I recently operated on a young male myope with a grade 3+ hazy white nuclear sclerosis that was softer than anticipated. During the first day of a learning curve for a new phacoemulsification machine, the settings were aggressive. My technique involves using burst mode to penetrate to the middle of the nucleus in a controlled fashion with a Kelman tip, facilitating a vertical chop of the nucleus into hemispheres. Subsequent vertical chops use minimal ultrasound to complete disassembly and allow removal. In this case, because of a high rise time and vacuum, after just two bursts the phaco needle emptied and sucked in the rest of the lens and the posterior capsule. This is one of the worst times to break the capsule, as the full nucleus is present.
I caught this surgical nightmare on video (eyetube.net/?v=bewen), and it now serves as a reminder that you do not want to blink during cataract surgery, because if you missed the sudden redistribution of fluid and the pupil expansion and chamber bounce lasting only a second (0:25 into the video; Figures 1A and 1B), you might not immediately see the complication. The sooner there is recognition, the more likely an optimal outcome can be achieved. Below I outline the appropriate steps to manage this difficult situation.
STABILIZE THE CHAMBER
The first thing to do in the event of a complication like this is to stabilize the anterior chamber by trading the phaco chopper for a cannula (Figure 1C) filled with a dispersive ophthalmic viscosurgical device (OVD). If the phaco tip is withdrawn and the chamber shallows, because vitreous follows a gradient from high to low pressure, the break in the capsule will expand and vitreous will follow out the incision. Once the situation is static after OVD injection, the instruments can be safely withdrawn, allowing thoughtful inspection and planning.
I contend that surgeons should occasionally run what I call a Code V. We are all accustomed to practicing for cardiac arrest and fire drills; similarly, because vitreous loss is rare, we should have our team practice what to do in a seamless fashion in a case like this. When I say the word timing, my nurses and techs know to get the Vit Kit, which consists of the tools that might be needed to combat vitreous loss, and to expect a longer procedure time.
In this case, I was able to push the vitreous back with dispersive OVD, complete the hemisphere dissection with my chopper and OVD cannula, and tire-iron one and then the other soft nucleus fragment into the anterior chamber without losing the integrity of the anterior continuous curvilinear capsulorrhexis (CCC). I then instilled Miochol E (acetylcholine chloride intraocular solution; Bausch + Lomb) to bring the pupil down behind the nucleus and compartmentalize the presumed prolapsed vitreous. I decreased the fluidics to slow motion, and, making sure to establish flow in the OVD-filled environment to avoid a wound burn, fed the soft nucleus into the phaco tip with the chopper.
AFTER NUCLEUS EVACUATION
Once the nucleus was evacuated, I instilled Triessence (triamcinolone acetonide; Alcon Laboratories, Inc.) diluted 10:1 with balanced saline solution to identify any prolapsed vitreous. Seeing that some had prolapsed forward, I pressurized the eye with OVD and made a small conjunctival peritomy in the appropriate quadrant after giving a sub- Tenon bleb of lidocaine with epinephrine for comfort of the patient, who was under only topical anesthesia. Measuring 3.5 mm back from the limbus, I created a 20-gauge sclerotomy with a microvitreoretinal blade. (This case preceded the availability of 23-gauge instrumentation for me.) Using the paracentesis for irrigation and the bare vitrector through the sclerotomy, I then brought all prolapsed vitreous back to the posterior segment and confirmed this with reinstillation of triamcinolone acetonide.
I always use the highest cutting rate possible, set the panel default to low flow, and employ the lowest vacuum to produce results while keeping the bottle high enough to maintain a normotensive eye. These parameters minimize vitreous traction. The posterior approach to vitrectomy is most efficient, results in the least vitreous removal, and has the least likelihood of re-presentation of vitreous during subsequent maneuvers. Placing a plug in the sclerotomy in case I needed to go back, I reestablished a closed eye and then instilled 1:4,000 bisulfite-free, preservative-free epinephrine into the anterior chamber to bring the pupil up again.
I was then free to remove all cortex using a dry technique with a dispersive OVD covering the capsule rent and a cohesive OVD in the capsular bag to maintain the chamber until the bag was clean. Unfortunately, I could not convert the posterior capsular tear to a true posterior CCC, and therefore I chose to implant a three-piece acrylic IOL in the sulcus. Although this portion of the case was not caught on film, this and other steps are demonstrated in subsequent videos (available at eyetube.net/?v=swezq and eyetube.net/?v=sanel). I captured the optic through the intact anterior CCC to hermetically seal the posterior chamber, permitting full removal of any OVD forward of the lens. The clear corneal incisions sealed well, and a double bite 8-0 polyglactin suture was used to close the sclerotomy and then the peritomy. Off-label intracameral Vigamox (moxifloxacin; Alcon Laboratories, Inc.) was instilled for antibiotic prophylaxis, and a final minim of triamcinolone acetonide was instilled to ensure that there was no vitreous forward as well as for its antiinflammatory properties.
I prescribe oral acetazolamide and oral moxifloxacin as a single prophylactic dose any time an open capsule occurs during surgery. A retinal exam with scleral indentation is necessary within the first week; in this case (and virtually every case), the exam was normal. Topical steroids are prescribed and tapered after the first routine month, and NSAIDs are prescribed for 6 to 8 weeks. We use optical coherence tomography to rule out cystoid macular edema in this setting.
After surgery, the patient experienced some floaters but otherwise had a normal outcome. He was made aware of his increased risk of retinal tear and detachment and understands the symptoms. He was sufficiently satisfied to request surgery on the fellow eye, which was done 2 months later and was, blessedly, uncomplicated.
Lisa Brothers Arbisser, MD, is in private practice with Eye Surgeons Associates PC, located in the Iowa and Illinois Quad Cities. Dr. Arbisser is also an Adjunct Associate Professor at the John A. Moran Eye Center of the University of Utah in Salt Lake City. Dr. Arbisser states that she has no financial interest in the products or companies mentioned. She may be reached at tel: +1 563 323 2020; e-mail: firstname.lastname@example.org.