Use a Fire Drill to Practice Managing Broken Capsules

Code red, code blue; disaster preparedness is a time-honored routine in both medicine and our daily lives. In those rare events requiring complex tools and responses for best outcomes, we—like the Boy Scouts of America—should follow the motto "Be prepared."

Yet, surgeons never drill for complications. Cataract surgeons may work months or years without encountering a complication requiring an abruptly redirected plan of action to achieve the optimal result. The more we repeat routines, the more competent we become and the fewer adverse events we face. Ironically, the better we master lensectomy, the less competent we are at vitrectomy.

FIRE DRILL CONCEPT FOR BROKEN CAPSULES
I propose that we periodically call a Code V, a fire drill approach to coaching our staff (and practicing ourselves) on how to seamlessly provide optimal care in the event of a broken posterior capsule.

This concept dawned on me while teaching Comprehensive Strategy for Unplanned Vitrectomy Technique for the Anterior Segment Surgeon courses at national meetings and codifying recommendations based on my quarter-century experience with anterior segment surgery and reconstruction, laboratory investigation of vitreous behavior and its removal, and collaborations with my vitreoretinal colleagues.

Multiple things should happen simultaneously during the Code V, including: (1) defining a rarely used skill set with staff members responsible for machine settings, (2) learning and/or reviewing the location of a variety of instruments, and (3) understanding the concentrations of drugs and the use of devices that are not a part of everyday practice.

I conceived the idea of an easily locatable vit kit, which contains necessary items for the management of a broken posterior capsule. Such items as the vitrector with separate infusion cannula; conjunctival scissors; intraocular instruments, such as scissors and graspers; micro vitreoretinal blades (MVRs); cautery; calipers; 8-0 Vicryl sutures; a nonirrigating vectis; triamcinoloe; lidocaine for subconjunctival injection over the intended pars plana sclerotomy; acetylcholine chloride (Miochol E; Novartis Ophthalmics, Basel, Switzerland) for miosis; sulfite and preservative-free epinephrine for mydriasis; and trypan blue dye to facilitate visualization are essential tools in this situation. We package some of these items together as the vit kit; however, all are available in locations known by both circulators and scrub nurses.

The vit kit should be periodically inventoried to confirm that no items are out of date and all are properly sterilized. Additionally, your staff should be prepared to rapidly locate (1) alternate implants appropriate to the capsule's final status and (2) capsular tension rings with corresponding insertion devices. The Cionni modified capsular tension ring (MCTR; Morcher GmbH, Stuttgart, Germany) is indicated for severe zonular pathology, and hollow bore 25-, 26-, and 30-gauge needles are handy for ab-externo techniques and initiation of a posterior capsulorrhexis when indicated. More dispersive and other types of viscoelastics, such as high viscosity cohesives and viscoadaptives, should also be available.

Iris hooks and capsule suspension/expander hooks are invaluable when the pupil must be managed or zonular integrity is severely compromised. Various sutures, such as 9-0 and 10-0 Prolene for iris fixation and repair and 8-0 Gore Tex, which is often my preference for scleral fixation (off-label use), as well as 10-0 Biosorb and nylon sutures for larger or nonself-sealing corneal and limbal incisions, can come in handy. IOL cutting scissors and forceps help explant a damaged lens. In complicated situations, a goniolens helps the surgeon visualize the angle; in the posterior segment, a condensing lens distinguishes a suprachoroidal hemorrhage from posterior directed fluid. A Barraquer tonometer is another useful tool, documenting final postoperative pressure.

SIGNALING THE UNEXPECTED COMPLICATION
Timing. I developed an unemotional verbal cue for my OR. The word timing, simply and calmly stated, signals an unexpected challenge requiring that the patient in the next room not be prepped on schedule. All are alerted to watch the progress of the current case and await further instruction. In this situation, the staff, the patient, and family observers maintain confidence that the surgeon remains in comfortable command of the situation. Vocal local goes a long way to helping the patient to cooperate, which is otherwise impossible when the staff is asking questions and scurrying around to impulsively barked orders.

Vitreous removal does not hurt, and topical anesthesia is usually adequate for managing complications; however, a sub-Tenon's cannula for parabulbar injection—if akinesia is needed—and the use of minute amounts of IV sedation and analgesia (eg, midazolam [Versed; Roche Laboratories, Inc., Nutley, New Jersey], propofol [Baxter Pharmaceutical Products, Inc., New Providence, New Jersey], alfentanil, [Alfenta; Akorn, Inc., Buffalo Grove, Illinois]) to comfort but not obtund can help the patient cooperate, leading to a smoother experience for all.

Vitrector. In my OR, the word vitrector means that the instrument will be assembled and the proper parameters confirmed.

Pars plana. The phrase pars plana indicates we will use that approach, calling for the assembly of the cautery and the opening of the MVR blade, scleral plugs, calipers, and sutures. Because vitreous follows a gradient from high to low pressure, the posterior approach is far more efficient. It greatly reduces the chance of prolapsed vitreous during subsequent maneuvers, such as IOL placement.

Kenalog. When the word Kenalog (triamcinolone acetate; Bristol-Myers Squibb, New York, New York) is said, the staff knows to wash the preserved vehicle out with filter needles and resuspend the particles in balanced saline solution for vitreous identification—an invaluable tool to identify the endpoint of vitrectomy and to therapeutically reduce postoperative inflammation. Because of vitrectomy drills, this occurs unhesitatingly in approximately 3 minutes.

Vitrectomy settings and adjustments must be as facile for the surgeon, scrub nurse, and circulator as preferred phacoemulsification machine settings for routine cataract removal. All machines should have the irrigation-cut-aspiration mode set as a default. It is crucial for everyone to understand that irrigation-aspiration-cut mode is never used for vitreous removal; however, this mode may promote safe followability for cortex removal after the prolapsed vitreous is eliminated or allow a neat peripheral iridectomy if indicated.

Vitrectomy settings must always use the highest cut rate available on the machine. Although some manufacturers set the default linear vacuum to 200 mm Hg, I prefer panel settings for vacuum. As a consequence, I can put the pedal to the metal, so to speak, without being concerned about maintaining control of linearity in foot position three. The scrub nurse raises the vacuum by increments of 50 mm Hg—from the 200 mm Hg setting until I observe effective movement. The current default settings presume no dispersive viscoelastic (which is always present in anterior segment vitreous prolapse or loss), and so anterior vitrectomy often requires vacuum of at least 250 mm Hg—and sometimes as high as 350 mm Hg—to get action. The bottle is set low by default, and it must be raised as vitrectomy progresses. The increasing bottle height is balanced with the vacuum to keep the globe normotensive and prevent hypotony. The aspiration flow rate is usually panel set at 20 mL/min and can be left alone. This little dance of adjusting the bottle height and vacuum on the fly requires practice with the scrub nurse or tech which greatly enhances confidence during an actual event.

CASE PRESENTATION
I recently encountered one of my toughest cases, and my staff responded admirably. This patient presented with a traumatic cataract with loss of iris function and tissue almost 3 years previously. There was limited zonular damage with no vitreous prolapse, and I implanted Morcher aniridia rings (Morcher GmbH, Stuttgart, Germany) upon approval of a compassionate use request with the US Food and Drug Administration (FDA) and my Institutional Review Board (IRB). The patient achieved a perfect result.

A few months ago, the patient reinjured the eye and noticed inconsistent vision. The bag was nasally subluxated, yet the aniridia rings and the IOL remained solidly centered and stable within the bag. A knuckle of vitreous protruded around the missing zonules temporally. One week later, on the table with his peribulbar injection, to my horror, I found that his bag was hanging into the vitreous suspended by what looked like a single zonule.

HOW WOULD YOU PROCEED?
Removal of the bag-lens complex would require a large incision and result in no iris diaphragm with an uncovered IOL edge; I proceeded after a brief and timely telephone consult from one of my gurus, Michael E. Snyder, MD, of the Cincinnati Eye Institute.

If this were your patient, how would you proceed?

HOW I PROCEEDED
I first lassoed the bag, placing one end of a 9-0 Prolene suture above and one arm through the bag in the one and only gap in the interdigitated dual aniridia ring complex. I secured it to the sulcus with an ab-externo approach to prevent its descent entirely into the vitreous.

I then raised the complex through a pars plana approach and placed a 27-gauge needle across from pars to pars behind it to keep it in position for further fixation. The second scleral fixation suture traversed the peripheral optic of the one-piece acrylic IOL and looped loosely around the equator of the bag, thus fixating to the sulcus (the needle cannot pierce the black PMMA). Ehud I. Assia, MD, of Kfar Saba, Israel, devised this technique (personal communication).

The prolapsed vitreous, now about 180° around the temporal bag, was then particulate-identified with washed triamcinolone and removed through the pars plana incision, secured with a scleral plug. At this point, the bag remained slightly tilted. With no iris diaphragm to hold it back, it required sulcus fixation at a third point. All the sulcus fixation sutures were performed through a reverse scleral pocket, a technique described by Richard S. Hoffmann, MD, of Oregon, in a video at the 2008 annual American Society of Cataract and Refractive Surgery (ASCRS) meeting. This entails fashioning a 350-µm groove at the limbus and creating a pocket in the sclera with a crescent knife. The ab-externo needle is placed through the conjunctiva, the roof and floor of the pocket into the sulcus. The double-armed Prolene needle is passed through a paracentesis 180° away and docked into the needle. The needles are then removed and the sutures retrieved from under the scleral pocket and through the limbal groove. Therefore, the knot can be buried under the scleral pocket with no need for peritomy, cautery, or scleral flap creation.

The pars plana incision was sutured with 8-0 Vicryl. Although there was a little bleeding from the ciliary body with one needle pass that was slightly anterior, the case concluded with a well-centered bag, no vitreous in the anterior segment with sutureless paracenteses, and a well-sutured and covered pars plana sclerotomy.

FOLLOW-UP
The patient is still in the early postoperative period with an anatomically perfect appearance and an attached retina. The dispersed vitreous hemorrhage is delaying visual recovery. I am praying for his uneventful outcome.

My staff rolled with the punches, responding flawlessly to the situation and finding the medications and instruments needed to accomplish this complex surgical task.

WHAT HAVE I LEARNED FROM THIS CASE?
Every 6 months or when there is a personnel turnover, my staff and I invest a few minutes at the end of an OR day and perform a Code V drill. We practice setting up the vitrectors (preserved from a previous case to avoid wasting a disposable set) and discuss the instruments and confirm their location. We review settings, including why and how they vary.

Surgeons benefit from wet labs, such as the skills transfer session complementing my course at the ASCRS. Those who are first learning pars plana techniques should ask their retinal colleagues to observe a full vitrectomy case and listen to surgical pointers. As vitrectors are disposable, their OR may permit practice on animal or eye bank eyes. Alternatively, today's artificial models simulate reality without the fear of contamination. I encourage all to consider the value of this idea to implement a fire drill. The next time "Mr. V" appears, the team will be better able to assist in achieving an optimal outcome for their patient.

Lisa Brothers Arbisser, MD, is in private practice with Eye Surgeons Associates, PC, in the Iowa and Illinois Quad Cities, and is an Adjunct Associate Clinical Professor at the John A. Moran Eye Center, University of Utah. She states that she has received honoraria and research grants from Alcon Laboratories, Inc. Dr. Arbisser may be reached at tel: +1 563 323 2020; e-mail: drlisa@arbisser.com.

The author suggests the following readings:

1. Arbisser L, Charles S, Howcroft M, Werner L. Management of Vitreous Loss and Dropped Nucleus During Cataract Surgery. Ophthalmology Clinics of North America, Nov 2006.
2. Burk SE, Da Mata AP, Snyder ME, et al. Visualizing vitreous using Kenalog suspension. J Cataract Refract Surg. 2003;29:645-651.