**2. A case of successful implantation of a trifocal intraocular lens in the capsular bag after posterior capsule tear in posterior polar cataract surgery**

A 25-year-old male patient was admitted to the hospital for a complaint of blurred vision in the right eye since childhood, which had gradually aggravated and was accompanied by photophobia for 2 years. The patient had refractive errors bilaterally and amblyopia in his right eye and had worn glasses for many years.

#### *Current Cataract Surgical Techniques*

The eye examination revealed that the right eye had a visual acuity of 0.25, which could not be corrected; the left eye had a visual acuity of 0.1, wherein optometry showed (−2.50 D), and it was corrected to 1.0; the binocular intraocular pressure was normal. The right eye lens was disc-shaped, irregular porcelain, with white opacity seen in the posterior pole, and the left eye lens was transparent (**Figure 1**). The corneal endothelial cell count of the right eye was 2479.9 cells/mm2 ; No abnormality was evident in the optical coherence tomography (OCT) examination of the macular area. His condition was diagnosed as a posterior polar cataract of the right eye, amblyopia in the right eye, and refractive error in the left eye.

The patient was only 25 years old and had certain requirements for a full range of vision; however, the right eye of the patient had a posterior polar cataract. Based on the results of Pentacam, the posterior capsule was very likely to be severely organized or incomplete, and the patient had amblyopia in the right eye. Therefore, before the operation, the patient was informed about the surgical procedure such that the patient fully understood that the posterior capsule might be organized, opaque, or incomplete during the operation, and it would be necessary to perform posterior capsule continuous circular capsulorhexis. If the capsulorhexis was successful, then a trifocal IOL could be implanted. Otherwise, a prepared three-piece single-focus IOL would be implanted. Even if the trifocal IOL was successfully implanted, the postoperative far, medium, and near visions would not reach the normal level due to amblyopia and would need to be corrected by wearing glasses. With the patient's full understanding, the right eye cataract phacoemulsification and trifocal IOL implantation was performed on March 31, 2020. Before the

#### **Figure 1.**

*Slit-lamp photography after mydriasis of the surgical eye shows that the posterior capsule is opaque, dense, and organized (A, B). Pentacam examination after mydriasis shows that the posterior capsule is opaque and demonstrates high reflective brightness, with a high brightness value (C red box); there is 1.4 D@93° regular corneal astigmatism at 15° of the center of the anterior surface of the cornea under the measurement of the natural pupil (D red box).*

**57**

**Figure 2.**

*Special Cases in Cataract Surgery*

*DOI: http://dx.doi.org/10.5772/intechopen.98260*

operation, the 0-180° axial position was marked in the surgical eye in the sitting position. After routine disinfection and draping during the operation, the Placido disc marked the meridian position of the steep axis of corneal astigmatism at the 93° and 273° axial positions of the surgical eye; a 3.0-mm skeratome was then used to make a symmetric incision at the corneal limbus of the steep axis of the cornea, and 5.5-mm continuous circular capsulorhexis and hydrodelineation were performed. Phacoemulsification was used to aspirate and remove the nucleus and cortex. The posterior capsule was not found to be incomplete; however, the thick white mass of the opaque, organized tissue attached to the upper center of the posterior capsule could not be polished or aspirated. The viscoelastic agent was injected into the anterior chamber, and a 1-mL syringe needle was used to remove the opaque, organized tissue that adhered to the posterior capsule. Subsequently, a posterior capsule continuous circular capsulorhexis of approximately 4.0 mm was successfully performed, and while a +19.0 D trifocal IOL (AT LISA tri 839mp, Zeiss) was implanted in the capsular bag, during which the IOL was rapidly unfolded. It was found that the posterior capsule annular capsulorhexis opening had partial dehiscence at approximately the 8 o' clock position; however, no vitreous was observed. The IOL was rotated to make its long axis perpendicular to the angle of the posterior capsule dehiscence such that the IOL was centered in the capsular bag, the residual viscoelastic agent in the anterior chamber was aspirated, and the stability and centering of the IOL were verified again. The incision was watertight and the IOL position was observed to ensure that it was centered, and the operation was complete (**Figure 2**).

*According to the preoperative corneal astigmatism of the patient, a 3.0-mm-wide symmetric transparent corneal incision was made on the steep axis of the cornea to relieve corneal astigmatism (A, blue arrow). After the nucleus and cortex were aspirated, the thick white mass of opaque and organized tissue attached to the upper center of the posterior capsule could not be polished or aspirated (B, blue arrow). A 1-mL syringe needle was used to remove the opaque and organized tissues that adhered to the posterior capsule (C, blue arrow and the blue circular area). After the completion of the continuous circular capsulorhexis of the posterior capsule, there were manifestations of the irregular capsulorhexis opening at nearly the 8 o' clock position, which was a hidden danger for the subsequent occurrence of posterior capsular rupture at this location (D, yellow arrow); the platetype trifocal intraocular lens (IOL) was rapidly unfolded during implantation, and pressure was applied to the weak part at nearly the 8 o' clock position of the posterior capsular opening to cause rupture (E, green arrow); finally, the long axis of the IOL was placed in the direction perpendicular to the posterior capsular dehiscence angle, the IOL was stable and centered, and, simultaneously, the dehiscence site of the posterior capsulorhexis* 

*opening and the opaque and organized site in Figure D corresponded to each other (F, red arrow).*

#### *Special Cases in Cataract Surgery DOI: http://dx.doi.org/10.5772/intechopen.98260*

*Current Cataract Surgical Techniques*

The eye examination revealed that the right eye had a visual acuity of 0.25, which could not be corrected; the left eye had a visual acuity of 0.1, wherein optometry showed (−2.50 D), and it was corrected to 1.0; the binocular intraocular pressure was normal. The right eye lens was disc-shaped, irregular porcelain, with white opacity seen in the posterior pole, and the left eye lens was transparent (**Figure 1**).

mality was evident in the optical coherence tomography (OCT) examination of the macular area. His condition was diagnosed as a posterior polar cataract of the right

The patient was only 25 years old and had certain requirements for a full range of vision; however, the right eye of the patient had a posterior polar cataract. Based on the results of Pentacam, the posterior capsule was very likely to be severely organized or incomplete, and the patient had amblyopia in the right eye. Therefore, before the operation, the patient was informed about the surgical procedure such that the patient fully understood that the posterior capsule might be organized, opaque, or incomplete during the operation, and it would be necessary to perform posterior capsule continuous circular capsulorhexis. If the capsulorhexis was successful, then a trifocal IOL could be implanted. Otherwise, a prepared three-piece single-focus IOL would be implanted. Even if the trifocal IOL was successfully implanted, the postoperative far, medium, and near visions would not reach the normal level due to amblyopia and would need to be corrected by wearing glasses. With the patient's full understanding, the right eye cataract phacoemulsification and trifocal IOL implantation was performed on March 31, 2020. Before the

*Slit-lamp photography after mydriasis of the surgical eye shows that the posterior capsule is opaque, dense, and organized (A, B). Pentacam examination after mydriasis shows that the posterior capsule is opaque and demonstrates high reflective brightness, with a high brightness value (C red box); there is 1.4 D@93° regular corneal astigmatism at 15° of the center of the anterior surface of the cornea under the measurement of the* 

; No abnor-

The corneal endothelial cell count of the right eye was 2479.9 cells/mm2

eye, amblyopia in the right eye, and refractive error in the left eye.

**56**

**Figure 1.**

*natural pupil (D red box).*

operation, the 0-180° axial position was marked in the surgical eye in the sitting position. After routine disinfection and draping during the operation, the Placido disc marked the meridian position of the steep axis of corneal astigmatism at the 93° and 273° axial positions of the surgical eye; a 3.0-mm skeratome was then used to make a symmetric incision at the corneal limbus of the steep axis of the cornea, and 5.5-mm continuous circular capsulorhexis and hydrodelineation were performed. Phacoemulsification was used to aspirate and remove the nucleus and cortex. The posterior capsule was not found to be incomplete; however, the thick white mass of the opaque, organized tissue attached to the upper center of the posterior capsule could not be polished or aspirated. The viscoelastic agent was injected into the anterior chamber, and a 1-mL syringe needle was used to remove the opaque, organized tissue that adhered to the posterior capsule. Subsequently, a posterior capsule continuous circular capsulorhexis of approximately 4.0 mm was successfully performed, and while a +19.0 D trifocal IOL (AT LISA tri 839mp, Zeiss) was implanted in the capsular bag, during which the IOL was rapidly unfolded. It was found that the posterior capsule annular capsulorhexis opening had partial dehiscence at approximately the 8 o' clock position; however, no vitreous was observed. The IOL was rotated to make its long axis perpendicular to the angle of the posterior capsule dehiscence such that the IOL was centered in the capsular bag, the residual viscoelastic agent in the anterior chamber was aspirated, and the stability and centering of the IOL were verified again. The incision was watertight and the IOL position was observed to ensure that it was centered, and the operation was complete (**Figure 2**).

#### **Figure 2.**

*According to the preoperative corneal astigmatism of the patient, a 3.0-mm-wide symmetric transparent corneal incision was made on the steep axis of the cornea to relieve corneal astigmatism (A, blue arrow). After the nucleus and cortex were aspirated, the thick white mass of opaque and organized tissue attached to the upper center of the posterior capsule could not be polished or aspirated (B, blue arrow). A 1-mL syringe needle was used to remove the opaque and organized tissues that adhered to the posterior capsule (C, blue arrow and the blue circular area). After the completion of the continuous circular capsulorhexis of the posterior capsule, there were manifestations of the irregular capsulorhexis opening at nearly the 8 o' clock position, which was a hidden danger for the subsequent occurrence of posterior capsular rupture at this location (D, yellow arrow); the platetype trifocal intraocular lens (IOL) was rapidly unfolded during implantation, and pressure was applied to the weak part at nearly the 8 o' clock position of the posterior capsular opening to cause rupture (E, green arrow); finally, the long axis of the IOL was placed in the direction perpendicular to the posterior capsular dehiscence angle, the IOL was stable and centered, and, simultaneously, the dehiscence site of the posterior capsulorhexis opening and the opaque and organized site in Figure D corresponded to each other (F, red arrow).*

The uncorrected visual acuity of the right eye was (far vision 0.4, medium vision 0.4 near vision 0.63) at 1 day after operation, (far vision 0.5, medium vision 0.5, near vision 0.63) at 1 week after operation, and (far vision 0.5, medium vision 0.5, near vision 0.63) at 42 days after operation, and (far vision 0.5, medium vision 0.5, near vision 0.63), optometry showing −0.75DCX138°, which was corrected to +0.5 at 7 months after operation. At this time, the IOL position was stable and centered as revealed in reexamination (**Figure 3**). There were no manifestations of anisometropia or complaints of obvious glare, halo, and other adverse visual phenomena in the postoperative reexaminations at various stages.
