Comments on peeling and aspiration of posterior capsular epithelial pearls

Sir, I read with interest an article by Bharghava et al.[1] It is challenging to persuade patients for such a surgical technique. Potential disadvantages of the procedure are recurrence of posterior capsular pearls (11.05%) and second surgical procedure, which patient may have to undergo. Inadequate removal of epithelial pearls and residual lens epithelial cells in the equatorial area could be the possible cause of recurrence in this study. This is substantiated by the presence of epithelial cells on the periphery of the posterior capsule at 3 months of follow up as displayed in Fig. 4 of the aforementioned article. I would like to draw attention of the authors to the interchange of aspiration probe and the anterior chamber maintainer. This will help in the removal of epithelial pearls from the posterior capsular area hiding in the subincisional area of the respective ports. In that endeavor, anterior chamber may become shallow. Viscoelastic may have to be injected to form the anterior chamber. The procedure described by the authors needs rotation of the intraocular lens IOL in the capsular bag to find a potential space between IOL optic and the continuous curvilinear capsulorhexis margin in the bag implanted IOLs. Viscoelastic comes handy in such a situation. However, viscoelastic material needs to be cleansed at the end of the procedure. Visual acuity is expected to improve after clearing the epithelial pearls from the posterior capsule. However, it may change the effective lens position leading to change in the postoperative refraction. Methodology section mentions retrospective analysis of 217 eyes with pearl form of posterior capsular opacification for age-related cataract (>45 years). However, result section states the mean age as 56.84 years (range 40-87 years), suggesting few patients in the study were less than 45 years. It is also stated that 20 patients were lost in follow up by 6 months. However, if the range of follow up is 23-40 months, how were 20 patients lost to follow up at 6 months? The authors have quoted, 186 eyes (85.71%) had final best-corrected visual acuity of 20/20 at 3 months. Twenty-nine (13.36%) eyes had a final vision between 20/30 and 20/40. Two (0.92%) eyes had a final vision of worse than 20/40. However, result section mentions the mean follow up period was 30.13 months (range 23-40 m). Three months is too short period for follow up in such type of study. What tests were used for calculating mean age and follow-up duration? Where was Chi-square test used is not clear from the results shown. Young patients undergoing such type of procedure for membranous posterior capsular opacification (PCO) after cataract surgery and getting mentioned complications could be a drawback of the procedure. Recurrence of the epithelial pearls may need similar procedure or neodymium-doped: Yttrium aluminum garnet (ND: YAG) laser posterior capsulotomy in future. Caballero et al., have demonstrated the safety of ND: YAG laser capsulotomy in membranous type of PCO and clear posterior capsule overtime in most of the cases. [2,3] Finally, there would be an issue of lost to follow up over longer period, especially in country like India.