Discussion:
Blunt ocular trauma may damage cornea, sclera, retina, and subluxate or luxate lens. However, there are few literary sources on isolated PCR following blunt eye injury [2].
The management of PCR depends on several parameters like the extent and location of the tear, the amount of residual nucleus and cortex, and the presence of vitreous in the anterior chamber. As there are limited articles reporting capsular tear fibrosis and successful IOL implantation in the bag [2], the primary plan regarding this case was the IOL implantation in the capsular bag. Considering the extension of the PCR and prolapsed vitreous in the tear, pars plana vitrectomy with lensectomy was selected as the most appropriate method for the treatment of the issue.
Another important point is the selection of the IOL. In case of PCR with the loss of posterior capsule support, many surgeons would consider a 3-piece IOL designed for the sulcus fixation. Unfortunately, such an option was not available in our clinic. Although iris-fixated IOL is one of the options, it must be remembered that most of the lenses of this design are single-piece polymethyl methacrylate (PMMA) IOL and the total length of the lens is 8.5 mm with an optic of 5 or 6 mm in diameter. As a result, these lenses are not foldable and require a wide corneal incision and sutures inducing astigmatism[6]. There is no denying that this was not considered to be the best treatment for a 39-year-old male. The surgeons should remember that if the reverse optic capture does not work, it is possible to remove the lens and replace it with a 3-piece IOL with sulcus fixation or iris-fixated IOL. However, if none of this is available, and the only option is a single-piece IOL, a reverse optic capture or so-called forward optic capture can be considered. Reverse optic capture has been mentioned in a previous study during the treatment of similar cases[4]. Reverse optic capture is a technique of IOL implantation during which the haptics of a 3-piece or single-piece lens are positioned posterior to the anterior capsulotomy, while the optic is anterior to the edge of the anterior capsular opening. This technique requires that the anterior capsular rim of the CCC is intact for the full 360 degrees and smaller in diameter than the IOL optics6. During the surgery, the IOL optic is brought through the CCC anteriorly to achieve a reverse rhexis fixation. This technique is useful when the IOL is placed in the capsular bag, but a posterior capsule tear occurs as soon as the IOL is placed in the bag or is noticed or extends after IOL placement. Therefore, the IOL fixation is not considered stable[7].
The main advantage of reverse optic capture is the possibility of using a single-piece IOL. Currently, these are the most common type of lenses applied in our operation room and are readily available. The injector system and incision size remain constant, while the reverse optic capture cannot be performed if the capsulotomy is too big to capture the optic effectively. Such an issue may occur in case of a manually performed CCC. In reverse optic capture, although the haptics are at a distance from the iris, the optic edge is anterior to the capsule and, therefore, close to the iris plane. This could predispose some patients to iris chafe, pigment dispersion, and Uveitis-Glaucoma-Hyphema (UGH) syndrome. It is important to monitor patients for these issues so that any problem can be addressed as soon as possible[7].
Another potential disadvantage highlighted by Dr. Jason J. Jones is the remaining fibrotic posterior capsular opacification caused by the optic not serving to separate the anterior and the residual posterior capsule. Posterior capsular YAG laser capsulotomy can and should be applied in cases of opacification occurrence[7].
In conclusion, isolated lens posterior capsule rupture after blunt eye injury is a rare complication and demands a special surgical management strategy in order achieve good visual outcome.