EyeWorld Asia-Pacific December 2012 Issue

28 EWAP CATARACT/IOL December 2012 Dropped but not lost Managing the posterior capsular rupture and dropped nucleus with the IOL scaffold technique T he biggest nightmare for a cataract surgeon is a sinking nucleus because of a posterior capsular rupture, said Amar Agarwal, FRCS , Dr. Agarwal’s Eye Hospital, Chennai, India. Managing these cases is a challenge. If the surgeon refers the case to a posterior segment surgeon, the patient is going to get upset because he will know there is a serious problem, he said. Dr. Agarwal and colleagues therefore described the IOL scaffold technique that can be used by anterior segment surgeons to rescue the situation. The principle is very simple, he said. With a sinking nucleus, the first step is to bring the nucleus up anteriorly with a rod. The posterior assisted levitation technique (PAL), described by Charles Kelman, MD , can be used, Dr. Agarwal said. After that, the next obstacle is removing the nucleus from the eye. “If I now emulsify it with a phaco machine, some pieces will fall as there is no capsule. The second choice is to open my incision and make it a large incision of 6-8 mm; that means if I’m clear corneal, I have to cut the sclera, I have to put sutures in, then I have to put the lens in, which is another challenge. So in other words, my small incision has become a large incision,” he said. A third alternative would be to use a glide that expands, place it right under the nucleus, and then emulsify the nucleus, but again, the incision would have to be extended, he said. This is where the IOL scaffold technique comes in. As described by Enette Ngoei EyeWorld Contributing Writer by Dr. Agarwal and colleagues, an anterior chamber maintainer is introduced through a 1.2 mm stab micro-vitreoretinal blade incision. The position of the AC maintainer should be away from the PCR and flow should be kept low. Anterior vitrectomy is done with the vitrectomy cutter to remove the vitreous prolapsed in the anterior chamber. An Agarwal globe stabilization rod (Katena, Denville, NJ, USA) passed through the sideport helps to push the fragment away from the PCR. The fragments are brought into the anterior chamber. A foldable IOL is then injected via the existing corneal wound and is maneuvered below the nucleus. The leading haptic of the IOL is positioned above the iris, and the trailing haptic is placed just outside the incision site. Using a dialer in the non-dominant hand, the junction of the optic haptic junction on the trailing side is maneuvered so that the IOL blocks the pupil. Thus the IOL acts as a scaffold and prevents the fragments from falling into the vitreous cavity. The nucleus fragment is then removed with the phaco probe (low flow and vacuum). Cortex is removed with suction and low aspiration using a vitrectomy probe. The non-dominant hand adjusts the trailing optic haptic junction so that the IOL is well centered over the pupil acting as a scaffold while emulsifying the nucleus. Once cortical cleaning is done, the IOL is placed over the capsular remnants in the ciliary sulcus. The AC maintainer is then removed and wound hydration done. With this technique, the incision is not enlarged, the pieces have not fallen down, so the physician doesn’t need to refer the patient to a retina doctor later on, and the same lens that was going to be used is implanted into the sulcus, Dr. Agarwal said. The only difference is instead of implanting the lens after the nucleus removal, it’s done before that. “It’s such a simple technique and can be done by any anterior segment surgeon,” he said. Having started this technique in 2011, Dr. Agarwal and colleagues have used it in more than 20 patients. “I personally believe an anterior segment surgeon should know a little bit [about] how to manage posterior capsular ruptures,” he said. However, he warned, “If you have a very hard nucleus and a full nucleus, I would advise you to extend the incision and remove it manually.” Other management strategies According to William F. Mieler, MD , professor and vice-chairman, Department of Ophthalmology & Visual Sciences, University of Illinois at Chicago, Ill., USA, Dr. Agarwal’s technique can work. “It’s just a matter of how much of the nucleus has fallen backward and how far back the vitreous cavity has gone. If particles are not too terribly far behind the posterior capsule in the anterior vitreous then a technique like that can certainly work,” he said. Mark Packer, MD , clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Ore., USA, said that anything the surgeon can do to support the nucleus and phaco it would be a good idea. He said he’s also seen a sling technique used where the bag had broken and the nucleus was in danger of falling but had not yet fallen. “This surgeon passed a 10-0 prolene suture back and forth through the sulcus like you would if you were going to suture fixate an IOL, but he did that temporarily, passed it one way, matched it with a needle, passed it the other way, and left the two needles sitting there; it acts like a hammock, which held the nucleus in place long enough to complete the phacoemulsification,” he said. The key is not to pull on vitreous and cause a retinal detachment, which is the tricky part, he said. “That’s why we have a vitrectomy cutter; anterior segment Dr. Agarwal uses the IOL scaffold technique to manage a sinking nucleus due to posterior capsular rupture. Source: Amar Agarwal, FRCS