Cataract surgeons should become more familiar with vitrectomy procedures

A surgeon offers advice on handling complicated cataract cases.

Louis D. Nichamin

NEW YORK — A presenter here offered advice for cataract surgeons managing a broken capsule and performing subsequent vitrectomy.

“Aside from endophthalmitis, I think we would all agree that breaking a capsule and violating the vitreous remains, arguably, our single most feared complication,” Louis D. “Skip” Nichamin, MD, said at OSN New York 2011. “When faced with such a threat, we need to have the discipline to stop working, [without retreating] from the eye.”

Dr. Nichamin advised colleagues to stabilize the anterior chamber with viscoelastic and slowly withdraw instrumentation to avoid anterior chamber depth loss, which may in turn lead to vitreous loss. In a significant number of cases, and with proper technique, it is possible to keep the anterior hyaloid face intact.

“The final visual outcome and final anatomical outcome of these complex cases can and really should equal that of an uncomplicated case if we adhere to the same tenets that our vitreoretinal, posterior segment colleagues do, and that would start with maintaining a closed chamber,” Dr. Nichamin said, emphasizing that a watertight environment is crucial.

Surgeons should minimize turbulence, avoid unnecessary vitreoretinal traction and thoroughly clean up the anterior segment.

Once the capsule breaks

“Our two enemies once the capsule breaks are hypotony, or any fluctuation in pressure, as well as excessive infusion,” Dr. Nichamin said.

Not losing the lens is crucial. Clinicians can maintain support with viscoelastic or a lens glide and should remove all lens material and perform a proper vitrectomy as done by retina specialists.

Avoiding enlargement of the capsular opening and preserving capsular support are key and can be accomplished by only infusing the volume required to maintain anterior chamber space, Dr. Nichamin said. In addition, a posterior capsulorrhexis will prevent extension and enlargement of a capsular tear.

“A closed chamber environment renders control,” he said. “As such, we dictate to the eye what is going to happen, instead of the other way around.”

Pars plana approach recommended

For cases involving a broken capsule, pars plana vitrectomy may be preferred. According to Dr. Nichamin, the complication rate tends to be higher when working from the limbus and pulling the vitreous up.

“The pars plana is preferable because it allows us to accomplish our goal: perform a limited but thorough and safer vitreous cleanup, affording a more defined endpoint,” he said. “By pulling vitreous down out of the chamber, where it is not supposed to be, we have a definitive point where we can stop the vitrectomy.”

This maneuver decreases traction and is less likely to bring vitreous up to limbal wounds; it also allows better access to remaining lens material and increases the likelihood of preserving capsular support, he noted.

An emergency kit that features a disposable 20-gauge cutter, separate infusion cannula, a 19-gauge micro-vitreoretinal blade and a phaco glide, among other tools, can be kept in the operating room. Dr. Nichamin recommended placing infusion through a limbal paracentesis, emphasizing that this should be performed through a separate incision rather than where delicate vacuuming and cutting of vitreous occur.

Using the highest possible cutting rate and lowest possible vacuum is optimal for vitreous removal, and surgeons can titrate the cutting rate down and vacuum up for removal of lens material. Releasing vacuum when repositioning the cutter is also very important to minimize tractional forces, he said.

“Work with a retina colleague or someone who has experience with this technique. Think about getting credentialed in your OR,” Dr. Nichamin said. “As with any complication, it is really important to be candid with patients. Let them know what happened. … Complications occur. What really matters is how we manage them.” – by Michelle Pagnani

• Louis D. “Skip” Nichamin, MD, can be reached at Laurel Eye Clinic, 50 Waterford Pike, Brookville, PA 15825; 814-849-8344; fax: 814-849-7130; email: nichamin@laureleye.com.
• Disclosure: Dr. Nichamin has no relevant financial disclosures.

This talk is important for any cataract surgeon, because it emphasizes the need to be prepared should a complication arise. It is essential to have a plan in the event of vitreous loss. Dr. Nichamin suggests a tray setup to prevent one from worrying about instrumentation and to deal with the situation at hand. He also recommends bimanual anterior vitrectomy or a posterior approach. The key here is to split irrigation and the vitrector and to move away from the primary wound; this will ensure the best vitreous cleanup, which translates to better patient outcomes. Hopefully, this talk will either support what cataract surgeons are already doing or perhaps encourage them to reevaluate their approach so they feel more comfortable should a capsule break.

– Rosa Braga-Mele, MD, MEd, FRCSC
Associate Professor, University of Toronto
Disclosure: Dr. Braga-Mele has no relevant financial disclosures.