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62 EW RESIDENTS Hole continued from page 61 them to the concerning discovery depicted in the photos. Sometimes there are clues that the "hole" involves a violation of the posterior capsule (PC). First there can be a sudden shift in the anterior chamber dynamics when the phaco probe goes through the PC. This can appear as a sudden shallowing or deepening of the lens-iris complex, sometimes with atypical flow of small lens fragments through the eye. Second, audio clues may indi- cate that the phaco tip is generating unexpected vacuum despite what appears to be an unoccluded tip; this often means that the tip is occluded with vitreous. A third clue is that the cataract no longer rotates freely as it did following initial hydrodissec- tion/hydrodelineation. Let's assume that none of these things occurred, but there is still concern about a ruptured PC. At this point, the surgeon could inject a generous amount of disper- sive viscoelastic into the area of concern, preferably between the epinuclear shelf and the PC. Then preservative-free kenalog should be injected into the anterior chamber as described elsewhere in the man- agement of suspected vitreous loss. If vitreous is identified, I would sug- gest suturing the main phaco inci- sion and converting to a two-port anterior vitrectomy through water- tight paracentesis ports. I would focus on removal of any remaining nuclear fragments first before turn- ing attention to the epinucleus. If no vitreous is identified, first I would inject more dispersive vis- coelastic into the area of the "hole," and I would avoid rotation of the cataract. Then I would proceed with phacoemulsification of the nuclear material using a tumbling technique with the second instrument so as to mobilize remaining nuclear frag- ments while leaving any epinuclear material in situ until all the nuclear pieces were removed. If all the nuclear pieces can be removed safely, the epinucleus can then be addressed. At this point, one could directly assess the integrity of the PC and respond appropriately with ei- ther anterior vitrectomy and a sulcus IOL or hopefully routine placement of the IOL into a still intact capsular bag. Dr. Yeu: Initially, it is difficult to distinguish if the hole is limited to the epinuclear plate or if it has gone through the posterior capsule. The surgery should proceed as if a true capsular rent has occurred. First and foremost, while the phacoemulsifi- cation needle is still irrigating within the eye, use the second hand to di- rect a dispersive OVD into the area of the hole. This initial step can be very telling; if there is a true hole, the OVD will fall back posteriorly (indicating that indeed a violation has occurred) and also serve to tam- ponade any potential vitreous from coming forward. But if the bag is in- tact, one may notice that the disper- sive OVD will just occupy space and accumulate within the bag as well as fill anteriorly. After the OVD is used to "plug" the potential hole, proceed with caution. The nucleus still needs to be split and then rotated. If there is more resistance than expected during the nuclear rotation, this may be an indication that there is a posterior capsular problem. If possi- ble, place the least amount of stress on the posterior capsule during the nuclear disassembly. I prefer a hori- zontal chop technique to minimize any posteriorly directed stress. Regardless of the specific technique used, the safest route is to try and get as many nuclear fragments out of the bag and emulsified more ante- riorly than the iris plane in order to prevent pieces from potentially falling into the vitreous cavity. Lastly, try to prevent any anterior August 2012