Eyeworld

EW CATARACT 30 August 2018 Presentation spotlight by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer the anterior chamber, then con- sider how to remove the nucleus," he explained. "Options to remove the nucleus are phaco, convert to extracapsular cataract extraction (ECCE), or letting the nucleus drop and thereby causing as little damage as possible and referring the patient to a vitreoretinal surgeon." According to Dr. Rosen, the technique of posterior assisted levitation (PAL) is somewhat con- troversial. It involves inserting a needle 2.5 mm behind the limbus via the pars plana into the posterior chamber and injecting OVD behind the lens to support the lens and prevent it from falling. This meth- od provides a cushion that keeps it from dropping any deeper. "Some people say PAL is a bad choice be- cause it will cause vitreous traction and potentially risk retinal detach- ment," he said. "I think it is useful if you don't have immediate access to a vitreoretinal surgeon. Its use depends on a facility's availability for secondary repair, risk of vitre- ous base/retinal damage, or if the surgeon prefers to allow the nucleus to drop and plan a secondary pro- cedure. PAL raises the lens material coming through the wound, and when the phaco appears to stop working or vibrates. Management of events during phaco When the posterior capsule is torn during phaco, the surgeon needs to stop and observe the nucleus. What the surgeon does next depends on the position of the nucleus, whether it is dropping or has dropped into the vitreous. "If the nucleus is ante- rior enough to enable the surgeon to stabilize it, clear the vitreous from How does the nucleus drop? A dropping or dropped nucleus has a number of etiologies, including an anterior capsule rim tear that can extend posteriorly to become a posterior tear, a posterior capsule tear that can occur during phaco, and zonular disinsertion. Posterior capsule tears are associated with a number of telltale signs that indicate something is wrong, such as a deepening anterior chamber, an unstable lens, pupil contour changes like dilation or an irregular shape caused by vitreous A cataract expert gives best course of action in cataract cases involving a torn posterior capsule M anaging complicated cataract surgery that involves a dropping or dropped nucleus requires experience. According to Paul Rosen, MD, Oxford Eye Hospital, Oxford, U.K., who spoke on the topic at the 22nd ESCRS Winter Meeting, these unwanted events happen to both highly practiced and less practiced cataract surgeons with an incidence of 0.18%. Knowing how to handle the situation in the moment is key, he said. "You need a planned treat- ment pathway," Dr. Rosen noted. "Primary management involves an anterior vitrectomy, without IOL implantation. Secondary man- agement should happen within 3 weeks, but best within 10 days, and include a vitrectomy, nucleus removal, and IOL implantation. The key is early intervention, especially if there is raised IOP or uveitis. We can prevent sequelae with prompt surgery and achieve nearly normal outcomes." The dropping and dropped nucleus continued on page 34 " The key is early intervention, especially if there is raised IOP or uveitis. We can prevent sequelae with prompt surgery and achieve nearly normal outcomes. " —Paul Rosen, MD

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