Eyeworld

EW CATARACT/IOL 26 May 2011 by Lisa Arbisser, M.D. Vitrectomy for the anterior segment surgeon Lisa Arbisser, M.D., adjunct clinical associate professor, John A. Moran Eye Center, University of Utah, Salt Lake City, details how to trou- bleshoot a capsular rupture during cataract surgery A nterior segment surgeons are familiar with what to do when there is a closed chamber and everything is contained during cataract surgery. The task of obtain- ing a good outcome becomes chal- lenging when the capsule breaks. The main goals in this situation are not to lose lens material if possi- ble and to ensure that there's no in- traoperative or post-op vitreous traction. Vitreous traction can lead to retinal tears and retinal detach- ment, and that's what causes bad outcomes in the long run. Being pre- pared for something that happens infrequently is the first step in ob- taining a good outcome. Early recognition It is important to recognize a capsule rupture as quickly as possible and then limit the complication. The first signs of this complication include a significant change in pupil position, change in chamber depth, inability to rotate the nucleus, loss of effi- ciency of phacoemulsification, and not understanding why lens material won't continue to come to the port. When these happen, the first thing to do is stop in the middle of phaco and control the chamber. Vitreous follows a gradient from high to low pressure, so if you with- draw the instrument from the eye then you allow a break in the cap- sule to enlarge or vitreous to follow out of the incision. Ideally, the point of recognition should be from when the surgeon breaks the capsule but not the hyaloid so he or she can deal with that accordingly; if not then, it should be when there is vitreous prolapse, but not when there is vit- reous all the way out of the incision. What to do when it happens The main thing to do is stabilize the chamber, preferably with viscoelastic through a side port; then the sur- geon can see what the situation is. If in doubt, he could use Triesence (tri- amcinolone acetonide injectable sus- pension, Alcon, Fort Worth, Texas) or a washed kenalog to identify the particular vitreous that's prolapsed. If there's a break in the capsule, try to convert it to a true curvilinear continuous capsulorhexis. Even when the tear looks round, it will not behave as a true capsulorhexis and will still extend, so one way to stay out of trouble if the hyaloid is kept intact is by covering it with dis- persive viscoelastic and compart- mentalizing it. If nuclear material is present when the surgeon suspects there is a problem and tries to compartmen- talize the nucleus, raising it above the iris and keeping any vitreous or tear in the capsule stable with the OVD might allow the surgeon to continue phaco. If there's any ques- tion of mixture of lens material and vitreous, then phaco should not be used. Neither phaco nor I/A can remove vitreous and will cause trac- tion and risk of tear and detach- ment. If there are nuclear fragments that fall below the posterior capsule, it's controversial whether or not to bring it up; I teach to let it be. If there's going to be access to a three- part vitrectomy in competent hands, the best outcomes are obtained that way. Although visco-levitation is an option, there's a risk in putting vis- coelastic through the pars plana in that the surgeon may put pressure on the vitreous base or push lens material peripheral under the iris without knowing it. I feel it's appro- priate to leave any lens material be- hind that's fallen posterior to the posterior capsule. Anything that's anterior to the posterior capsule, we want to lift and remove through an appropriate-sized incision by con- verting to an extracap if it's not clear that vitreous is completely separated from the lens material. P roper management of a broken capsule during complicated cataract extraction is an elemen- tal skill in which each of us should be proficient. Unfortunately, the better we get at cataract surgery, the fewer in- stances of broken capsules we experi- ence and the less comfortable and proficient we become at dealing with vitreous prolapse. I, of course, would rather become skilled at dealing with these complications through the wis- dom of others, rather than through the education that comes from the horrors of personal experience. In this month's column, Lisa Arbisser, M.D., gives us the essentials for managing vitreous loss and reducing the potential comorbidity of these infre- quent events. No matter how capable we believe we are in dealing with the broken capsule, repeated reinforcement of the basics helps us maintain a sys- tematic approach in the face of adver- sity that reduces sheer panic, eliminates operative mistakes, and maximizes good outcomes. I hope you find her article informative and useful … and hopefully unnecessary for the near future. Richard Hoffman, M.D. Column Editor happens in another surgical setting, Dr. Shum advised against using brute force to withdraw the probe. "If there is resistance on with- drawing the phacoemulsification probe, one can try rotating the probe first, in order to reverse the jam, before attempting to withdraw it again," Dr. Shum noted. "Exces- sive force should be avoided to pre- vent complete severance of the sleeve." Bjorn Johansson, M.D., Linkoping University Hospital, Linkoping, Sweden, said that al- though he has never experienced a fractured phacoemulsification sleeve during surgery, he understands how it could have happened. "With a decrease in incision size, instruments are getting thinner and more delicate, and that goes for phaco sleeves as well," Dr. Jo- hansson said. "That means there's a bigger risk for phaco sleeves to tear." Dr. Johansson said he has wit- nessed a phacoemulsification sleeve tear outside of the eye with some amount of manipulation. If a frac- ture does happen inside the eye, Dr. Johansson, like the authors, sug- gested it is not insurmountable to get fractured pieces out. "If you lose a part, it should not be a big challenge to get it out," Dr. Johansson said. "If it is silicone, I'm not sure that it would be so harmful to the eye." EW Editors' note: Dr. Johansson has no financial interests related to his comments. Dr. Shum has no financial interests related to this study. Contact information Johansson: bjorn.johansson@lio.se Shum: jennishum@gmail.com Phacoemulsification continued from page 24 Although capsular rupture (pictured here) during ca taract surgery occurs infrequently, it can lea d to serious com plications Source: David Allen, F.R.C.S., F.R.C.Ophth. continued on page 27

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