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Bag placement. Sometimes even with a posterior capsular tear an IOL can be gently placed in

the bag most commonly when the tear is round or converted to a round tear. It is very important

that the posterior capsular tear is stable as the force of placing the IOL can extend the tearfurther, releasing more vitreous, and could lead to placement of the IOL onto the retina. Here is a

videoof a planned posterior capsular rhexis and the gentle placement of a single piece acrylic

into the bag.

Sulcus Placement. Usually when you have a posterior capsular tear the IOL is placed in the

sulcus. The most important thing is to have a proper IOL for the sulcus ready to go in your OR atall times. The best IOL for the sulcus has a large optic that allows for mild decentration and a

better view of the retina. The best IOL for the sulcus has long haptics that will center the IOL

even in large eyes. The best IOL for the sulcus has smooth thin haptics to reduce chaffing of the

posterior leaf of the iris3, 4

. I prefer acrylic over silicon IOLs for sulcus implantation as patientswith capsule trauma are at increased risk for retinal detachment and the possible use of silicon

oil. I like the Alcon MA50 3 piece IOL as it has wide haptics, a large yet injectable 6.5 mm optic

and it is acrylic. Others advocate for the large Starr silicon IOL (AQ2010V) as they feel that the

larger haptics and rounded optic edge out weigh the advantage of the acrylic material. Pleaseremember to always use a large 3 piece IOL for this job and not a single piece acrylic (SPA).

SPA IOLs are not designed for the sulcus and the large square edge haptic can cause uveitis,hyphema, vitreous hemorrhage, and glaucoma.

The second most important thing is to place the IOL with both haptics in the sulcus. If you place

one haptic in the sulcus and the other in the bag the IOL will be unstable and often decentered.One reason that it is hard to get both haptics in the sulcus is that the most common area of

damage to the capsule is directly across from the wound. This area is vulnerable to radial tears as

OVD is often running low as the capsulorhexis passes this point and this area is vulnerable as thephaco tip and chopper are active in this region. Unfortunately this is the same area where the

leading haptic naturally flows during IOL insertion. If the capsule is damaged in this area thenthe sulcus is poorly defined and the leading haptic can end up posterior to the anterior capsule

rather than in the sulcus as intended. Defining the sulcus with a viscous dispersive viscoelastic(e.g. Viscoat) will greatly ease placement of the haptics.

Combination of Sulcus and Bag. . When you have a posterior capsular tear with a nicely

centered and intact anterior capsulotomy you have more options. One of the nicest options is to

first place the IOL in the sulcus and then prolapse the optic posteriorly capturing it by the

anterior capsule while leaving the haptics securely in the sulcus [1]. This technique allowscoverage of most of the IOL edge with capsule, allows the centered anterior capsulotomy to keep

the IOL centered, and still allows suture fixation of the sulcus based haptics to the iris if needed.

Here is a nicevideoshowing this technique:

Rarely, you will encounter the situation with a late tear of the posterior capsule when a SPA IOL

is already placed in the bag. In this situation you should strongly consider simply exchanging the

SPA IOL for a 3 piece IOL designed for the sulcus. However another option with a perfectlycentered intact anterior capsulotomy is to anteriorly displace the optic from the bag such that the

optic is captured by the anterior capsulotomy and the haptics remain in the bag which protects

the iris from the square edge. Here is avideoshowing this technique which will rarely present.

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AC IOL. When the IOL cannot be adequately supported by the sulcus, surgeons have several

options: place an AC IOL, suture the IOL to the iris, or suture the IOL to the sclera. Another

option which is often not available in an emergent setting is to use an iris clip IOL such as theArtisan but this IOL has not been approved for this indication by the US FDA [2]. None of these

approaches is clearly superior. Wagoner as part of an American Academy of Ophthalmology

study reported that there is no significant difference in results when comparing AC IOLs, irissutured IOLs, or scleral sutured IOLs when capsular support is insufficient [3]. As such practicalconcerns such as availability of devices, ease of the procedure, and surgeon preference drive this

decision. I haveoutlinedthe placement of AC IOL in this blog.

Iris sutured IOLs offer some practical advantages over scleral sutured IOLs in the emergent

situation of a posterior capsular tear (I almost never place scleral sutured IOLs in this situation).

One advantage is that you can place a 3 piece IOL in the sulcus and then asses if the residualcapsule alone will support the IOL. If the 3 piece IOL does not center or seems unstable, the IOL

can be readily sutured to the iris without changing the IOL or explanting haptics to tie scleral

based suture. The IOL optic is moved anteriorly and captured by the pupil with the addition of

acetylcholine (Miochol-E Novartis). The haptics are sutured to the peripheral iris usingmodifications of McCannels technique [4] with either an external knot [5,6] or with a sliding

internal knot as described by Chang [7]. Typically 10-O prolene suture is used with a longcurved needle such as a CTC-6 needle (Ethicon # 9090G-SD) to secure the haptics to the iris.Here is avideowhere the zonlues were severly damaged and after placing the IOL in the sulcus

the IOL was sutured to the iris.

Suturing IOLs to the sclera especially in an emergent setting is probably the most difficult

option. Techniques to suture IOLs to the sclera often employ special IOLs with haptic eyelets

[8], require more robust suture material such as 9-O prolene, and may require a scleral flap ortutoplast to cover the external suture material [9]. The routine use of 10-O prolene suture

material has been reconsidered as many of these sutures eroded and broke over time.

Additionally, suturing an IOL to the sclera after placing the IOL is difficult as the haptics would

have to be externalized to set the suture which is more complicated than the iris suture technique

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