Eyeworld

89 EW FEATURE October 2016 • Challenging and complicated cataract surgery the phaco or irrigation and aspira- tion tip. If a rupture is suspected, sur- geons should stabilize the chamber with viscoelastic and then have tri- amcinolone prepared and ready for intracameral installation. The pres- ence of vitreous is best confirmed by using triamcinolone to particulate stain the vitreous. "Essentially we throw a sheet over the ghost," Dr. Arbisser said. Early steps When the rupture is identified, surgeons should resist the instinct to come out of the eye, said Bryan Lee, MD, JD, in private practice, Altos Eye Physicians, Los Altos, California. "Keep irrigating and have the scrub nurse hand you whatever vis- coelastic is available," Dr. Lee said. "Don't stop irrigating until you have the viscoelastic cannula in the eye, then fill the eye with viscoelastic to try to tamponade the vitreous." Dr. Lee warned against letting the eye get hypotonous because that will let the vitreous prolapse ante- riorly. "Once you have the visco- elastic in the eye, you can bring the phaco handpiece out of the eye and take a breath and come up with a plan," Dr. Lee said. Next steps Dr. Arbisser suggested compart- mentalizing the eye prior to lens remnant removal. That means first using a dispersive viscoelastic over the area that needs to be isolated, such as a tear, and then barricading the dispersive agent by adding a cohesive viscoelastic behind it. As the cohesive agent dissipates, the surgeon can work where that agent used to be while the remaining dis- persive OVD keeps the eye compart- mentalized. "Then you need to decide whether or not there is vitreous pro- lapse that will require a vitrectomy, and what other problems you may need to deal with," Dr. Arbisser said. In cases of zonular loss, a cap- sular tension ring may be needed. If it is a ruptured capsule, convert- ing it to a capsulorhexis may work. However, if vitreous prolapse has occurred then the vitreous has to be removed first to avoid traction. A non-coincident transconjunctival partial thickness scleral entry at 30 degrees to the scleral surface is made 3.5 mm posterior and parallel to the limbus to create a self-sealing tunnel with the trocar system. The self-sealing PPI is completed after 1-2 mm limbus parallel travel intrasclerally by lifting the heal of the trocar system to penetrate perpendicular to the scleral wall, thereby installing the trocar and removing the blade within. Point pressure is applied to collapse the scleral tunnel upon removal, preventing vitreous incarceration. continued on page 90

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