EyeWorld Asia-Pacific December 2015 Issue

13 December 2015 EWAP FEATURE holes—even anteriorly, giving rise to retinal detachment or macular holes that will lead to permanent visual loss. If the rupture occurs during nucleus rotation, the tear is usually peripheral. In these cases, even with a large rent, after controlling the position of the capsule, a lens can be implanted into the ciliary sulcus. A three-piece lens is particularly useful in these cases, and a spare should be handy just in case. If a rupture occurs during nucleus emulsification, the problem can be addressed by lowering the fluidics conditions. In one of Dr. Bellucci’s cases in which he recognized the problem a little late, he rotated the half of the nucleus against the posterior capsule rupture and was able to successfully complete the surgery. Again, he was able to implant a three-piece lens over an anterior capsular ring. In such cases, he also recommended using a metal or plastic glide to assist in the IOL implantation. If a rupture occurs towards the end of phaco, Dr. Bellucci said that most cases can be completed whether by automated I/A or by manual removal of peripheral lens cortex. He said that an anterior vitrectomy is eventually always required to remove the anterior vitreous. In one such case, Dr. Bellucci was able to successfully implant a four-haptic IOL. “Two-haptic IOLs are probably not the best solution for those cases because the pressure they exert against the bag equator is much too high,” he said. When performing vitrectomy, triamcinolone injection can reveal vitreous, while a closed system allows better control of the vitreous. “I always separate irrigation and aspiration because otherwise with coaxial irrigation the vitreous will be pushed away from our aspiration port,” Dr. Bellucci said. “Since the vitreous is always attached to much larger pieces of vitreous, it will behave differently from our lens material; it will not be attracted to the aspiration port. So separation of the irrigation and aspiration is better.” Dr. Bellucci also said that surgeons should keep in mind that vitreous is usually adherent to the iris, both anteriorly and posteriorly. This should be carefully removed without touching the iris with the vitreous cutter to prevent iris coloboma. Leaving the worst for last, Dr. Bellucci presented a case of dropped nucleus. In a case with a posterior polar cataract, Dr. Bellucci said they did everything they could to avoid a dropped nucleus—they didn’t do any hydrodissection; they used very, very low fluidics—but it happened anyway. Changing strategies, they applied local anesthesia, waited 15 minutes, then performed a posterior vitrectomy. Because the nucleus was hard, they avoided using a fragmatome. “In the vitreous cavity, we did not inject any heavy fluid to protect the retina, but simply went carefully with our vitrector to remove all the material and were successful in doing so.” After completing the vitrectomy, they were able to implant a three-piece IOL during the same surgical session. In such cases, Dr. Bellucci said, “for sure we need someone who is trained in posterior segment surgery.” Postoperatively, posterior capsule rupture increases the risk of retinal detachment and endophthalmitis; vitreous floaters are also more frequent, and visual recovery will be delayed. “We immediately tell the patient that the problem was encountered even when we were able to solve it in the best way and that visual recovery will be delayed,” Dr. Bellucci said. “In conclusion, posterior capsule rupture can involve both simple and complicated procedures,” he added. “It may develop at any stage of our surgery, excluding anterior capsulotomy, but immediately can start in anterior capsulotomy if an anterior tear develops. “Surgery should change as the doubt arises, and we should have a plan immediately and planning is mandatory and should be tailored to surgeon experience.” Anterior capsular tear Among the cataract surgery complications explored at CSCRS, the one discussed by Tal Raviv, MD , New York, presents surgeons with challenges “earlier in the event horizon.” According to Dr. Raviv, the first study on his topic—anterior capsular tear—was published in 1991. 6 At the time, he said, while surgeons were already performing phaco, ECCE was the main surgical procedure for cataract surgery and there were three competing techniques for creating a capsulotomy: the can opener capsulotomy, the linear or envelope capsulotomy, and continuous curvilinear capsulorhexis. In the study, David J. Apple, MD, Ehud I. Assia, MD, and their colleagues looked at 57 eyes to see what percentage undergoing which technique had tears. They found that 86% of can- opener eyes had tears, while 100% of the linear or envelope eyes had tears—“that’s exactly what the capsulotomy was doing,” Dr. Raviv said: “It was just creating a tear all the way out. And it’s still used in some small incision cataract surgery.” However, they also found that, in these eyes, none of the tears extended posteriorly. The reason for this was the zonules. “The zonules are really our friends,” Dr. Raviv said. “The equatorial zonules actually go to both sides of the tear…allowing us to not have an extension.” When the authors went further and attempted to induce capsular tears, they found they need to exert a lot of pressure in the eye to do so. “What I learned from this is that from extracap, when we weren’t phaco probing, we weren’t putting a lot of pressure into the eyes, these tears never extended, or very infrequently did,” Dr. Raviv said. “With phaco, we’re putting a lot of irrigation in the eye, and because of that we have, perhaps, possible complications.” Dr. Raviv said that the first literature review of anterior capsular tear, published in 2006, reviewing 2,646 cases found an incidence of 0.79%. 7 continued on page 14