Management of a broken posterior capsule and vitreous prolapse remains one of the most significant challenges that cataract surgeons encounter. Fortunately, if one employs modern small-incision techniques that afford maintenance of control over the intraocular environment, the vast majority of such cases will result in excellent anatomic and visual outcomes.
In one of two cases I present in an Eyetube video (eyetube. net/?v=suvuse), a pars plana approach using a bimanual technique for anterior vitrectomy is demonstrated. This case started off as a routine phaco procedure; however, the anterior chamber deepened and the lens tilted after the first or second chop (Figure 1). At the first sign of zonular dehiscence, my priority was to spear or harpoon the lens, thus preventing it from falling backward. I secured the nucleus in the anterior chamber with a phaco glide and sandwiched it with ophthalmic viscosurgical device (OVD) above and below. After completing phacoemulsification, I created a pars plana incision with a microvitreoretinal blade (Figure 2).
To perform pars plana vitrectomy, I placed the vitreous cutter in my left hand and an infusion cannula in my right (Figure 3). Varying the cutting speed and vacuum setting, I alternated between removing the vitreous (with a high cutting speed and the least amount of vacuum possible) and the remaining lens material (with high vacuum and low cutting speed). Once the anterior vitrectomy was complete, the vitrector was removed, and infusion was lowered to prevent vitreous prolapse through the pars plana incision. OVD was injected to re-form the anterior chamber and prevent chamber collapse. Only then, the infusion cannula was removed from the eye.
After cleaning any remaining vitreous from the incision, a suture can be placed if necessary.
Although anterior segment surgeons may be averse to using a pars plana approach to anterior vitrectomy, this strategy has several distinct advantages. First, pulling vitreous down from the anterior chamber is more efficient than bringing it up from a limbal approach. Second, it permits more thorough and safer vitreous clean-up because vitreoretinal traction is reduced. Third, it provides a better endpoint for vitrectomy, and fourth, it is less likely to leave vitreous near the anterior segment wounds. A pars plana approach also affords better access to any remaining lens material, and it is more likely to preserve capsular support.
Louis D. “Skip” Nichamin, MD, is the Medical Director of Laurel Eye Clinic in Brookville, Pennsylvania. Dr. Nichamin may be reached at tel: +1 814 849 8344; e-mail: firstname.lastname@example.org.