Never too late to ruin the case: How not to manage vitreous trouble with phaco-DMEK
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This column is the latest article in the ongoing series “I wish I hadn’t done that.” Past submissions can be read here.
This case went south when posterior capsular rupture occurred.
This month’s edition of “I wish I hadn’t done that” is particularly painful, not only because of the recency of events, but also because of the sheer number of unforced errors involved.
Cataract extraction proceeded uneventfully, except that the capsulorrhexis was sized large at 6 mm — intentionally but unwisely — to facilitate removal of the dense lens.
Descemetorhexis followed, and then injection of a single-piece acrylic IOL into the capsular bag. So far, so good.
Next, the irrigation/aspiration (I/A) handpiece was introduced into the eye to remove viscoelastic from behind the IOL. But as soon as the lens was tipped up and the handpiece started diving back, I started vacuuming, and this is where it all went wrong.
Big mistake 1: Although the port on the handpiece was pointed up, it was not pressed flush against the back surface of the IOL, and my sharp angle of attack brought the port into dangerous proximity to the capsular bag. In a flash, a gigantic posterior capsular (PC) rupture occurred, and the I/A port was choked with vitreous (Figure 1a).
Big mistake 2: Upon observing the enormous PC rent, I overreacted to the threat of the IOL dropping back. In reality, this was unlikely because of the vitreous support and because the haptics of the IOL were tucked into the capsular fornix. Nevertheless, I pulled the IOL up into the anterior chamber, bringing vitreous up with it (Figure 1b).
Source: Jack S. Parker, MD, PhD
Big mistake 3: After performing a limited anterior vitrectomy, rather than simply explanting the lens and replacing it with a three-piece sulcus IOL, I decided to reverse optic capture the existing one-piece lens. This was the decisive mistake because it left the IOL only tenuously balanced within an overly large capsulorrhexis (Figure 1c).
Finally, the Descemet’s membrane endothelial keratoplasty graft was injected, and although unfolding was uneventful, I was unable to firmly pressurize the anterior chamber with air at the conclusion of the case for fear of blowing the precariously perched IOL into the back of the eye. Adding insult to injury, even after the graft was in place, I was dismayed to discover vitreous to the wound, which had come around the incompletely captured IOL, requiring a dismal Weck-Cel vitrectomy (Figure 1d).
Of course, at the 1-day postoperative examination of this patient, the eye was a complete mess. The IOL was partially dislocated, there was vitreous in the anterior chamber, and the DMEK graft was totally detached.
Among all the errors in this case, the back-breaking blunders pertained to what happened after the PC rupture. Even with an open posterior capsule, leaving the IOL in the bag would have been better than yanking it up into the anterior chamber and then trying to force it back using reverse optic capture. And once the IOL was brought up, it should have been removed and replaced with a three-piece lens, which could be stably positioned in the sulcus. Reverse optic capture was a terrible idea because the overly large capsulorrhexis permitted both the IOL to fall back and the vitreous to come forward during the subsequent DMEK unfolding maneuvers.
One week after this nightmare, the patient was returned to the operating room for an anterior vitrectomy, IOL exchange and repeat DMEK, and fortunately, she has done well. But this was certainly a humbling lesson in how (not to) handle a large PC rupture in the setting of planned DMEK.
- For more information:
- Jack S. Parker, MD, PhD, can be reached at Parker Cornea, 3745 Corporate Woods Drive, Vestavia Hills, AL 35242; email: jack.parker@gmail.com.
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