Eyeworld

EW FEATURE 88 Challenging and complicated cataract surgery • October 2016 AT A GLANCE • Signs of a broken capsule can include a pupil suddenly bouncing or snapping. • When a rupture is identified, resist the instinct to come out of the eye. • Diluting triamcinolone can allow better visualization. by Rich Daly EyeWorld Contributing Writer Although such cases are rare, surgeons should have a plan and tools ready to execute it in every cataract surgery A lthough rare, the odds are that a cataract surgeon will eventually face un- planned vitreous loss. One national registry puts the rate as high as 2%, which means every surgeon needs a plan and readily available tools to execute that plan in every cataract case, said Lisa Arbisser, MD, adjunct pro- fessor, John A. Moran Eye Center, University of Utah, Salt Lake City. "When optimally managed, outcomes in such cases can rival uncomplicated surgery," Dr. Arbisser said. Identifying a broken capsule is not always easy. Signs can include a pupil suddenly bouncing or snap- ping due to a rupture in the posteri- or capsule changing the distribution of fluid, which affects the anterior chamber's depth and often the pupil's size. An increase or decrease in the anterior chamber's depth during phacoemulsification or irrigation and aspiration are both warning signs. Unless there is a good expla- nation for the change, stabilize and explore, Dr. Arbisser said. Other signs include a momen- tary spider of the posterior capsule, which requires inspection after sta- bilizing the chamber and protecting the hyaloid with OVD. An unusually clear appearance of the posterior capsule is usually a rent or hole. If lenticular material suddenly stops coming to the phaco tip, there is likely vitreous in the way. This is caused by vitreous following a gradient from high to low pressure, which causes it to seek the flow into Have a game plan for capsule rupture Suture of 20-gauge pars plana incision with a two bite 8-0 vicryl closure. Any gauge direct entry incision for anterior vitrectomy requires suturing to avoid vitreous incarceration. The same suture is used to close the fornix-based conjunctival flap for reliable coverage. Triamcinolone is used to particulate identify the presence of prolapsed vitreous, like throwing a sheet over a ghost. Reinstill as the last maneuver to confirm complete removal and for its anti-inflammatory properties.

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