EyeWorld Asia-Pacific December 2016 Issue

December 2016 8 EWAP FEATURE Have a game plan for capsule rupture by Rich Daly EyeWorld Contributing Writer Although such cases are rare, surgeons should have a plan and tools ready to execute it in every cataract surgery A lthough rare, the odds are that a cataract surgeon will eventually face unplanned vitreous loss. One national registry puts the rate as high as 2%, which means every surgeon needs a plan and readily available tools to execute that plan in every cataract case, said Lisa Arbisser, MD , adjunct professor, John A. Moran Eye Center, University of Utah, Salt Lake City. “When optimally managed, outcomes in such cases can rival uncomplicated surgery,” Dr. Arbisser said. Identifying a broken capsule is not always easy. Signs can include a pupil suddenly bouncing or snapping due to a rupture in the posterior capsule changing the distribution of fluid, which affects the anterior chamber’s depth and often the pupil’s size. An increase or decrease in the anterior chamber’s depth AT A GLANCE • Signs of a broken capsule can include a pupil suddenly bouncing or snapping. • When a rupture is identified, resist the instinct to come out of the eye. • Diluting triamcinolone can allow better visualization. Suture of 20-gauge pars plana incision with a two-bite 8-0 vicryl closure. Any gauge direct entry incision for anterior vitrectomy requires suturing to avoid vitreous incarceration. The same suture is used to close the fornix-based conjunctival flap for reliable coverage. A non-coincident transconjunctival partial thickness scleral entry at 30 degrees to the scleral surface is made 3.5 mm posterior and parallel to the limbus to create a self-sealing tunnel with the trocar system. Triamcinolone is used to identify the presence of prolapsed vitreous, like throwing a sheet over a ghost. Reinstill as the last maneuver to confirm complete removal and for its anti- inflammatory properties. during phacoemulsification or irrigation and aspiration are both warning signs. Unless there is a good explanation for the change, stabilize and explore, Dr. Arbisser said. Other signs include a momentary spider of the posterior capsule, which requires inspection after stabilizing the chamber and protecting the hyaloid with OVD. An unusually clear appearance of the posterior capsule is usually a rent or hole. If lenticular material suddenly stops coming to the phaco tip, there is likely vitreous in the way. This is caused by vitreous following a gradient from high to low pressure, which causes it to seek the flow into the phaco or irrigation and aspiration tip. If a rupture is suspected, surgeons should stabilize the chamber with viscoelastic and then have triamcinolone prepared and ready for intracameral installation. The presence of vitreous is best confirmed by using triamcinolone to particulate stain the vitreous. “Essentially we throw a sheet over the ghost,” Dr. Arbisser said. Early steps When the rupture is identified, surgeons should resist the instinct to come out of the eye, said Bryan Lee, MD , JD , in private practice, Altos Eye Physicians, Los Altos, California. “Keep irrigating and have the scrub nurse hand you whatever viscoelastic is available,” Dr. Lee