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).

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