posterior chamber intraocular lenses
(PC-IOLs) in cases of phacoemulsification cataract and
IOL surgery with posterior capsular rupture.
 PATIENTS AND METHODS: Preoperative di-
agnosis, intraoperative events, surgical parameters,
intraoperative and postoperative complications, and
preoperative and postoperative visual acuity and refrac-
tion of 16 eyes that underwent ROC were reviewed
and analyzed. The fellow eye of 12 patients undergoing
uneventful phacoemulsification without optic capture
served as the control group.
group achieved a best-corrected visual acuity of 20/25 or
better. Ninety-four percent of eyes in the ROC group and
100% in the control group had postoperative spherical
equivalent 1.00 D of the intended refraction. Refraction
was stable between 1 month and final follow-up in both
groups. In all eyes with ROC, the IOL remained well cen-
tered with a securely captured optic. There were no vision-
threatening complications throughout the follow-up.
 CONCLUSION: The comparable outcomes in
both groups suggests that optic capture of a single-
piece acrylic IOL through an anterior capsulorhexis
merits consideration for IOL placement in selected
cases of insufficient posterior capsule support.

 RESULTS: Over a mean of 19 months follow-up, [Ophthalmic Surg Lasers Imaging 2012;43:480-
94% of eyes in the ROC group and 92% in the control 488.]

INTRODUCTION plete or insufficient capsule support remains controver-

sial. One implantation technique, optic capture, was
The selection, placement, and implantation tech- first described by Neuhann as rhexis-fixation lens in
nique of an intraocular lens (IOL) in cases of incom- 1991 (Neuhann T. The Rhexis-fixated Lens film pre-

From Jones Eye Clinic and Surgery Center (JJJ, GJCJ), Sioux City, Iowa; the Department of Ophthalmology (TAO, GMR), University of Iowa, Iowa; and the
Department of Ophthalmology and Visual Sciences (GJCJ), University of Utah, Salt Lake City, Utah.

Originally submitted October 6, 2011. Accepted for publication July 16, 2012. Posted online September 6, 2012.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to George J. C. Jin, MD, PhD, Jones Eye Clinic and Surgery Center, 4405 Hamilton Boulevard, Sioux City, IA 51104. E-mail: george-
jin@live.com
doi: 10.3928/15428877-20120830-02

480 COPYRIGHT SLACK INCORPORATED

sented at the Symposium on Cataract and Refractive
Surgery, Boston, Massachusetts, April 1991). With this
technique, a three-piece posterior chamber IOL (PC-
IOL) is placed in the ciliary sulcus and then the op-
tic is depressed posteriorly beneath the rim of anterior
continuous curvilinear capsulorhexis (CCC) to achieve
IOL stability. This technique was advocated for cases
of posterior capsule rupture (PCR) and is also termed
as anterior capsular support for posterior chamber
IOL,1 anterior capsule rhexis fixation,2 or rhexis
IOL fixation.3 This conventional optic capture tech-
nique (haptics in the sulcus and optic in the bag using
a three-piece PC-IOL) is most often referred to as optic
capture or posterior optic capture in the literature.
In contrast, reverse optic capture (ROC) (anterior
optic capture or reverse rhexis fixation) is achieved by
capture of the optic anteriorly through the anterior cap-
sulorhexis opening (haptics in the bag, optic anterior to
rhexis) or both anterior and posterior capsulorhexes (hap-
tics behind the posterior capsule, optic anterior to rhexis ).
Gimbel and DeBroff3 proposed this technique of reverse
rhexis fixation for cases where a posterior capsule tear oc-
curs after the IOL is placed in the bag or is noticed or ex-
tends after IOL placement. Pushker et al.4 reported a case
in which a three-piece AcrySof IOL (Alcon Laboratories,
Inc., Fort Worth, TX) was implanted with anterior optic
capture in a patient with isolated traumatic PCR.
ROC has been used for other purposes in cataract
surgery. Akaishi et al. presented the results of capturing
the IOL optic through anterior CCC in a subsequent
surgery to correct the residual refractive error after pre-
vious cataract surgery with multifocal IOL implanta-
tion.5 Masket and Fram recently reported successful
results of 3 cases using ROC to treat patients experi-
encing negative dysphotopsia.6
We prefer the term reverse optic capture because
this not only describes the procedure properly but also
avoids confusion with the conventional optic capture
in the literature. To our knowledge, no peer-reviewed
publication detailing results of ROC in eyes with poor
capsular support exists in the literature. The purpose
of this study is to describe our technique of ROC and
assess the results of this technique.
PATIENTS AND METHODS
This retrospective study reviewed the medical re-
cords of all patients who had ROC performed during
OPHTHALMIC SURGERY, LASERS & IMAGING VOL. 43, NO. 6, 2012
phacoemulsification or IOL surgery at Jones Eye Clinic
and Surgery Center, Sioux City, Iowa, and the Depart-
ment of Ophthalmology, University of Iowa, Iowa City,
Iowa, from November 2007 to April 2011. Fellow eyes
that had phacoemulsification with the IOL implanted
in the capsular bag but without optic capture during the
same period served as the control group. Inclusion cri-
teria were: the cataract surgery had been performed in
patients with no combined glaucoma or retinal surgery
and the patients age was at least 40 years. The study de-
sign and protocol were approved by the Siouxland and
the University of Iowa Institutional Review Boards.
Medical records of the patients were analyzed us-
ing a standardized case report form designed for the
study. Data on age, sex, coexisting eye disease, history
of ocular trauma, type of cataract, IOL power determi-
nation (IOL calculation formula used, target refraction
chosen), and date of cataract surgery were collected.
Intraoperative information was obtained from surgical
records and surgical videos. Data collected included
the size, centration, and integrity of the anterior cap-
sulorhexis, time of occurrence or recognition of PCR,
condition of zonules, posterior capsule and vitreous,
use of mechanical pupil dilation or a capsular tension
ring, type of IOL, location of IOL, and whether a pos-
terior CCC was performed.
An invitation to attend a current follow-up visit
was sent to all included patients. If the patient was un-
available for the visit, the data of last visit was used for
the study. Data collected after cataract surgery included
uncorrected visual acuity (UCVA), best-corrected vi-
sual acuity (BCVA) and corresponding manual refrac-
tion, intraocular pressure (IOP), presence of flare and
cells in the anterior chamber, vitreous in the anterior
chamber, anterior or posterior synechiae, IOL centra-
tion, and additional procedures including Nd:YAG la-
ser treatment for posterior capsule opacification. Addi-
tionally, patients were asked questions regarding photic
symptoms (halo or glare), wearing glasses for distance
or near, and scoring for their satisfaction of the visual
outcome. This study assessed the data from preopera-
tively, same day or 1 day postoperatively, 1 week post-
operatively, 1 to 3 months postoperatively, and the last
follow-up visits.
Surgical Technique
Two surgeons (JJJ, TAO) performed all surgeries
using a similar technique. Topical and intracameral an-
481
esthesia were used. A paracentesis and a 2.7-mm clear
corneal incision were created with keratome blades. The
anterior chamber was inflated with a dispersive oph-
thalmic viscoelastic device, and a round, well-centered
CCC was fashioned with Utrata forceps. The CCC was
sized approximately 5.0 to 5.5 mm to ensure complete
overlap of the intended in-the-bag IOL optic. This was
followed by hydrodissection and phacoemulsification.
The nucleus was removed with the phacoemulsifica-
tion handpiece and second instrument. Residual cortex
was removed with the irrigation/aspiration handpiece.
A cohesive ophthalmic viscoelastic device was used for
capsular bag expansion, and the IOL was implanted in
the capsular bag with an injector system.
In cases where the PCR was recognized following
IOL implantation into the bag, ROC was achieved by
positioning a spatula (modified Baes ICL manipulator;
Rhein Medical, St. Petersburg, FL) or a Kuglen hook
through the main incision reaching underneath the optic
and pulling the optic forward gently, thus vaulting the en-
tire optic through the opening of intact CCC. The optic
was therefore entrapped centrally in front of the bag and
the haptics remained in the capsular bag. Care was taken
to ensure that the optic was completely but not partially
captured by inspecting the shape of the CCC.
The ophthalmic viscoelastic device was aspirated
slowly from the anterior chamber using irrigation/as-
piration or automated vitrector. The ophthalmic visco-
elastic device behind the IOL was left in place. The an-
terior chamber was restored with balanced salt solution
and the incisions were hydrated and tested for leakage.
In cases where the PCR was recognized prior to im-
plantation of the IOL, the spatula was placed through
the paracentesis and underneath the IOL as it was be-
ing injected to avoid descent into the vitreous. Either
a syringe-style plunger injector or assistant activation
of the screw mechanism of a traditional injector aided
in this process. As the anterior segment was fully stabi-
lized with ophthalmic viscoelastic device, the lens was
temporarily suspended and allowed for opening of the
haptics and entrapment of the optic as described above.
At the end of the operation, a drop of antibiotic
was placed on the surface of the eye. In some cases at
high risk for ocular hypertension, sustained-release ac-
etazolamide 500 mg was taken after surgery. Further
postoperative treatment included topical antibiotic for
1 week, steroid for 4 weeks, and nonsteroidal anti-in-
flammatory drops for 4 to 8 weeks.
482
The single-piece acrylic foldable IOLs (AcrySof
IOLs; Alcon Laboratories, Inc.) used in this study were
AcrySof SN60WF in 15 eyes and AcrySof ReSTOR
SN6AD3 in one eye. In the control group, all had an
AcrySof SN60WF IOL implanted into the capsular bag.
Statistical Analysis
Descriptive statistics (patient age, IOL power, pre-
operative and postoperative visual acuity, and postopera-
tive objective refraction) were analyzed using SPSS for
Windows (version 13.0; SPSS, Inc., Chicago, IL). Data
analysis was based on the number of eyes. Snellen acuity
was converted to the logarithm of the minimum angle of
resolution (LogMAR) values. Predicted refractive error
was calculated using the actual postoperative refraction
at the last follow-up visit minus the target postopera-
tive refraction. The Students t test was used to evaluate
the significance of the difference. The paired t test was
used to evaluate the significance of measurements preop-
eratively versus postoperatively and 1 month postopera-
tively versus last follow-up. Data were expressed as mean
standard deviation, and a P value of less than .05 was
considered statistically significant.
RESULTS
Patient Characteristics
The study group enrolled 16 eyes of 16 patients (9
women, 7 men). The mean age of the patients at the time
of surgery was 74.3 12.0 years (range: 42 to 89 years).
The mean follow-up was 19.1 months (range: 1 to 43
months). The control group included 12 patients fellow
eyes. There was no significant difference of the age, axial
length, keratometry, IOP, and follow-up periods between
the two groups (Table 1).
Visual Acuity
Table 2 shows the postoperative visual acuity in
each group. The final mean LogMAR UCVA was simi-
lar in these two groups (P = .780). At last follow-up,
50% of eyes in each group had UCVA of 20/25 or bet-
ter and 81% of eyes in the ROC group and 75% in the
control group had UCVA of 20/40 or better.
The preoperative mean LogMAR BCVA was 0.52
0.46 in the ROC group and 0.53 0.33 in the con-
trol group. There was no significant difference between
the groups (P = .939). At last visit, the mean LogMAR
BCVA was 0.07 0.13 in the ROC group and 0.05
COPYRIGHT SLACK INCORPORATED
 TABLE 1
Patient Demographics
Demographics ROC Group Control Group P
Eyes/patients (no.) 16/16 12/12
Age (y)
Mean SD 74.3 12.0 73.9 13.1 .934
Range 4289 4289
Sex (M/F) 7/9 5/7
Right/Left Eye 10/6 5/7
Type of cataract (no.)
Lens sclerosis/PSC 12 9
White 2 1
Posterior polar 1 1
Pseudophakia 1 0
Ocular comorbidity (no.)
Age-related macular degeneration 1 1
Branch retinal venous occlusion 1 0
Previous myopic LASIK 1 1
Axial length (mm), mean SD 23.43 0.65 23.66 0.84 .416
Preop mean K (D), mean SD 44.05 1.16 44.12 1.46 .872
Preop SE (D), mean SD 0.66 2.0 0.29 3.0 .690
Preop IOP (mm Hg), mean SD 15.1 2.5 15.3 2.8 .791
Follow-up (mo)
Mean SD 19.1 16.7 16.5 17.1 .694
Range 143 144
No. eyes with follow-up  12 months (%) 10 (63) 7 (58)
ROC = reverse optic capture; SD = standard deviation; PSC = posterior subcapsular cataract; preop = preoperative; D = diopters; SE = spherical
equivalent; IOP = intraocular pressure.

0.12 in the control group. The improvement of BCVA
from preoperatively to postoperatively was significant
in each group (P = .001 in the ROC group and P =
.000 in the control group, paired t test), which cor-
responds to 94% of eyes in the ROC group and 92%
of eyes in the control group achieving a postoperative
visual acuity of 20/25 or better. No eye lost BCVA in
either group. There was preexisting age-related macular
degeneration in 1 eye in each group having BCVA of
20/60. There was no significant difference in BCVA at
last follow-up between the groups (P = .717).
Predictability
Table 3 shows the refractive changes following sur-
gery and the percentage of eyes within 0.50 diopters
(D) and within 1.00 D of emmetropia during the
follow-up. In the ROC group, the mean spherical equiv-
alent decreased from 0.66 2.00 D preoperatively to
-0.53 0.73 D at 1 month postoperatively and -0.39
0.77 D at last follow-up. In the control group, the mean
spherical equivalent was 0.29 3.00 D preoperatively,
-0.23 0.31 D 1 month postoperatively, and -0.18
0.28 D at last visit. There was no significant difference
in the mean spherical equivalent preoperatively (P =
.690), at 1 month postoperatively (P = .191), and at the
last follow-up visit (P = .369) between the groups. The
mean spherical equivalent remained stable between 1
month postoperatively and the last visit in both groups
(P = .252 in ROC group and P = .210 in control group,
paired t test). At the last visit, 88% of eyes in the ROC

OPHTHALMIC SURGERY, LASERS & IMAGING VOL. 43, NO. 6, 2012 483
 TABLE 2
target refraction and predicted refractive error was not
Postoperative Visual Acuity at Last Visit significant in the ROC group (P = .326) or the control
group (P = .373). No difference of the target refraction
Control
ROC Group Group (P = .859) and the predicted refractive error (P = .112)
Visual Acuity (n = 16) (n = 12) P occurred between these two groups. However, there was
UCVA a slight myopic shift in the ROC group (-0.32 D). At
(LogMAR) the last follow-up, 63% of eyes in the ROC group and
Mean SD 0.21 0.19 0.19 0.21 .780 100% in the control group achieved predicted refractive
 20/20 (%) 4 (25) 5 (42) error within 0.50 D, and 94% of eyes in the ROC
 20/25 (%) 8 (50) 6 (50)
group were within 1.00 D of the target refraction.
 20/40 (%) 13 (81) 9 (75)
Complications and Visual Quality
BCVA ROC was performed uneventfully on all eyes in the
(LogMAR)
series. No complications occurred during the ROC pro-
Mean SD 0.07 0.13 0.05 0.12 .717
cedure. At the same-day or 1-day postoperative exami-
 20/20 (%) 7 (44) 8 (67) nation, no eyes in either group had hyphema or severe
 20/25 (%) 15 (94) 11 (92) anterior chamber reaction (anterior chamber cells were
< 20/40 (%) 1 (6.3) 1 (8.3) trace or 1+ or less in all eyes). The IOP was higher than
ROC = reverse optic capture; UCVA = uncorrected visual acuity; 25 mm Hg in 5 eyes (31%, range: 25 to 34 mm Hg)
LogMAR = logarithm of the minimum angle of resolution; SD =
standard deviation; BCVA = best-corrected visual acuity.
in the ROC group and 1 eye (8%) in the control group.
These patients were treated with oral carbonic anhydrase
inhibitors, topical aqueous suppressants, or both. IOP
group and 100% of eyes in the control group achieved was rapidly controlled and became normal (less than 21
refraction within 1.00 D of emmetropia. mm Hg) without medication in all patients at the 1-week
Table 4 shows the IOL power and predicted refrac- follow-up. There were no vision-threatening postopera-
tive error in both groups. The difference between the tive complications such as cystoid macular edema, retinal

TABLE 3
Refraction Over Time
Preoperativea Postoperative 1 Monthb Last Visitc
ROC Control ROC Control ROC Control
Time Groups (n = 16) (n = 12) (n = 16) (n = 12) (n = 16) (n = 12)
SE (D)
Mean 0.66 0.29 -0.53 -0.23 -0.39 -0.18
SD 2.02 3.00 0.73 0.31 0.77 0.28
Range
Minimal -3.00 -5.50 -2.50 -0.63 -2.50 -0.63
Maximal +4.25 +4.63 +0.75 +0.38 +0.75 +0.25
Eyes (%)
 0.50 D 4 (25) 0 8 (50) 9 (75) 9 (56) 10 (83)
 1.00 D 7 (44) 3 (25) 14(88) 12 (100) 14 (88) 12 (100)
 1.50 D 9 (56) 8 (67) 1 (6) 1 (6) 0
ROC = reverse optic capture; SE = spherical equivalent; D = diopters.
a
P = .690.
b
P = .191.
c
P = .369.

484 COPYRIGHT SLACK INCORPORATED

 TABLE 4 TABLE 5
IOL Power, Target Refraction, Intraoperative Events in the ROC Group
and Predicted Errora Events No. of Eyes
ROC Control Time PCR occurred or being
Group Group recognized
Variable (n = 16) (n = 12) P
After IOL Implantation 2 (15%)
IOL power (D)
Before IOL Implantation 11 (85%)
Mean SD 21.00 20.88 .866
1.82 2.05 Phaco, nucleus removal 2

Range 18.50 to 18.00 to I/A, cortex 1

23.50 24.50 PC polishing with Terry Squeegee 6
Target refraction (D) During PCCC 1
Mean SD -0.12 -0.16 .859 During haptics removal in IOL 1
0.64 0.13 exchange
Range -1.89 to -0.43 to Size of PCR at its recognition
+1.53 +0.02
Large  6 mm 6 (46%)
Predicted error (D)
Small < 6 mm 7 (54%)
Mean SD -0.32 -0.09 .112
0.44 0.23 Location of PCR

Range -1.27 to -0.42 to Center 4 (31%)

+0.64 +0.43 Peripheral 9 (69%)
Eyes with Edge of PCR visualized
predicted error
Yes 7 (54%)
 0.50 D (%) 10 (63) 12 (100)
No 6 (46%)
 1.00 D (%) 15 (94) 12 (100)
Vitreous
 1.50 D (%) 16 (100)
Prolapse/loss 5 (38%)
IOL = intraocular lens; ROC = reverse optic capture; D = diopters;
SD = standard deviation. Heriating to PCR 7 (54%)
a
Predicted error = actual postoperative refraction minus target
refraction. Vitrectomy 5 (38%)
PCCC performed 1 (8%)
Incision sutured 2 (16%)
detachment, persistent uveitis, and no cases of IOL decen-
tration, tilt, or dislocation at any time during the follow- ROC attempted once 13 (100%)
ROC = reverse optic capture; PCR = posterior capsular rupture;
up in both groups. By the last postoperative visit, 3 eyes IOL = intraocular lens; phaco = phacoemulsification; I/A = irriga-
(18.8%) in the ROC group and 1 eye (8.3%) in the con- tion/aspiration; PC = posterior capsule; PCCC = posterior continu-
ous curvilinear capsulorhexis.
trol group had undergone an Nd:YAG laser capsulotomy.
There were no complications after Nd:YAG capsulotomy.
All patients had a clear cornea and a clear visual axis at the which the surgical videos were available for analysis. Pos-
last follow-up. terior capture rupture occurred after IOL implantation
The patient questionnaire was received from 12 in 2 eyes (15%) and before IOL implantation in 11 eyes
patients; all but one reported being satisfied with the (85%). The size of PCR at the time of its recognition
procedure (92%). Nine patients (75%) did not need was greater than 6 mm in 6 eyes (46%) and the edge of
glasses for distance. One patient noted mild halos at PCR was not visible in these eyes. Minor vitreous her-
night. No other complaints were reported. niation through the PCR occurred in 7 eyes (54%). An-
terior vitrectomy was performed in 5 eyes with vitreous
Intraoperative Events prolapse or vitreous loss before ROC procedure. A cap-
Table 5 presents the intraoperative events of the sular tension ring was not used in any case. In one case
eyes in the ROC group. The data comprised 13 eyes in with white cataract, a posterior CCC was performed in

OPHTHALMIC SURGERY, LASERS & IMAGING VOL. 43, NO. 6, 2012 485

Figure 1. Red reflex photograph of study patient 1 day following
surgery showing the reverse optic capture. Filled arrow shows an
edge of the torn posterior capsule. Open arrow shows the anterior
capsule posterior to the optic but anterior to the haptics.
combination with ROC. In all eyes, the optic was cap-
tured through the CCC centrally in the sulcus and the
haptics were fixated in the bag (Figure 1).
DISCUSSION
PCR is a significant intraoperative complication
of current cataract surgery that is estimated to occur
in approximately 1% of phacoemulsification cases.
Even an experienced surgeon, with the best technique,
cannot eliminate this unanticipated complication.
Management of PCR, and in particular the selection,
placement, and implantation technique of an IOL in
cases of incomplete or insufficient capsule support, is
an important and controversial topic.7 Various options
including an anterior chamber IOL, iris suture-fixated
PC-IOL, or sclera-sutured PC-IOL are acceptable.
A report by the American Academy of Ophthalmol-
ogy concluded that there was insufficient evidence to
demonstrate the superiority of one lens type or fixation
site.8 Many alternative fixation techniques have been
described and compared in the literature.9-12 Among
them, sulcus implantation of a foldable three-piece
PC-IOL and IOL optic capture technique have attract-
ed the most attention.3,13-17 The current study evalu-
ated outcomes and the merit of ROC of single-piece
486
acrylic PC-IOLs in eyes presenting with an unantici-
pated PCR.
Efficacy was evaluated by postoperative UCVA.
The LogMAR UCVA at last visit was similar in the
ROC and control groups (P = .780). Fifty percent
of eyes in each group had a UCVA of 20/25 or bet-
ter and 81% of eyes in the ROC group and 75% of
control eyes had a UCVA of 20/40 or better, which
corresponds to 75% of patients not wearing glasses for
distance in our series. Almost all of our patients (92%)
were satisfied with their outcomes, and this may indi-
cate that patients not achieving a UCVA of 20/40 are
still pleased with the visual improvement after surgery.
With regard to safety, no eye lost more than one
line of BCVA in either group. There were no significant
differences in preoperative and postoperative LogMAR
BCVA between the groups. At the final visit, 94% of
eyes in the ROC group and 92% in the control group
had a BCVA of 20/25 or better. The final visual acu-
ity results in the ROC group in this study compared
favorably with those in other studies of phacoemulsifi-
cation in the presence of PCR, which reported 68% to
89% of patients achieved BCVA of 20/40 or better.18-20
However, comparison between studies should be done
with caution because of different inclusion criteria,
sample size, and follow-up periods.
The other important safety issues are postoperative
complications and a need for further surgery. In our
series, there were no vision-threatening complications,
such as endophthalmitis, cystoid macular edema, and
retinal detachment, in our patients in the follow-up
period. No further surgery was needed except for YAG
capsulotomy.
Contact between the IOL and the iris is one of
the major concerns when all or a portion of the IOL is
placed in the sulcus. A valid concern with ROC is that
the optic is in the sulcus and could come in contact
with the iris. However, we did not detect this compli-
cation in our series. As shown in the study by Chang
et al.,13 complications such as induced pigment disper-
sion, secondary IOP elevation, recurrent iridocyclitis,
and lens decentration requiring surgical intervention
are the most common issues after sulcus placement of
a single-piece foldable acrylic IOL and seemed to be
related to the large haptics being in the sulcus, unlike
ROC where only the optic and not the haptics are in
the sulcus. Our lack of any iris issues from the ROC
is most likely related to the secure fixation of the lens
COPYRIGHT SLACK INCORPORATED
and the sequestration of the haptics away from the
iris, sealed within the remaining bag. The optic posi-
tion does not seem to be as anterior with ROC as it is
in sulcus fixation, possibly held more posterior by the
non-angulated haptic position in the bag. The minimal
amount of induced myopia from the ROC IOL posi-
tion supports this observation. The ROC-fixated IOL
is securely located within the capsular rim, which can-
not move even with a large anterior segment. No cases
of Uveitis-Glaucoma-Hyphema syndrome were noted
in our series, which was also reassuring.
The axial IOL position is the major parameter in-
fluencing postoperative refractive outcome after cata-
ract surgery.21 A significant myopic refraction (-0.8 D)
was observed in eyes in which the entire PC-IOL was
placed in the sulcus in two separate studies with dif-
ferent lens designs.15,22 The mean difference of 0.44 D
between the sulcus IOL used and the in-the-bag IOL
that would provide the same refraction was reported in
a study of sulcus implantation in patients with PCR.23
A reduction of 0.5 to 1.0 D in IOL power has been
recommended to compensate for the axial change in
the position of the optic from bag to sulcus.22 With
conventional optic capture (haptics in the sulcus and
optic in the bag), the same IOL power calculated for
bag fixation can be used without adjustment because
minimal change of the optic axial position occurs.
In this study, the ROC eyes had a more myopic
mean spherical equivalent refraction than control eyes
with uneventful surgery. A slight myopic predicted re-
fractive error (-0.32 D) was observed in the ROC eyes.
This myopic shift was less than that in a study by Akai-
shi et al., in which the ROC technique was performed
in a subsequent surgery to correct the residual refrac-
tive error after previous cataract surgery with multifo-
cal IOL implantation.5 The mean difference in refrac-
tion from before to after ROC was -0.81 D in their
study. The discrepancy between these two studies may
be due to the following: (1) different IOLs were used
(the single-piece AcrySof IOL with 0 haptic angula-
tion in our study and the three-piece silicone multi-
focal IOL with 6 haptic angulation [Tecnis ZM900;
Abbott Laboratories, Abbott Park, IL] in their study);
(2) ROC was performed in all cases with PCR in our
study and in a secondary surgery with no PCR in their
study; and (3) different follow-up periods were used,
with 19 months in our study and 6.5 months in theirs.
Vajpayee et al.24 recommended that a PC-IOL
OPHTHALMIC SURGERY, LASERS & IMAGING VOL. 43, NO. 6, 2012
could be inserted in the capsular bag if the PCR is
small (< 6 mm) or if the margins are visible with no
vitreous prolapsed, otherwise an anterior chamber IOL
or sutured PC-IOL should be used. Hao et al.25 rec-
ommended PC-IOL implantation in eyes with periph-
eral PCRs of less than 120 or with a central PCR of
less than 4.0 mm. In our cases, 46% had large PCR of
6 mm or greater and, among them, half had PCR of
180 or greater; 69% of cases were peripheral and the
edge of PCR was not visualized in 46% of eyes. In 85%
of eyes, PCR occurred before IOL implantation. The
ROC technique is primarily useful for eyes in which
the PCR occurs after the IOL is implanted in the bag
or is noticed after IOL placement. However, our study
suggests that the ROC also provides a safe option for
PC-IOL implantation in other PCR conditions.
ROC cannot be achieved in every patient. This
technique is a skill-dependent procedure requiring
manipulating an instrument posterior to the IOL to
pull the optic forward and achieve capture. Care must
be taken not to lose control of the IOL into the vit-
reous space. The key points for successful optic cap-
ture include the following. First, the optic cannot be
captured through the CCC if the capsulorhexis is too
small or too large. In our series, all CCCs were 5.0 to
5.5 mm, which were smaller than the size of planned
optic of a single-piece IOL. Second, an intact and well-
centered CCC is a prerequisite for the successful ROC:
this ensures stability and centration of IOLs in all of
the patients in this study. Third, zonular support is an
important consideration when contemplating ROC: if
there is zonular damage requiring a capsular tension
ring, then a different IOL fixation technique must be
used. Finally, all vitreous must be removed from the
plane of the anterior capsule to avoid vitreous entangle-
ment and its potential negative consequences.
This study has limitations due to its retrospective
nature. The case number is small even after joining the
data from two busy centers because the indication for
our surgeons to use the ROC technique is specific. Our
follow-up is relatively short and we recognize that some
complications, especially IOL decentration, can occur
years after surgery.26 Another limitation in this study is
that a variable number of patients was used for analysis
due to availability of information. However, using the
data from the patients fellow eye as control makes the
comparison more meaningful.
Our medium-term results suggest that ROC mer-
487
its consideration in selected cases with PCR. The rates
of postoperative complications were low, and there
were no vision-threatening complications throughout
the follow-up. Future studies with a larger number and
longer follow-up are necessary to assess the late-onset
complications and monitor the long-term stability of
the IOLs.
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