EyeWorld Asia-Pacific March 2019 Issue

46 March 2019 EWAP CATARACT / IOL Recovering from a posterior capsule hole by Rich Daly EyeWorld Contributing Writer Surgeon explains the challenges of and recovery from a posterior capsular hole during cataract surgery P osterior capsule holes happen. But watching for them and quickly responding can keep a bad situation from becoming worse. Uday Devgan, MD, clinical professor of ophthalmology, Jules Stein Eye Institute, University of California Los Angeles (UCLA), chief of ophthalmology, Olive View- UCLA Medical Center, and private practice, Devgan Eye Surgery, had a routine cataract case where the challenge arose. Such ruptures stem from inadvertent contact with a very thin—usually about 4 μm— posterior capsule during the course of cataract surgery. They can arise with any cataract patient. “The problem was not the patient, it was me, the surgeon,” Dr. Devgan said about the case. “When I was removing the cataract, the phaco tip inadvertently made contact with the capsule and made that rupture occur.” When the capsule breaks and a surgeon doesn’t notice it, the problem can quickly worsen if the vitreous prolapses and the cataract falls back toward the retina. But because the complication is a round hole in the capsule, early recognition allows taking steps to avoid any further issue. In this case, Dr. Devgan’s vigilance avoided any prolapse, avoided the need for a vitrectomy, and prevented the cataract from falling back. He was even able to use the original lens implant chosen to go into the capsular bag. “That’s all because we recognized the error when it happened and immediately took the steps to counter it,” Dr. Devgan said. Watchful eye Cataract surgeons should be routinely looking for posterior capsule holes during procedures. “Maybe I’m too extreme, but I don’t even play music in the operating room,” Dr. Devgan said. “I want to focus intently on this 5–8-minute surgery, and I’m looking at everything, even the slightest change. It’s like when you are driving—are you paying attention or are you doing it passively? I want to be active and present, notice what I’m doing and see what my hands are doing. If I detect anything that is not normal, I act on it.” There are no tricks to detecting such holes beyond visual indicators. In this case, the phaco tip went through the nuclear piece to puncture a hole in the posterior capsule. One hint that Dr. Devgan got of a violation of the posterior capsule was a briefly visible hole through a hemi-nucleus. “That’s another warning sign— there shouldn’t be a through and through hole in a nuclear piece,” Dr. Devgan said. But attitude may be the most important part of finding such breaks. “The best thing to do is avoid the common instinct of denial,” Dr. Devgan said. “That’s what most surgeons—myself included—tend to do. The best way is to go in with the expectation that things will occasionally happen.” How to respond When a capsular break is found, Dr. Devgan has a standard approach. First, don’t pull the phaco probe out of the eye, and then, try to close the hole. This is accomplished by injecting dispersive viscoelastic through the posterior capsule and preventing the anterior chamber from collapsing. That also can prevent any cataract pieces from going backward. “That keeps the vitreous back and keeps the cataract in the anterior segment,” Dr. Devgan said. “When I have a hole, the barrier is broken, so the first step is to close that hole. You must temporarily plug the hole.” Second, keep the hole from enlarging. That includes avoiding any aspiration in the hole and reducing the aggressiveness of your irrigation/ aspiration settings. Once the cortex is all removed, prevent anterior chamber collapse by instilling more viscoelastic to tamponade the hole, and to fill the anterior chamber and capsular bag. “The defect didn’t open up more and the posterior capsule stayed in place,” Dr. Devgan said. “Normally, if there’s a large OVD is injected into the posterior capsule to block the hole during surgery. To minimize damage to the hole, the lens haptics are placed 90 degrees away from it. Source: Uday Devgan, MD Continued on page 48