What to do when the rhexis won’t tear

Take-Home: Metabolic insult from silicone oil exposure can cause lens epithelial cells to undergo fibrous metaplasia, making the lens capsule resistant to tearing. Instead of persisting in trying to initiate a tear, surgeons should use an instrument to cut through the fibrotic material. This non-standard approach for opening the capsule recognizes potential for capsular fibrosis in eyes filled with silicone oil. 

Reviewed by Michael A. Mahr, MD

Rochester, MN-Chronic exposure to silicone oil can result in fibrous pseudometaplasia of lens epithelial cells that can make it impossible to initiate the capsulorhexis tear during cataract surgery.

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Surgeons who encounter this situation should abandon their standard capsulorhexis technique and create the anterior capsule opening, instead using an instrument for cutting through the toughened tissue, said Michael A. Mahr, MD.

“Surgeons should not hesitate to cut the capsule due to concern about causing a radial tear because the good news is: a capsule that won’t intentionally tear because it is fibrotic is also less likely to unintentionally tear,” said Dr. Mahr, assistant professor of ophthalmology, Mayo Clinic, Rochester, MN. “On the other hand, surgeons should recognize that continued effort to tear the capsule is risky as the stress can lead to zonular damage or some other problem.”

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Dr. Mahr spoke from personal experience with a patient who was referred for surgery for a white cataract. The patient had undergone vitreoretinal surgery eight years earlier for a giant retinal tear with pars plana vitrectomy, endolaser, scleral buckle, and placement of silicone oil that was never removed.

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