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128 EW RESIDENTS March 2013 Nucleofractis continued from page 126 for avoiding touching the phaco tip to the capsule (and all it takes is a touch) include using a blunt second instrument to hold the capsule back and paying close attention to the post-occlusion surge that can occur when a nuclear fragment is either completely aspirated or if a tunnel through a fragment is completed allowing aspiration of fluid and the capsule on the other side. So now we're faced with finishing the case. Our goals are to get the vitreous out of the anterior segment, remove remaining cataract material while avoiding posterior segment trauma, and preserve support for an implant. There are several good references for the steps involved and these are listed below. In summary, we'll want to inject a dispersive viscoelastic to plug the hole and to isolate the small nuclear piece anteriorly. Once isolated the piece can either be aspirated with the phaco tip or with a vitrector in the I/A/Cut mode. If there is already vitreous in the AC this needs to be cleaned up first using the vitrector in I/Cut/A mode. Visualization of vitreous can be enhanced using a 1:10 (4 mg/ml) suspension of triam- cinolone. The picture shows a capsule wonderfully devoid of cortex. I'm rarely that lucky and usually have to clean up the cortex with the vitrector in I/A/Cut mode or just I/A to avoid traumatizing what's left of the capsule. There are some who would consider placement of a lens in the bag when faced with a round hole in the capsule. I never have. Placement of a three-piece sulcus lens is safe and straightforward and allows me to sleep well knowing where I will find the implant the next morning. I have a low threshold for use of subconjunctival antibiotics in cases that have gone long. I have a low threshold for the use of oral glaucoma medications in cases that have gone long. I think it's very important to explain the complication to the patient and his or her family in the postop area. The OSIT should listen carefully to how the preceptors do this. These patients need to be watched more carefully for postop complications such as endophthalmitis, CME, and retinal tears and detachment.EW References Chang, D, Phaco Chop, Chapter 16, Strategies for Managing Posterior Capsular Rupture Coombes, Gartry & Lightman, Cataract Surgery, Chapter 11 Vitreous Loss, BMJ Books Fishkind, The Torn Posterior Capsule: Prevention, Recognition and Management, Focal Points, June 1999 Nichamin, Phaco Chop, Chapter 15, Posterior Capsular Rupture and Vitreous Loss Reeves & Kim, How to Perform an Anterior Vitrectomy, Eyenet, April 2006 Waxman, E, Capsular Complications and Management, in Henderson, BA, Essentials of Cataract Surgery, Slack 2007 Editors' note: The physicians have no financial interests related to this article. Contact information Hart: j.c.hartjr@sbcglobal.net Thliveris: atthlive@WISC.EDU Waxman: waxmane@upmc.edu Nordlund et al, Techniques for managing common complications of cataract surgery, Current Opinion in Ophthalmology, 2003, 14:7-19 EyeWorld @EWNews Follow EyeWorld on Twitter at twitter.com/EWNews Find us on social media Are you a fan of EyeWorld? Like us on Facebook at facebook.com/EyeWorldMagazine