Eyeworld

69 EW RETINA October 2016 Editors' note: Dr. Charles practices at Charles Retina Institute, Germantown, Tennessee. He has financial interests with Alcon. illusion of anterior vitrectomy be- cause it liquefies hyaluronan gel, but it doesn't break up collagen fibers. Using the phaco probe in vitreous in an attempt to prevent lens material from falling posteriorly is a very dangerous practice. Jagged, hard nuclear fragments will never damage the retina if dropped unless a sur- geon manipulates them. Similarly, using a lens loop in the vitreous is to be avoided; vitreoretinal traction is inevitable with this technique. Some surgeons have advocated irrigating posterior dislocated lens material in an attempt to mobilize it anteriorly, apparently unaware that forceful irrigation is used to create retinal detachment in experimental models. If lens material becomes dislocated into the vitreous cavity the cataract surgeon should perform an anterior vitrectomy and then remove residu- al cortex anteriorly without produc- ing vitreoretinal traction. If the capsular defect is small, an IOL can be implanted in the capsular bag. If there is insufficient posterior capsular integrity to sup- port in-the-bag implantation, sulcus implantation with an appropriate IOL is often possible. If there is in- sufficient capsular support for sulcus implantation, the surgeon can use an anterior chamber lens unless the patient has Fuchs' dystrophy or sig- nificant glaucoma. Although many surgeons use sutured or glued IOLs, I urge caution. Many cases of late weakening and breakage of sutures, endophthalmitis from erosion of the suture through a scleral flap and the conjunctiva, and even suprachoroi- dal hemorrhage from suture passage through the pars plicata have been reported. Iris suturing can lead to uveitis, hyphema, glaucoma, and CME. If posterior lens material is present, the cataract surgeon should suture the cataract wound after vit- reous and cortex cleanup to prevent iris prolapse at a subsequent posteri- or vitrectomy for removal of the lens material. Only in special circum- stances should pars plana vitrectomy and removal of the posterior lens material be performed during the same procedure. A clear cornea and well-dilated pupil are needed for optimal visualization; complicated cataract surgery does not always provide this. Endoillumination, a fundus contact lens or wide-angle viewing system, a 7,500–10,000 cuts/minute cutter, and a fragmenter are required for posterior vitrecto- my and removal of lens material in addition to requisite training and experience. Adequate visualization behind the equator is not possible without endoillumination and fundus visualization optics. Using the phaco probe in the vitreous cavity is unwise; it is too short and not the correct diameter for 20/25 sclerotomy adaptors. The current Alcon fragmenter is 20 gauge and has exactly the same phaco power as the phaco probe, albeit without Ozil. A complete core vitrectomy should be performed before remov- ing lens material with the fragment- er to avoid vitreoretinal traction. Triamcinolone particulate marking facilitates more efficient and com- plete vitrectomy. Suction only mode is utilized to lift lens material away for the retinal surface; the first arc of pedal travel controls vacuum with the Constellation Vision System (Al- con). The second arc of pedal travel proportionally controls ultrasonic power. Continuous aspiration and ultrasound energy is mandatory to prevent scleral burns and plugging. Power should be stopped instant- ly if so-called lens milk indicating plugging occurs; scleral burns will occur very rapidly without fluid flow. The fragmenter must then be back flushed outside the eye while ultrasonic power is applied. Careful examination of the retinal periphery must be done to find any retinal breaks so endolaser retinopexy and fluid-gas exchange with SF6 can be performed. Liquid perfluorocarbon is unnecessary in the vast majority of cases but can be used to float a rock hard, black nucleus into the anteri- or chamber after core vitrectomy is performed. In summary, patients have very high expectations with modern cat- aract surgery and are not mentally prepared for a retinal detachment. It is essential to focus on the inescap- able fact that many, if not most, retinal detachments after cataract surgery are driven by incorrect intra- operative management and there- fore preventable. EW Contact information Charles: scharles@att.net

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