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January 2013 Rhexis continued from page 49 optic to ensure stability of the IOL during OVD aspiration. Cynthia S. Chiu, M.D., Associate professor, director Comprehensive Ophthalmology & Optometry University of California, San Francisco www.myregistration.net/woc2014_reg y g _ g Join us April 2-6, 2014 Join April www. oc2014.org .w www.woc2014.org fa ebook.com/WOC2014 facebook.com/WOC2014 ac twitter.com/WOC2014 twitter. om/WOC2014 .c To avoid this, I try to encourage residents to tackle the subincisional rhexis within their first 180 degrees. The flap is shorter and easier to handle. I know most residents are trained in the Little technique these days. This is hard to do under the gun, and especially hard to do from the subincisional vector. Ironically, when I trained, rather than the Little technique, we were trained to keep the flap folded over and to pull radially directly inward to the center of the lens capsule. This would initiate a new, smaller radius for the rhexis at that point, but by definition the rhexis would have to go out a little before it came back in. In this particular situation, I would have abandoned the original rhexis flap and I would have initiated a new flap going in the opposite direction, intersecting with the original tear and by definition leaving an anterior capsular tear. With gentle nuclear/cortical removal, most AC tears can be left undisturbed. I ask the resident to perform gentle, slow hydrodissection from multiple points around the capsule, carefully decompressing after each small push of fluid. If the lens does not rotate easily, we usually proceed to a first crack (I usually recommend stop-and-chop in this situation and not quick-chop). I do ask residents to avoid the area of the tear in terms of manipulating with the chopper/ second instrument and to be very gentle with lens rotation. If possible, I have them lift pieces out of the capsule to emulsify once there is space to do so. For cortical removal, I ask them to avoid the area of the tear until all the rest of the cortex has been removed first. During filling of the bag with viscoelastic, we carefully inspect the bag by touching with the viscoelastic cannula to see if the posterior capsule is intact. If so, I will usually recommend implanting a single-piece acrylic IOL (slower, more gentle opening), and, although I know this is controversial, I usually like to orient the haptics away from the tear. I know some surgeons think this will stretch the bag and propagate the tear, but with one-piece IOLs I have never had this happen, whereas I have seen threepiece IOL haptics that were oriented in line with the tear get through the tear and horribly entangled in zonule fibers, causing IOL decentration. I then routinely use acetylcholine in these situations because the rhexis is incompetent, in order to keep the IOL posteriorly positioned. Most patients do just fine. There were two cases where things did not work out this way. In one case, during hydrodissection, the red reflex was so good I could actually appreciate a posterior capsular flap moving with the injection of fluid. For this case, we converted to ECCE. In one other case, nuclear removal was fine, but I think the resident was a little too aggressive during cortical removal and the AC tear zipped around posteriorly. We had to perform AVx/SIOL. All the other cases I can remember did fine with an isolated AC tear. Linda M. Tsai, M.D. Associate professor, Department of Ophthalmology and Visual Sciences Washington University, St. Louis This is a difficult situation, but one that can still end with an excellent clinical result if approached carefully. First, confirm that the capsulorhexis is entirely detached or use scissors to complete it prior to pulling the capsule from the eye. The next steps would be 1) evaluation of the clinical scenario, 2) adjustment of the nuclear and cortical removal procedure to prevent posterior extension of the tear, and 3) care during IOL implantation. Evaluate for the presence of vitreous or instability of the lens. Fill (but do not overfill) the chamber with viscoelastic and use a Kuglen