Eyeworld

JULY 2021 | EYEWORLD | 81 C Reference 1. Yeoh R. The 'pupil snap' sign of posterior capsule rupture with hydrodissection in phacoemul- sification. Br J Ophthalmol. 1996;80:486. Relevant disclosures Devgan: None Oetting: None Yeoh: None Contact Devgan: devgan@gmail.com Oetting: oetting143@gmail.com Yeoh: ersryeoh@gmail.com lead to the dropping of heminuclei or quadrants if the rent is not detected promptly. The most common situation leading to dropping of an intact whole nucleus, Dr. Yeoh said, is hydrorupture of the posterior capsule during hydrodissection. He noted that he de- scribed the pupil snap sign of posterior capsule rupture with hydrodissection in phacoemulsi- fication in 1996 1 (see page 82 for more on the pupil snap sign). Management strategy Dr. Yeoh noted that there are two stages of a dropped lens: the "dropping" nucleus and the dropped nucleus. He said it's essential that the surgeon recognizes if the nucleus is tilting away from the anatomical position and about to slide backward into the vitreous. "If this is recognized, a 25 G needle can be inserted via the pars plana, aiming to go behind the drop- ping nucleus and the lens elevated forward into the anterior chamber where it can be delivered with the help of a vectis through an enlarged incision. Care has to be taken that vitreous traction is minimized," he said, adding that if the nucleus has already dropped to the retina, a vitreoretinal surgeon's assistance to retrieve the nucleus is needed. "If there is one good thing about hydrorup- ture of the posterior capsule, it is the fact that the capsular bag with an intact capsulorhexis is usually still well supported by the zonules, and it is straightforward to implant a three-piece lens implant into the sulcus, leaving the haptics in the sulcus and capturing the optic behind the capsulorhexis opening," Dr. Yeoh said. If a toric lens implant was planned, it is pos- sible to put the lens into the remaining capsular bag in the right alignment, capturing the optic anterior to the capsulorhexis opening, he added. Dr. Devgan noted the need for cortical cleanup after a dropped lens. With the nucleus in the vitreous cavity, you're not getting it up, but you should put in viscoelastic and clean up the cortical material. He recommended avoiding the main phaco incision because "it's too big, and it leaks." It is important to preserve as much of the capsule as possible so you can still get the lens into the eye. Dr. Devgan said it's good if the surgeon is still able to get the lens into the sulcus or anterior chamber. Then the patient can be referred to a retinal colleague. When this situation occurs, Dr. Devgan stressed not chas- ing the nucleus, not trying to retrieve it, and not denying that a complication occurred. After a dropped lens, Dr. Oetting focuses on cleaning up residual cortical material and doing the best anterior vitrectomy possible. He said you can usually still place a lens (typically a three-piece lens in this situation) where you put the haptics in the sulcus and prolapse the optic posteriorly so it's captured. "I think that's the best service I can do for the patient to get the IOL in as good a position as possible," he said. One of the most important things to do is communicate with patients, Dr. Oetting said, describing his three phases of communication. First, in the operating room, he said it's important to let the patient know that a compli- cation has occurred. Also let the patient know you are prepared to handle the problem but that you're shifting gears to address it. "The reason this is important is because the patient is going to know something is different, so they're going to assume that something bad happened," Dr. Oetting said. He added that if the surgeon does not feel comfortable handling the cortical material or placing the lens, just stop. His second phase of communication is to sit down with the patient after the surgery is over. Apologize for the complication and explain what happened, he said. His third phase of communication is to continue to communicate with the patient and be the patient's guide. They may have to see a retina surgeon or go to a completely different hospital, so it's important to be there for the patient, he said. "My experience has been that if you com- municate like this and tell them you're sorry and it's clear that this complication occurred but you're still involved and still care, you'll find these to be your most loyal patients," Dr. Oetting said, adding that cataract surgeons shouldn't be embarrassed to ask their retina colleagues for help in these cases. Overall, Dr. Oetting stressed the importance of communication, sticking with the patient, and getting a network of people who can help handle any complication you might have.

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