1039
ARTICLE
Intraoperative posterior polar cortical disc
defect: sign of intact posterior capsule
Jeewan S. Titiyal, MD, Sridevi Nair, MD, Manpreet Kaur, MD, Jyoti Rawat, BSc(H),
Saima Ahsan Mazumdar, MOptom
Purpose: To describe the incidence and morphological charac-
teristics of posterior polar cortical disc defect (PPCDD) sign ob-
served during phacoemulsification in posterior polar cataract (PPC).
Setting: Rajendra Prasad Centre for Ophthalmic Sciences, All
India Institute of Medical Sciences, New Delhi, India.
Design: Prospective case series.
Methods: Sixty-seven eyes of 56 patients with PPC undergoing
phacoemulsification were evaluated. Outcome measures were the
incidence and characteristics of the intraoperative PPCDD sign, as
well as its relation to the intraoperative surgical dynamics and
posterior capsule (PC) dehiscence.
Results: Of the 67 eyes evaluated, the PPCDD sign was seen in
86.5% of eyes (58/67). Among these, 93.1% of eyes (54/58)
showed a complete disc defect, whereas 6.9% of eyes (4/58)
P
osterior polar cataract (PPC) is surgically challenging
with an increased risk for intraoperative posterior
capsular rupture (PCR).1,2 A preexisting posterior
capsule (PC) defect may be observed in up to 20% of the
cases; in addition, the extremely fragile PC and firm ad-
herence of the plaque to the PC predisposes to the de-
velopment of intraoperative PC dehiscence.3,4
Various clinical signs and morphological features have
been described for PPC based on slitlamp assessment or
anterior segment optical coherence tomography (OCT)
findings in an attempt to identify cases at a high risk for
developing intraoperative PC dehiscence.3,5–7 Recently,
Titiyal et al described intraoperative OCT assisted classi-
fication and risk stratification of PPC, based on the re-
lationship of the PC to the posterior polar opacity and the
real-time intraoperative dynamics of PPC.8
During phacoemulsification, a well-defined disc-shaped
defect in the posterior cortex is often observed after the
removal of the nucleus and epinucleus in PPC, which may
Submitted: November 18, 2020 | Final revision submitted: December 11, 2020 | Accepted: December 27, 2020
From the Cornea, Cataract & Refractive Surgery Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New
Delhi 110029, India.
Corresponding author: Jeewan S. Titiyal, MD, Cornea, Cataract & Refractive Surgery Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of
Medical Sciences, New Delhi, India. Email: titiyal@gmail.com.
Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS
Published by Wolters Kluwer Health, Inc.
Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS. Unauthorized reproduction of this article is prohibited.
had a partial disc defect with incomplete margins. In the majority
of cases (89.6%; 52/58), the PPCDD sign was seen after epinuclear
plate and plaque aspiration. Among the 9 eyes that did not show
the PPCDD sign, en bloc separation of the plaque and cortical
matter from the PC was observed in 2 eyes, the plaque remained
adherent to the PC till the end of cortical fiber aspiration in 3 eyes,
and intraoperative PC rupture (PCR) was observed during the
plaque separation in 4 eyes. The incidence of PCR in eyes without
PPCDD sign was significantly higher (44.4% vs 0%; P < .001).
Conclusions: The visualization of intraoperative PPCDD sign
during phacoemulsification in PPC is suggestive of an intact PC
and associated with a significantly lower rate of intraoperative PCR
as compared with eyes without the PPCDD sign.
J Cataract Refract Surg 2021; 47:1039–1043 Copyright © 2021 Published
by Wolters Kluwer on behalf of ASCRS and ESCRS
be mistaken for a PC defect.9 However, the PC in these eyes
showing a posterior polar cortical disc defect (PPCDD) sign
is intact, and the presence of this sign may, in fact, be
predictive of a low risk for PC dehiscence. We herein
describe the incidence, morphological characteristics, and
intraoperative dynamics of the PPCDD sign observed
during phacoemulsification in PPC as well as its association
with PC dehiscence.
METHODS
We prospectively analyzed 67 eyes of 56 patients with PPC
undergoing phacoemulsification at a tertiary care ophthalmic
center. Patients older than 18 years with posterior polar cat-
aract planned for phacoemulsification were consecutively
enrolled from January 2016 to January 2019. Ethical clearance
was obtained from the Institutional Ethics Committee, AIIMS,
New Delhi. We adhered to the tenets of the Declaration of
Helsinki. Written informed consent was obtained from all
patients. The diagnosis of posterior polar cataract was based on
the characteristic slitlamp appearance of well-circumscribed
onion ring/bull’s-eye appearance of posterior capsular opacity
0886-3350/$ - see frontmatter
https://doi.org/10.1097/j.jcrs.0000000000000578
1040 CORTICAL DISC DEFECT SIGN IN POSTERIOR POLAR CATARACT
Figure 1. Surgical dynamics of posterior polar cataract with
posterior polar cortical disc defect (PPCDD) sign. A: The typical
appearance of the PPCDD sign seen after the plaque aspira-
tion, showing a characteristic donut-shaped central defect in
the posterior cortex with a surrounding whitish gray rim of
variable thickness and relatively sharp margins (yellow arrow).
B: A partial disc defect with arc shaped margins due to the
sectoral absence of the rim (yellow arrow) and cortical sheet. C:
A thick white rim encompassing a defect in the epinuclear plate
and cortex, seen immediately after nucleus aspiration. D:
PPCDD visualized after majority of the cortex was aspirated,
seen as a defect (yellow arrow) in the thin remaining cortical
layer.
with or without associated nuclear sclerosis. 10 The diagnosis
was confirmed on anterior segment OCT (RTVue-100; Op-
toVue, Inc.) wherein the polar cataract and PC involvement
were visualized.3 Patients with a preexisting PC defect or total
cataract wherein the PC status could not be determined on
preoperative slitlamp examination were excluded. Patients
with other coexisting ocular morbidities were also excluded.
Detailed preoperative clinical evaluation was performed for all
patients including the uncorrected and corrected distance vi-
sual acuity assessment, slitlamp examination, intraocular
pressure assessment, fundus evaluation, and biometry using
IOL Master 700.
Surgical Technique
A temporal clear corneal phacoemulsification was performed in
all cases using an active fluidics phacoemulsification system by a
single surgeon (J.S.T.). A 2.2 mm clear corneal incision followed
by 2 side-port entries was made using disposable keratomes. The
anterior chamber was filled with an ophthalmic viscosurgical
device (OVD; 1% sodium hyaluronate), and a continuous cur-
vilinear capsulorhexis with an intended size of 5 mm diameter
was performed using a 26-gauge cystotome introduced from the
side port. A gentle hydrodelineation was performed with an
attempt to create multiple delineation rings whenever feasible.
Hydrodissection was avoided. A slow-motion phacoemulsifi-
cation was performed through the temporal 2.2 mm clear corneal
incision.11 For nuclear emulsification, the stop-and-chop tech-
nique was used for the harder cataracts, and a layer-by-layer
phacoemulsification was performed for the soft cataracts.12 A
dispersive OVD was injected from the side port before removing
the phacoemulsification probe to maintain the anterior chamber.
A coaxial or hybrid bimanual irrigation aspiration system was
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Figure 2. Surgical dynamics of posterior polar cataract without
posterior polar cortical disc defect (PPCDD) sign. A: En bloc
aspiration of the entire cortex and posterior plaque observed
following the nucleus emulsification without the appearance of a
PPCDD. B: Posterior plaque strongly adhered to posterior
capsule even after the cortex was completely aspirated. C: The
characteristic elliptical-shaped posterior capsular rupture (yel-
low arrow) seen during the separation of posterior plaque from
the capsule.
used to aspirate the epinuclear plate, the posterior plaque, and
the cortical matter, directed from the periphery to center. The
PPCDD sign was observed after the aspiration of the nucleus and
epinuclear plate. The stage of its appearance was determined
based on the number of layers that were aspirated before the sign
was noted. The characteristic morphological appearance of the
PPCDD was a donut-shaped central defect in the posterior
cortex with a surrounding whitish gray rim of variable thickness
and relatively sharp margins (Figure 1). This central cortical
defect was characterized by an intact PC as visualized on in-
traoperative OCT (OPMI Lumera 700 and RESCAN 700; Carl
Zeiss Meditec AG) and the size of the defect roughly corre-
sponded to the preoperative size of the posterior plaque. The
cortical aspiration was completed, and a single-piece foldable
intraocular lens was placed in the bag. The corneal incisions were
hydrated at the end of the surgery.
In cases in which an intraoperative PC rupture was ob-
served, a dispersive OVD was injected over the defect to
tamponade the ruptured PC. The PC defect was converted to
a continuous curvilinear capsulorhexis when feasible and a
limited anterior vitrectomy was performed in cases of vit-
reous prolapse. An intraocular lens (IOL) was placed in the
bag or sulcus based on status of the anterior capsulorhexis
and PC.
The outcome measures were the incidence and morphological
characteristics of PPCDD sign, as well as its relationship with the
intraoperative dynamics and PC dehiscence.
Statistical Analysis
Statistical analysis was performed with Stata-11.1 program for
Windows. The paired t test was applied for quantitative data, and
the x2 test for the qualitative data. A P value of less than 0.05 was
considered significant.
RESULTS
Sixty-seven eyes of 56 patients fulfilling the inclusion
criteria were included in the study. The mean age of
patients was 55.1 ± 6.7 years. Thirty-eight patients were
male, and 18 patients were female. Seven eyes were ex-
cluded; of these, 2 eyes had a preexisting PC defect, 2 eyes
 CORTICAL DISC DEFECT SIGN IN POSTERIOR POLAR CATARACT 1041

Table 1. Characteristics of Eyes With and Without Intraoperative Cortical Disc Defect Sign.
Stage of appearance

After epinuclear plate After majority cortex After nucleus

PPCDD sign seen (n = 58 eyes) aspiration aspiration aspiration PCR incidence
Complete disc defect (n = 54) 48 eyes 5 eyes 1 eye 0% (0/58 eyes)
Partial disc defect (n = 4) 4 eyes 0 eyes 0 eyes

No PPCDD sign seen (n = 9) No. of eyes PCR incidence

PCR during plaque separation 4 eyes 44.4%* (4/9 eyes)
En bloc separation of plaque and 2 eyes
cortex from the PC
Plaque adherence to the PC until 3 eyes
completion of cortical aspiration

PCR = posterior capsule rupture; PPCEDD = posterior polar cortical disc defect
*
Statistically significant

had dense cataract, which precluded PC assessment, and 3
eyes had coexisting posterior segment pathology.
Intraoperative PPCDD sign was observed in 86.5%
(58/67) eyes with PPC. Of these, a complete disc defect
sign was observed in 93.1% of eyes (54/58), and a partial
disc defect with incomplete margins of variable arc size
was observed in 6.9% of eyes (4/58) (Figure 1, A and B).
Fine granular deposits in a ring-like configuration rem-
iniscent of the original whitish rim were observed on the
PC after complete aspiration of the cortex in 67.1% of eyes
(45/67).
PPCDD sign was observed immediately after the nucleus
emulsification in 1.7% (1/58), after aspiration of the epi-
nuclear plate in 89.6% (52/58) and subsequent to the as-
piration of majority of the cortex in 8.6% (5/58) cases
(Figure 1, A, C, and D).
The characteristic PPCDD sign was not observed in 9 eyes.
Of these, en bloc aspiration of the cortex and posterior plaque
was performed in 22.2% (2/9), adherence of the posterior
plaque to PC was observed in 33.33% (3/9), and PC rupture
during the separation of posterior plaque was observed in
44.4% (4/9) cases (Figure 2, A–C). Table 1 describes the
characteristics of the eyes with and without the PPCDD sign.
Intraoperative posterior capsular rupture (PCR) was
observed in 5.97% of eyes (4/67). No case with the PPCDD
sign had an intraoperative PCR. In contrast, 44.6% of eyes
(4/9 eyes) without the PPCDD sign had an intraoperative
PCR due to traction exerted on the fragile PC while re-
moving the PC plaque. The defect had a characteristic
elliptical shape with smooth margins involving the entire
diameter of the PC. The incidence of PCR in eyes without
the PPCDD sign was significantly higher than that ob-
served in eyes with the sign (44.4% vs 0%; P < .001). No
case had a PCR during hydrodelineation. No cases had an
intraoperative nucleus drop into the vitreous cavity. A
posterior chamber IOL was implanted in the bag in 65
eyes, and a sulcus implantation of the IOL was performed
in 2 eyes.
Postoperatively, the posterior chamber IOL was stable
in the bag or in the sulcus in all cases. All patients had
a visual acuity of 20/25 or better at the end of 1 month.
No case developed cystoid macular edema or corneal
decompensation.
DISCUSSION
Phacoemulsification in PPC is associated with a high
risk for intraoperative PC rupture and may require
considerable surgical expertise in handling complicated
scenarios. Various preoperative and intraoperative
morphological features have been described to enable

Table 2. Differentiating Features Between Intraoperative PCR in Posterior Polar Cataract vs Iatrogenic PCR.
PCR feature during phacoemulsification
1 Location
2 PCR progression
3 Shape of PC defect
4 Edges of defect
5 Associated vitreous loss
6 Surgical stage when PCR occurs
Posterior polar cataract
Begins at center of PC
Progresses in a relatively controlled pace
along the PC diameter
Defects acquire characteristic elliptical
shape
Smooth edges
Is seen less commonly due to minimal
disturbance of the anterior hyaloid
Usually seen after endonucleus aspiration
completion; during epinuclear plate
aspiration or thereafter
Iatrogenic PCR
May occur at any quadrant
Usually shows precipitous progression
Defect may assume a circular or an
irregular shape
Irregular shape often with jagged edges
Is seen commonly due to iatrogenic
disturbance of anterior hyaloid
May be seen during nuclear emulsification
or at any step thereafter

PC = posterior capsule; PCR = posterior capsular rupture

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1042 CORTICAL DISC DEFECT SIGN IN POSTERIOR POLAR CATARACT
risk stratification of PPC with respect to development of
intraoperative PCR.3,5,6 In most cases of PPC, a posterior
capsular rupture is observed during the aspiration of the
epinucleus or cortex and may result from the tangential
traction exerted on the PC during the separation of the
posterior plaque.
We describe the PPCDD sign classically observed after
the aspiration of the epinuclear plate, which is indicative
of an intact PC and suggestive of a low risk for PC
dehiscence. The pathophysiology of this disc-shaped
defect within the cortical layer seems to be related to
the embryological development of a posterior polar
cataract, which involves the migration of dysplastic
abnormal lens fibers from the equatorial region toward
the central PC. It leads to the formation of a clearly
demarcated discoid plaque at the posterior pole of the
lens with variable degrees of adhesion to the PC.13,14
Internal hydrodelineation during phacoemulsification
may lead to the separation of the plaque from its sur-
rounding lens fibers and the center of the PC. The as-
piration of this plaque reveals a discoid defect in the
cortical sheet complex leading to the appearance of a
PPCDD. We hypothesize that more thorough the hy-
drodelineation, easier it is for the plaque to separate
from the PC-cortical matter complex during surgery.
The variance in the stage at which the defect appears
may in part be determined by the number of cleavage
planes or rings formed within the lens matter during
hydro procedures. Multiple cleavage planes formed
within the cortical matter, coupled with the stronger
adhesion of the plaque to the deeper cortical layers, may
explain the delay in its aspiration and the ensuing ap-
pearance of the disc-shaped cortical defect sign after
aspiration of the majority of cortex as observed in some
of our cases.
A central defect in the cortical layer may be observed
after nucleus emulsification in some cases of posterior
subcapsular cataracts. The differentiating features from a
classical PPCDD sign include the absence of a well-
defined structured circular white rim, a sudden expan-
sion of the defect seen with the increase in infusion
pressure, and the distinct fluttering of its frail margins
induced by the fluids currents, because of its lack of
adhesion to the PC.
The cortical disc defect sign was not observed in 9 of the
67 eyes in our study. The firm adherence of the posterior
polar opacity to the surrounding cortex and PC may
explain the absence of the sign in these cases. The in-
cidence of intraoperative PCR was significantly higher in
cases without the PPCDD sign (44.4% vs 0%; P < .001) and
was characteristically observed during the attempted
separation of the posterior plaque from the cortical
layer–PC complex. This incidence is also higher than the
PCR rate in PPC cases reported in the literature, ranging
from 0% to 36%.1,4,15–17 PCR in these eyes, enabled by an
inherent PC fragility had a characteristic elliptical shape,
commenced in the center and progressed toward the
periphery up to the equator. Loss of vitreous was rarely
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seen, possibly due to minimal disturbance of the anterior
hyaloid. In contrast, iatrogenic PCR is characterized by a
variable shape and high incidence of vitreous loss
(Table 2).18
Recognition of the signs suggestive of an intact PC
during phacoemulsification in cases of PPC can help the
surgeon in prompt decision making. The appearance of a
disc defect sign during cortical aspiration is indicative of
safe separation of the posterior polar plaque with an intact
PC, and the surgeon may safely proceed with cortical
aspiration and IOL implantation. Careful aspiration of
remnant cortex is essential to prevent iatrogenic trauma to
the fragile PC. Cases without an intraoperative PPCDD
sign are associated with a high incidence of posterior
capsular rupture.
WHAT WAS KNOWN
 Posterior polar cataract patients are predisposed to an in-
creased risk for posterior capsular rupture (PCR) during
phacoemulsification.
 Preoperative slitlamp examination and anterior segment
optical coherence tomography may help in identification of
high-risk features predictive of an increased incidence of
PCR.
WHAT THIS PAPER ADDS
 The appearance of the intraoperative posterior polar cortical
disc defect (PPCDD) sign during cortical aspiration is in-
dicative of an intact PC during phacoemulsification in PPC.
 There is a higher incidence of PCR in cases without the
PPCDD sign. The PC dehiscence has a classical elliptical
shape in these cases.
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