This article is more than 5 years old. Information may no longer be current.
Several factors affect management of posterior capsule rupture
The stage of the surgery at which the rupture occurs and the surgeon’s experience need to be taken into account.
Click Here to Manage Email Alerts
A posterior capsule rupture, or PCR, is a situation that every cataract surgeon has to face, and it is therefore imperative to learn how to manage this situation.
The management of a PCR depends on the stage at which the PCR occurs and on the surgeon’s experience. The surgeon should check if the anterior hyaloid face is broken and proceed accordingly. Most important is to resist the temptation to withdraw the phaco probe as soon as a PCR occurs.
Dropped nuclear fragments
As soon as the surgeon recognizes the PCR, it is important to inject viscoelastic through the side port before withdrawing the phaco probe. This is because a sudden decompression of the anterior chamber can result in an enlargement of a previously small rent. While maintaining only irrigation, a dispersive viscoelastic should be injected into the anterior chamber and over the rent using the left hand, and only after thus stabilizing the posterior capsule should the phaco handpiece be withdrawn. The bottle height is then decreased for all further maneuvers.
A 23-gauge sutureless vitrectomy system can be used for removing the dropped nuclear fragments. The trocar is passed in a tangential manner through the sclera to pierce into the vitreous cavity so that a self-sealing tunnel is created (Figure 1). The infusion cannula is turned off during insertion. The tip of the infusion cannula has to be visualized within the vitreous cavity before turning it on to avoid an inadvertent retinal or choroidal detachment. Superior ports are then similarly created with the trocar system. The cortex is freed of all entangling vitreous by using the vitrector on cutting mode.
Once it is free, the vitrector is changed to aspiration mode and the cortex stripped off the undersurface of the anterior capsular flap. This is continued until the entire cortex has been removed. At this point, if any small fallen pieces of nucleus are floating in the vitreous, they will be seen to move toward the vitrectomy probe. These can be levitated and brought to rest on the iris. The endoilluminator is introduced with the nondominant hand. The retina is inspected using a wide-field lens and inverter system to look for any nuclear or epinuclear pieces/vitreous traction. Larger nucleus pieces that have fallen on the retina can be removed using the FAVIT technique. One can alternatively use perfluorocarbon liquids to float the fragments anteriorly. A chandelier illumination system in which the light is attached to the infusion cannula leaves both hands free to perform bimanual vitrectomy.
Figure 1. Twenty-three-gauge vitrectomy for nucleus drop.
Figure 2. Vitreous staining with triamcinolone.
Images: Agarwal A
Triamcinolone
Preservative-free triamcinolone acetonide suspension is injected intracamerally. The particles get enmeshed within the vitreous, thereby making difficult-to-visualize strands of vitreous visible. This helps in performing a thorough vitrectomy and in completely removing all vitreous traction. All the granules should be removed at the end (Figure 2).
PCR during nucleus removal
If a PCR occurs during nucleus removal, it is most important to prevent any of the nuclear fragments from going through the rent into the vitreous cavity. The pieces should be brought out of the bag and placed over the iris. One can insert a three-piece foldable IOL under the fragments so that it acts as a scaffold. The fragments are then emulsified in the iris plane using low-flow, low-vacuum, slow-motion phaco, taking care no fragments drop into the vitreous cavity. A Sheets glide may also be inserted to prevent nucleus drop during emulsification. Larger nuclear pieces may be brought out after extending the incision.
Posterior-assisted levitation
Posterior-assisted levitation is used to bring a subluxated nucleus that is still in the anterior vitreous into the anterior chamber. A sclerotomy is made 3.5 mm behind the limbus. The same needle or another blunt instrument is used to levitate the nucleus into the anterior chamber (Figure 3). Once it is brought into the anterior chamber, it can be emulsified, taking care not to drop any fragments posteriorly, or delivered out through an extended incision.
Figure 3. Posterior-assisted levitation.
Figure 4. Posterior chamber IOL in sulcus.
PCR during cortical wash
In case of a rent occurring during cortical wash, the vitrector probe is used and cortex is removed by alternating between the cutting and aspiration modes. The nondominant hand can be freed by inserting an anterior chamber maintainer for fluid inflow so as to enable performing bimanual procedures more easily. IOL placement is decided depending on the size of the rent and the presence or absence of capsular support. The IOL can be injected into the bag in case of very small rents after converting it into a posterior capsulorrhexis, if possible. For larger rents, sulcus placement (Figure 4) with or without optic capture or a glued IOL is preferred. A single-piece acrylic IOL should not be placed in the sulcus because it can cause pigment dispersion, iris transillumination defects, dysphotopsia, elevated IOP, intraocular hemorrhage and cystoid macular edema.