EyeWorld Asia-Pacific December 2016 Issue

December 2016 EWAP FEATURE 9 continued on page 12 The self-sealing PPI is comleted after 1–2 mm limbus parallel travel intrasclerally by lift- ing the heal of the trocar system to penetrate perpendicular to the scleral wall, thereby installing the trocar and removing the blade within. Point pressure is applied to collapse the scleral tunnel upon removal, preventing vitreous incarceration. The mircrovitreoretinal (MVR) blade sharply enters the pars plana 3.5 mm back from the limbus perpendicular to the scleral wall aiming for the ocular center. It should always be seen through the pupil to confirm complete penetration. Source (all): Lisa Arbisser, MD said. “Don’t stop irrigating until you have the viscoelastic cannula in the eye, then fill the eye with viscoelastic to try to tamponade the vitreous.” Dr. Lee warned against letting the eye get hypotonous because that will let the vitreous prolapse anteriorly. “Once you have the viscoelastic in the eye, you can bring the phaco handpiece out of the eye and take a breath and come up with a plan,” Dr. Lee said. Next steps Dr. Arbisser suggested compartmentalizing the eye prior to lens remnant removal. That means first using a dispersive viscoelastic over the area that needs to be isolated, such as a tear, and then barricading the dispersive agent by adding a Views from Asia-Pacific Mohan RAJAN, MD Chairman and Medical Director Rajan Eye Care Hospital Pvt No. 5 Vidyodaya 2nd Street, T. Nagar, Chennai – 600017, Tamil Nadu, India Tel. no. +91-9841031838 Fax no. +91-044-28343711 drmohanrajan@gmail.com T he article “Have a game plan for posterior capsule rupture” covers the entire spectrum of posterior capsule rupture. However, I would like to suggest the following for posterior capsule rupture, prevention, recognition and management: “THE TEN COMMANDMENTS”. A posterior capsular rupture should be managed properly and effectively to prevent complications such as cystoid macular edema, retinal detachment, endophthalmitis, secondary glaucoma, etc. Commandment No. 1 – Anticipate posterior capsule rupture in traumatic cataracts, posterior polar cataracts, post cataract, post vitrectomy, and hard brown cataracts with pseudoexfoliation. Commandment No. 2 – Sudden deepening of the anterior and posterior chamber is a tell tale sign of underlying posterior capsule rupture. Commandment No. 3 – Sudden loss of nucleus followability despite the fact that your vacuum and aspiration flow rates are high. Commandment No. 4 – When there is a posterior capsule tear, do not pull out of the eye. This will increase the size of the tear as well as increase the vitreous coming into the anterior chamber. Commandment No. 5 – Introduce viscoelastic, preferably Viscoat, through the side port and stabilize the anterior chamber. Commandment No. 6 – Lower the bottle height and withdraw the phaco hand piece gently out of the eye. Commandment No. 7 – Use bimanual technique with a right side port, bimanual cortical aspiration, and bimanual anterior vitrectomy. Do not use the main port. Commandment No. 8 – Central anterior vitrectomy using preservative-free triamcinolone acetate (Tricot) 0.5 mg in the anterior chamber. Pars plana vitrectomy with a single sclerotomy and anterior chamber maintainer is also a very good idea to remove the vitreous in the anterior chamber from behind. Commandment No. 9 – Access the capsule integrity and integrity of the bag. Commandment No. 10 – Suitable IOL – If the PC tear is small, convert that into a posterior capsulorhexis and implant a single-piece lens. If the PC tear is large, use a multipiece lens in the sulcus with optic capture in the capsulorhexis margin. If the PC rupture is huge and also the capsulorhexis margin is damaged, we have to go for a. Suture SFIOL b. Glued IOL c. Retrofixated iris claw lens. The take home messages are a. Early recognition of PCR b. Prevention of PCR c. Good vitrectomy d. Bimanual techniques e. Suitable IOL. Editors’ note: Dr. Rajan declared no relevant financial interests.