Novel internal analysis of metal irrigation/aspiration tips could explain mechanisms of posterior capsule rupture

Introduction: Posterior capsule rupture (PCR) rates are used to measure cataract surgeons' quality. We wished to evaluate the internal non-visible surfaces of metal irrigation/aspiration (I/A) tips to identify potential mechanisms for PCR via novel metallographic imaging. Methods: Ten metal I/A instruments underwent metallographic preparation by fine sectioning to expose inner surfaces near the aspiration opening. Analysis of inner bore, lumen, and opening aperture of metal aspiration tips was performed by optical microscopy, scanning electron microscopy (SEM), and 3D volume X-ray computational tomography (XCT). Distances from external aperture to first sharp metal surface were obtained and compared with a silicone-tipped instrument. Results: We identified metal burrs near the aspiration apertures and manufacturing defects within all tips. XCT confirmed optical and SEM findings of significant defects and metal irregularities within aspiration tips. Samples also showed variation in lumen size/thickness, rough surfaces and material inhomogeneity, most pronounced at the internal tip. Median distance from outer aperture opening to first metal burr was 30 microns (range 10–120) and to internal tip irregularity (manufacturing flaw) was 250 microns (range 100–350). By comparison, distance to metal from the silicone outer aperture opening was 850 microns. Conclusions: We have demonstrated the hidden sharp metallic irregularities within commonly used metal I/A tips. If an aspirated capsule encounters these sharp metal flaws, PCR could result. Minimising this risk would require lengthening potential distance between capsule and bare metal (as with polymer/silicone tips). Our study provides unique imaging evidence endorsing this principle and illustrates a hidden mechanism contributing to PCR.