Eyeworld

EW RESIDENTS 98 February 2015 W e are lucky to have 3 expert teachers to help us with a case. Drs. Springs, MacDonald, and Mian each have significant experience guiding resident surgeons through difficult cases. Here is our case: A 75-year-old man presented with gradual decline in vision, and we diagnosed him with a functionally significant cataract. The case went well, including a nicely centered and intact anterior capsulorhexis, until the very end when the phaco tip hit the posterior capsule and left the defect shown in Figure 1. Only a small amount of cortical material was left by the time we discovered the tear. The tear has a flap and was not completely round. No vitreous was noted to come forward (yet). We asked our expert teachers: How would you help to prevent this problem? After you detect a posterior capsule defect, how do you decide whether to convert to a continuous tear or leave as is? What is your strategy for IOL placement in this situation? Thomas A. Oetting, MD, Cataract M&M rounds editor Clark Springs, MD Director of cornea and refractive surgery, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis At this point in the case, the goals are to prevent vitreous prolapse, remove the cortical lens material, and to successfully implant an in- traocular lens, preferably with optic capture. To successfully accomplish these goals, a stable anterior cham- ber is essential. I would first place a cohesive viscoelastic in the anterior chamber and then carefully place a small aliquot of dispersive viscoelas- tic through the posterior capsular rent. The capsular rent appears to be relatively peripheral, and I would attempt to perform a posterior con- tinuous curvilinear capsulorhexis to stabilize the posterior capsule and prevent a wraparound tear to the anterior capsule. Following stabilization of the anterior chamber and vitreous tamponade with viscoelastic, I would attempt removal of the small amount of residual cortical materi- al with a J-cannula on a balanced salt solution syringe. I would avoid irrigation/aspiration handpiece, if at all possible, through the phacoemul- sification unit at this point for fear that the irrigation would lead to chamber destabilization and vitreous presentation. After successful removal of the residual cortical material, I would place a 3-piece intraocular lens with the haptics in the sulcus and the optic captured within the well-cen- tered anterior capsulorhexis. Since the optic will sit in the effective lens position of the capsular bag, no sulcus lens power adjustment is required. I would not attempt to place a single-piece intraocular lens in the capsular bag in this particular case due to the relatively peripheral location of the capsular rent, for fear of potential posterior displacement of the intraocular lens. Once the optic is captured within the anterior Leave it or tear it capsulorhexis, irrigation/aspiration can proceed as usual without con- cern for vitreous prolapse. To prevent this problem from occurring in the future, one can hy- drodelineate to provide a protective barrier between the phacoemulsifica- tion tip and the posterior capsule. In cases where hydrodelineation can- not be achieved, a similar effect can be obtained by placing viscoelastic in the anterior chamber prior to re- moval of the last nuclear fragments. One can also utilize the second instrument by placing it slightly below the phacoemulsification tip to prevent engagement of the posterior capsule. Susan MacDonald, MD Director of comprehensive ophthalmology, Tufts University School of Medicine, Boston It is a bit unsettling when we discov- er a posterior capsule tear, especially when we're not sure exactly when it happened. It is important to figure out the why, when, and how it hap- pened, but let's leave that discussion until the case is finished. The first priority is limiting the complication. It's important to try and stay calm and focused. A methodical approach can limit the consequence of the posterior rupture by preventing tear extension. This will reduce the risk of vitreous loss and preserve the capsule for IOL support. My first suggestion is to remind ourselves that we can handle this complication with ease and simply remember to keep the chamber stable. If the phaco or I/A tip is still in the eye, it is important to resist the impulse to pull the handpiece out. This is because removing the irrigation will cause acute shallow- ing of the anterior chamber with Cataract M&M rounds Figure 1. The case went well until the very end when the phaco tip hit the posterior capsule and left a defect. Source: Thomas Oetting, MD

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