Eyeworld

EW CATARACT 28 December 2018 Cataract editor's corner of the world by Rich Daly EyeWorld Contributing Writer Dr. Devgan said. "That's what most surgeons—myself included—tend to do. The best way is to go in with the expectation that things will occa- sionally happen." How to respond When a capsular break is found, Dr. Devgan has a standard approach. First, don't pull the phaco probe out of the eye, and then, try to close the hole. This is accomplished by inject- ing dispersive viscoelastic through the posterior capsule and preventing the anterior chamber from collaps- ing. That also can prevent any cata- ract pieces from going backward. "That keeps the vitreous back and keeps the cataract in the an- terior segment," Dr. Devgan said. "When I have a hole, the barrier is broken, so the first step is to close that hole. You must temporarily plug the hole." Second, keep the hole from en- larging. That includes avoiding any thing, even the slightest change. It's like when you are driving—are you paying attention or are you doing it passively? I want to be active and present, notice what I'm doing and see what my hands are doing. If I detect anything that is not normal, I act on it." There are no tricks to detecting such holes beyond visual indicators. In this case, the phaco tip went through the nuclear piece to punc- ture a hole in the posterior capsule. One hint that Dr. Devgan got of a violation of the posterior capsule was a briefly visible hole through a hemi-nucleus. "That's another warning sign— there shouldn't be a through and through hole in a nuclear piece," Dr. Devgan said. But attitude may be the most important part of finding such breaks. "The best thing to do is avoid the common instinct of denial," Surgeon explains the challenges of and recovery from a posterior capsular hole during cataract surgery P osterior capsule holes happen. But watching for them and quickly respond- ing can keep a bad situa- tion from becoming worse. Uday Devgan, MD, clinical professor of ophthalmology, Jules Stein Eye Institute, University of California Los Angeles (UCLA), chief of ophthalmology, Olive View- UCLA Medical Center, and private practice, Devgan Eye Surgery, had a routine cataract case where the challenge arose. Such ruptures stem from inadvertent contact with a very thin—usually about 4 μm—posterior capsule during the course of cataract surgery. They can arise with any cataract patient. "The problem was not the patient, it was me, the surgeon," Dr. Devgan said about the case. "When I was removing the cataract, the phaco tip inadvertently made con- tact with the capsule and made that rupture occur." When the capsule breaks and a surgeon doesn't notice it, the problem can quickly worsen if the vitreous prolapses and the cataract falls back toward the retina. But because the complication is a round hole in the capsule, early recognition allows taking steps to avoid any further issue. In this case, Dr. Devgan's vigilance avoided any prolapse, avoided the need for a vit- rectomy, and prevented the cataract from falling back. He was even able to use the original lens implant cho- sen to go into the capsular bag. "That's all because we recog- nized the error when it happened and immediately took the steps to counter it," Dr. Devgan said. Watchful eye Cataract surgeons should be rou- tinely looking for posterior capsule holes during procedures. "Maybe I'm too extreme, but I don't even play music in the operat- ing room," Dr. Devgan said. "I want to focus intently on this 5–8 minute surgery, and I'm looking at every- Recovering from a posterior capsule hole I n this "Cataract editor's corner of the world," we delve once again into a challenging complicated cataract case. We have the privilege of hearing from Uday Devgan, MD, on how to man- age a posterior capsular tear/rupture. He eloquently walks us through recognition and responses should such a case occur. As surgeons, we would ultimately like to have a complication-free record. However, the reality is that if you operate, complications are going to occur either due to the nature of the case/eye, the patient, or just because stuff happens. I had a great mentor once tell me when I was a senior resident, "It's not how you mess up, it's how you clean up." This holds true to this day. I tell my residents this all the time, and to try and learn from them, too. Dr. Devgan is bold enough to review his complications with us, and I am hoping we can all learn from them and take away useful pearls. Rosa Braga-Mele, MD, Cataract editor OVD is injected into the posterior capsular to block the hole during surgery. To minimize damage to the hole, the lens haptics are placed 90 degrees away from it. Source: Uday Devgan, MD

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