Eyeworld

30 | EYEWORLD | SEPTEMBER 2023 ATARACT C COMPLICATED CASES About the physicians Amandeep Rai, MD, FRCSC Residency Program Director Department of Ophthalmology and Vision Sciences University of Toronto Toronto, Canada Jonathan Rubenstein, MD Professor and Chairman Department of Ophthalmology Rush University Medical Center Chicago, Illinois by Liz Hillman Editorial Co-Director "The tilt can also induce astigmatism and/or coma. The ideal scenario would be a small AC rent that happens to coincide with the steep axis of corneal astigmatism. This would allow the physician to orient the toric IOL such that the haptic-optic junction is around the area of the rent, and both haptics will be entirely se- cured under the remaining capsulorhexis edge." A single-piece IOL may also be an option in the setting of a posterior capsule rupture (PCR), provided the posterior capsule surface area is large enough to support the IOL long term. "If the surgeon is able to keep the PCR small and controlled throughout the remainder of the surgery, a single-piece IOL is certainly a plausible outcome; in that scenario, a toric IOL should be considered," he said. "This is especial- ly true if the PCR can be converted to a poste- rior continuous curvilinear capsulorhexis. If the PCR is large and the surgeon thinks that the remaining posterior capsule cannot support an IOL, a common IOL placement is in the sulcus (with or without optic capture). In this scenario, the surgeon should not place a single-piece toric IOL in the sulcus due to the increased risk of UGH syndrome. Instead, a three-piece IOL with PMMA haptics should be used. An alternate option for placement of a single-piece IOL in the setting of a PCR is reverse optic capture; a single-piece IOL can be placed with the haptics in the capsular bag and the optic anterior to the capsulorhexis opening. This technique of reverse optic capture would allow a surgeon to still implant a single-piece toric IOL in a com- promised capsule." If capsular support is entirely insufficient, Dr. Rai also mentioned anterior chamber IOLs, iris-sutured IOLs, scleral-sutured IOLs, and intrascleral haptic fixation as possibilities. Jonathan Rubenstein, MD, shared his thoughts on what to do when there is a com- promised capsule and a toric IOL was planned. If there is a PC tear, he said you need to make sure you can visualize the entire extent of the tear to ensure that it won't tear out, producing instability. If it's localized (and ideally round), Dr. Rubenstein said it's unlikely to tear out, and thus OK to place a toric IOL, provided the zonules are still good. What to do? A compromised capsule when a toric IOL was planned P recise placement and subsequent sta- bility of a toric IOL are of the utmost importance for success in correcting astigmatism. Capsule tears can threat- en both factors. So what do you do when a capsule tear occurs during cataract sur- gery when you planned to implant a toric IOL? Amandeep Rai, MD, FRCSC, said recogni- tion is the first step with any case of capsule rent, whether or not a toric IOL is planned. "Once recognized, the surgeon should try to immediately tamponade the vitreous behind the compromised capsule with a dispersive visco- elastic device. It is incumbent on the surgeon to ensure that the anterior chamber remains formed; sudden shallowing may cause the rent to suddenly enlarge," Dr. Rai said. "Depending on the stage of the surgery, the surgeon should attempt to keep all lens material anterior to the rent and remove the cataract with altered fluid- ics. Generous use of viscoelastic can help com- partmentalize the lens fragments in the anterior chamber and keep the vitreous posterior. "A surgeon should alter the fluidics by reducing the flow rate, irrigation pressure, and vacuum," Dr. Rai continued. "Irrigation and aspiration may be done manually or at low flow settings. Surgeons should ensure that there is no vitreous prolapse, and this may be aided by the use of diluted triamcinolone intracamerally. Any vitreous should be removed using a vitrector, and the surgeon should be vigilant and check for vitreous regularly through the remainder of the case. Suturing the main wound is suggested, as this patient may require a vitrectomy and is also at increased risk of postoperative endoph- thalmitis. Intracameral antibiotics should also be considered." When it comes to IOL selection, Dr. Rai said it depends on capsular support and the type of rent. If it is an anterior capsule (AC) rent, Dr. Rai said that a single-piece IOL can be placed if the surgeon is confident in the long-term axial and rotational stability. "This depends on appropriate placement of the haptics so that a haptic does not tilt forward; if a single haptic is in the bag and the other haptic tilts forward into the sulcus, the patient is at high risk for postoperative uveitis- glaucoma-hyphema (UGH) syndrome," he said.

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