Primary posterior optic buttonholing as a new standard-of-care: rationale, technique, advantages, and special...

Posterior capsule opacification (PCO) is still frequent in spite of sharp-edged optic IOLs. With primary posterior capsulorhexis (PPCCC), lens epithelial cells (LECs) may still access the central posterior optic surface. Additional posterior optic buttonholing (POBH) deviates migrating LECs towards the anterior optic surface, thus excluding retro-optical opacification.

In 2004 the author started investigating POBH as a standard procedure for adult cataracts. 1000 consecutive POBH cases were evaluated and compared to standard in-the-bag IOL placement and sole PPCCC. Additional anterior capsule polishing (ACP) and capsule tension ring (CTR) implantation were also performed in sub-series.

In all eyes, retro-optical opacification was eradicated, and capsular fibrosis largely reduced. CTR implantation facilitated PPCCC with loose zonules or flaccid capsule bags. Postoperative refractive and rotational stability were immediate. No pressure rises or inflammatory response was observed. Retinal detachment and macular edema were not increased.

With POBH the IOL optic is placed in Berger´s space outside of instead of in the capsular bag. POBH is controlled, safe, and effective including costs. POBH is compatible with many open-loop IOL models independent of material properties. It avoids dysphotopsia as round-edged optic IOL may also be used. Planned POBH may be converted into sulcus or anterior capsule IOL fixation in case of posterior capsular complications. It provides immediate refractive and perfect rotational stability. POBH improves the performance of trifocal IOLs and facilitates delayed exchange if needed. It combines with Add-On IOLs and translimbal floaterectomy. POBH could therefore replace in-the-bag IOL implantation as standard of care.