I have managed many surgical nightmare cases, one of which I previously shared with CRST Europe readers (Iatrogenic Zonular Disaster; March 2010; pgs 51-52, 62) and posted on Eyetube (eyetube.net/?v=kozade). In this issue dedicated to surgeries gone amiss, I would like to have shared a recent case, a nightmare case of a posterior polar cataract with combined capsular block and blowout of the posterior capsule, in which I caused a severe wound burn on top of it all. Unfortunately, I regret to report that I was much too stressed at the time to turn on the video camera to record the case. Therefore, I can only report the happy ending: The patient achieved 20/20 vision postoperatively.
As a teacher of phaco surgery, I have seen many surgical nightmares during residentsí early cases. My aim is to limit complications at all costs, but accidents are not completely unavoidable. In this case, a resident made an unfortunate maneuver while sculpting the first groove in the nucleus. After he discovered a bright red spot at the bottom, he immediately called me from the operating room next door for assistance managing his first posterior capsular rupture. The description below covers my strategy to manage a posterior capsular rupture.
HOLD THE PHACO TIP STILL
Whenever a posterior capsular rupture is suspected, the most important thing to remember is this: Do not follow the impulse to retract everything from the eye. If all instruments are removed simultaneously, the sudden change of volume in the anterior chamber can lead to direct extension of the posterior capsular tear and displacement of nuclear fragments into the posterior segment.
The dogma I always follow in the event of a posterior capsular rupture is this: Hold the phaco tip still in the eye and carefully withdraw the second instrument, thus limiting the change in volume. Next, I inject an ophthalmic viscosurgical device (OVD) in the area of the suspected rupture to stabilize lens fragments and prevent them from falling into the posterior segment.
When these steps have been executed successfully, the phaco tip can be retracted and the surgeon can breathe a momentary sigh of relief before quickly deciding to consult a colleague or continue by him- or herself. If the decision is to proceed alone, I recommend executing the measures listed below.
FOLLOW THESE RECOMMENDATIONS
Recommendation No. 1. Lower the bottle height, aspiration flow, and vacuum, and switch to a preset dedicated low-flow program.
Recommendation No. 2. Inject a dispersive OVD through the posterior capsular rupture, thus creating a dispersive viscoshield barrier (Figure 1).
Recommendation No. 3. If vitreous is suspected in the anterior chamber, inject diluted triamcinolone (approximately 1:10) into the anterior chamber to stain the vitreous. If vitreous is detected, carefully remove it with bimanual low-flow anterior vitrectomy to prevent traction to the retina.
Recommendation No. 4. Reinstall the viscoshield barrier as often as needed to prevent nuclear fragments from falling into the posterior segment. (I suggest injecting profuse amounts of dispersive OVD to ensure that nothing can pass this barrier to the vitreous.)
Recommendation No. 5. Manually elevate nuclear pieces to a safe position, far from the capsular rupture (Figure 2).
Recommendation No. 6. Perform phacoemulsification at a low-flow setting to limit removal of the viscoelastic barrier (Figure 3). Vacuum should be moderate to reduce the surge response upon occlusion break. My settings with the Infiniti machine (Alcon) are 40 cm bottle height, 12 mL/min flow, and 200 mm Hg vacuum. These translate to comparable settings on other machines. I do not change my normal torsional ultrasound settings because this modality causes minimal nuclear repulsion. If using longitudinal ultrasound, however, limit power settings and reduce duty cycle to decrease repulsion.
Recommendation No. 7. After complete nucleus removalówith repeated dispersive OVD injections as necessaryóinitiate bimanual anterior vitrectomy through two sideport incisions. Check the sideports for signs of leakage, as flow can drag along vitreous with traction to the retina. A bimanual system with separate irrigation in one hand and vitrectomy and aspiration in the other is mandatory (Figure 4).
Recommendation No. 8: Inject additional diluted triamcinolone to detect remaining vitreous (Figure 5) and, if any is found, remove it with vitrectomy.
Recommendation No. 9: After removing all vitreous, perform bimanual irrigation and aspiration of residual cortex through the same sideport incisions. Low aspiration flow (5 mL/min) is preferred to minimize the risk of vitreous aspiration.
Recommendation No. 10: Choose your IOL implantation strategy based on the condition of the eye. If the capsulorrhexis is intact, sulcus-fixated three-piece IOL implantation is the most convenient solution. Optic capture through the capsulorrhexis is favorable to stabilize the IOL and sequester the posterior segment (Figure 6). Implant the IOL with an injector or forceps, depending on the surgeonís experience and instrumentation availability. In this and most cases, I used a one-handed Epsilon IOL injector (eyetube. net?v=geler). Do not use a nonangulated one-piece IOL because it is not designed for sulcus fixation. If the sharp edges of the lens come into contact with the back of the iris, pigment loss and inflammation can occur.
Using the 10 recommendations outlined above, I assisted the resident and prevented a suboptimal outcome. At the end of the day, this case ended well and the resident learned a few valuable lessons about managing a posterior capsular rupture.
Khiun F. Tjia, MD, is an anterior segment specialist at the Isala Clinics, Zwolle, Netherlands. Dr. Tjia is the Emeritus Editor of CRST Europe. He states that he is a consultant to Alcon. He may be reached at e-mail: firstname.lastname@example.org.