Posterior Capsule Folds as a Potential Early Sign of Positive Vitreous Pressure During Cataract Surgery: A Case Series.

Positive vitreous pressure (PVP) is a rare phenomenon encountered in intraocular surgery where increased vitreous pressure pushes the lens-iris diaphragm forward, which can result in posterior capsule bulging, shallowing of the anterior chamber (AC), iris prolapse, and intraocular lens (IOL) malposition. We present four cases of early PVP that presented as posterior capsule folds or wrinkles during cataract surgery or combined cataract surgery with minimally invasive glaucoma surgery (MIGS). Dense nuclear sclerosis and generalized zonular weakness were present in three of the four cases. In all cases, subtle capsular folds were seen during or shortly after IOL insertion. In all cases, AC shallowing or tilting of the IOL out of the capsular bag was seen. In three cases where early recognition of PVP was performed, vitreous pressure was successfully managed with wound closure and adjunctive intravenous mannitol or systemic acetazolamide with good visual outcomes of 20/25 or better. Late recognition in one case resulted in a posterior capsular rupture with vitreous loss from a silicone IOL puncturing the bag. Overall, early recognition of PVP, which may be associated with posterior capsule folds or wrinkles, can be helpful for anterior segment surgeons mitigating complications or invasive surgical treatments.