If you are an anterior segment surgeon, then you likely learned to sweep the internal incision from a sideport to release incarcerated vitreous when posterior capsular rupture (PCR) complicates cataract surgery. Traditionally ophthalmologists used cellulose sponges (eg, Weck-Cel; Beaver-Visitec International) to wick and identify vitreous loss, and then they performed a sweep in hopes of extracting trapped vitreous from the incision to promote wound closure prior to subsequent vitrectomy.
I hope to disabuse you of the temptation to sweep, because this maneuver places significant traction on the vitreous, risking retinal tears (Figure 1). I recorded a case illustrating this phenomenon before performing laboratory experiments to study best practices for managing complications at Utah’s Moran Eye Center with the help of Liliana Werner, MD, PhD, and the advice of Steve Charles, MD. The video can be viewed at eyetube.net/?v=foger.
GOAL: AVOID VITREOUS TRACTION
In order to achieve the best possible outcome in an eye with PCR, the primary goal is to avoid intra- and postoperative vitreous traction. Retinal detachment—not the rupture or the vitrectomy—leads to vision loss. When the posterior capsule is breached, cataract surgeons strive to limit the extent of the damage. They remove any vitreous forward of the posterior capsule with the highest cutting rate and the lowest effective flow rate and vacuum possible with biaxial automated vitrectomy, and they keep the eye normotensive. Ideally all nuclear remnants are removed, but if any fall into the posterior segment behind the posterior capsule, it is safest to refer the patient for timely removal of the fragments by a vitreoretinal colleague. Cataract surgeons should leave a clean anterior segment and stable implant.
TOOLS AND PRACTICES
Several tools and practices are designed to help the surgeon achieve the aforementioned goal. By stabilizing and compartmentalizing the eye, a dispersive ophthalmic viscosurgical device can help prevent further prolapse, because vitreous travels along a gradient from high to low pressure. Triamicinolone acetonide (Triesence; Alcon) sticks selectively to vitreous; essentially, it throws a sheet over the ghost, allowing you to identify what was once invisible. This frees you from what might be called wecking the incision to ascertain whether there is vitreous loss and helps you to see the endpoint of vitrectomy when prolapsed vitreous completely retracts to the posterior segment. Arbisser Nuclear Spears (Epsilon USA) can be useful in raising a descending nucleus for safe removal without potentially risky posterior levitation techniques.
TECHNIQUES
Intraoperative maneuvers. A biaxial technique with irrigation through the clear corneal sideport incision is always recommended. Alternative incisions for the bare vitrector needle include an additional clear corneal paracentesis, direct microvitreoretinal blade pars plana sclerotomy under a fornix-based conjunctival flap (requiring suturing), or the use of a sutureless transconjunctival pars plana trocar cannula system with a limbus-parallel scleral tunnel entry.
The pars plana approach is most efficient at removing the least amount of vitreous and leaving the lowest pressure posteriorly, thus discouraging repeated prolapse of vitreous. Because the vitrector is naturally below the posterior capsule and away from the iris edge with this approach, it best severs any anterior-posterior attachments of incarcerated vitreous strands without collateral damage and thereby eliminates the need to sweep. Once attachments have been amputated, you can weck away incarcerated remnants without causing traction.
After removing the prolapsed vitreous, avoid its repeat presentation by keeping the chamber from collapsing during all subsequent maneuvers. Scrupulously remove residual cortex to minimize inflammation and reduce the chance of infection; avoid collateral damage to the capsule, iris, and endothelium; and assess the status of the posterior and anterior capsules. When the PCR is not converted to a continuous capsulorhexis, ideally, capture the optic of a three-piece IOL through the anterior capsulorhexis and place the haptics in the sulcus.
Prophylaxis I strive to prevent endophthalmitis through the off-label use of intracameral antibiotics in every cataract case. When the anterior hyaloid is breached, I also prescribe an oral prophylactic dose of a fourth-generation fluoroquinolone before discharging the patient in order to achieve an effective minimum inhibitory concentration in the vitreous as well as in the aqueous. Additionally, I prescribe hypotensive medications as prophylaxis against pressure spikes. Finally, I am aggressive in my use of NSAIDs and a steroid, followed by a slow taper of the latter agent, to prevent cystoid macular edema. I ensure that all patients receive a timely indented peripheral retinal examination postoperatively.
CONCLUSION
Do what I now do and not what I once did. Avoid placing traction on the vitreous. Consider learning a safe pars plana approach to vitrectomy, and look forward to better outcomes, even in the face of complications during cataract surgery.
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. She states that she has no financial interest in the products or companies mentioned. Dr. Arbisser may be reached at tel: +1 563 323 2020; e-mail: drlisa@arbisser.com.
