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September 2012 EW CATARACT 47 tainer is then removed and wound hydration done. With this technique, the inci- sion is not enlarged, the pieces have not fallen down, so the physician doesn't need to refer the patient to a retina doctor later on, and the same lens that was going to be used is im- planted into the sulcus, Dr. Agarwal said. The only difference is instead of implanting the lens after the nu- cleus removal, it's done before that. "It's such a simple technique and can be done by any anterior segment surgeon," he said. Having started this technique in 2011, Dr. Agarwal and colleagues have used it in more than 20 patients. "I personally believe an anterior segment surgeon should know a lit- tle bit [about] how to manage poste- rior capsular ruptures," he said. However, he warned, "If you have a very hard nucleus and a full nucleus, I would advise you to extend the incision and remove it manually." Other management strategies According to William F. Mieler, M.D., professor and vice-chairman, Department of Ophthalmology & Visual Sciences, University of Illinois at Chicago, Dr. Agarwal's technique can work. "It's just a matter of how much of the nucleus has fallen backward and how far back the vitreous cavity has gone. If particles are not too ter- ribly far behind the posterior capsule in the anterior vitreous then a tech- nique like that can certainly work," he said. Mark Packer, M.D., clinical as- sociate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, said that anything the surgeon can do to support the nucleus and phaco it would be a good idea. He said he's also seen a sling technique used where the bag had broken and the nucleus was in danger of falling but had not yet fallen. "This surgeon passed a 10-0 Dr. Agarwal uses the IOL scaffold technique (pictured here) to manage a sinking nucleus due to posterior capsular rupture Source: Amar Agarwal, F.R.C.S. prolene suture back and forth through the sulcus like you would if you were going to suture fixate an IOL, but he did that temporarily, passed it one way, matched it with a needle, passed it the other way, and left the two needles sitting there; it acts like a hammock, which held the nucleus in place long enough to complete the phacoemulsification," he said. The key is not to pull on vitre- ous and cause a retinal detachment, which is the tricky part, he said. "That's why we have a vitrec- tomy cutter; anterior segment sur- geons have all used one through a limbal incision, but that may not be the best approach in many cases; it may be better to go through the pars plana, and I think most cataract sur- geons still don't do this," he said. Using the PAL technique, the surgeon would go in with some viscoelastic and very small 25-gauge vitrectors and remove the anterior vitreous through the pars plana, Dr. Packer said. "To me this is a superior tech- nique because you're pulling vitre- ous posteriorly instead of anteriorly so you have less likelihood of get- ting vitreous in the incision and these endless vitrectomies that end up with a very soft eye," he said. Dr. Mieler said that there have been some attempts to try to irrigate the particles forward, which gener- ally speaking is not very successful and certainly can induce additional retinal complications. "When a patient experiences loss of part of the nuclei, in most cases, it's going to require vitrec- tomy surgery to remove the frag- ments and clean things up because a lot of inflammation can be excited by the condition," he said. While there are times an ante- rior segment surgeon can manage a posterior capsular rupture, caution has to be exercised regarding where the nucleus particles are and how far back, he added. For Dr. Packer, his cut-off point is whether or not he can see the ma- terial and how fast it's falling. "If I can't see it, I'm not going after it," he said. EW Editors' note: The doctors mentioned have no financial interests related to this article. Contact information Agarwal: +91 44 2811 6233, dragarwal@vsnl.com Mieler: +312 996 7832, wmieler@uic.edu Packer: 541-687-2110, mpacker@finemd.com