The Devil Beneath the White Cataract

Tips for managing a fibrotic anterior capsule.

Ahmed Assaf, MD, PhD, FRCSEd, FEBO

Cataract and Refractive Surgery Today

KEY TAKEAWAYS White cataracts with anterior capsular fibrosis can hide dangerous capsular tension despite a smooth preoperative appearance A mini-capsulorhexis, OVD support, blunt dissection, microscissors, and microforceps can release fibrotic adhesions while limiting radial tear risk Diffuse zonular weakness may require pressure equalization, low-energy phacoemulsification, fibrotic remnant removal, and sulcus placement of a three-piece IOL with optic capture Often resembling a smooth summer moon, white cataracts can be deceptively beautiful under the microscope, but significant surgical challenges may lie beneath them. Sometimes, the anterior capsule is not only pressurized but also severely fibrotic, creating a complex situation in which performing the capsulorhexis becomes unpredictable and potentially dangerous. Successful surgery requires careful visualization, controlled decompression, and deliberate mechanical dissection of the fibrotic capsule. This article uses a case example to highlight practical pearls for safely managing a white cataract with a fibrotic anterior capsule. THE HIDDEN CHALLENGE In the case example, the cataract initially had a smooth and uniform appearance at the surgical microscope, but the underlying pathology soon revealed itself. The anterior capsule was stained with trypan blue dye under air to enhance visualization. Immediately afterward, severe corrugation of the capsule became evident, an early sign of significant underlying tension and fibrosis. The corrugation suggested that the anterior capsule was tethered by fibrotic adhesions to deeper structures of the lens (Figure 1).

The Patient Who Never Came Back

Closing gaps in glaucoma care is no longer optional.

Joe Casper, MBA, COE

Cataract and Refractive Surgery Today

Key Takeaways Many patients are unaware that they have glaucoma until it has decreased their vision. When patients fail to return for recommended testing and procedures, they may drift off the schedule. Closing care gaps can improve the quality of care delivered and revenue per encounter, particularly in clinics where time rather than demand is the limiting factor. Technological advances in ophthalmology often emphasize innovation, but are practitioners implementing these advances effectively? This month’s column focuses on the importance of embracing appropriate diagnostic protocols to ensure that technological progress benefits patients with glaucoma. At Brevium, Joe Casper, MBA, COE, focuses on implementing advanced data intelligence software to optimize patient recapture strategies. Data-driven insights can be used to improve care outcomes, increase operational efficiency, and support practice revenue growth. -Tracy J. Kenniff, MBA, OCS Unless they are experiencing an acute angle-closure attack, many patients are unaware that they have glaucoma until it has decreased their vision. My aunt is a case in point.

The Fellow Eye: Episode 4

David Fell, MD; Justin C. Muste, MD; Allen C. Ho, MD; and Curtis Heisel, MD, MBA

Eyetube

Co-hosts David Fell, MD, and Justin C. Muste, MD, sit down with Allen C. Ho, MD, director of Retina Research at Wills Eye Hospital, and Curtis Heisel, MD, MBA, a vitreoretinal surgery fellow at the University of California San Diego, to discuss the gene therapy landscape in retina. They share their journeys in the space, the therapies under investigation, and how fellows can get involved.