CATARACT 30 EWAP SEPTEMBER 2022 increase the likelihood of PCR. Posterior capsular tear or rupture can happen at any time during cataract surgery, Dr. Al- Mohtaseb stressed. Some might think this is just an issue when doing phacoemulsification, but she noted the importance of recognizing that it can happen at any time during a case. Dr. Behshad added that most risk factors that predispose cases to P R can be identified preoperatively. Twenty-five percent of PCR is thought to be due to posterior polar cataracts, which can be identified on slit lamp exam or with ultrasound biomicroscopy. It is important to not hydrodissect the nucleus in the setting of posterior polar cataracts. Instead consider gentle viscodelineation as this can help prevent extension of the capsular defect. It is key to identify any other preoperative risk factors that may increase risks for a PCR, such as small pupils, pseudoexfoliation, zonular weakness/loss from prior trauma, previous pars plana vitrectomy, and/or intravitreal injections, or a hypermature or black cataract. Care should also be taken ahead of time to prevent the case from progressing to a PCR. For example, in small pupils, consider iris expanding devices early and/or intracameral phenylephrine. Dr. Behshad added that some other risk factors may be out of the surgeon’s hands, such as the patient’s involuntary movement during the surgery. In any patient where there is concern for poor cooperation during surgery, consider taping their head or using general anesthesia. There are also surgeon or machine-related risk factors for PCR, he added. On the surgeon’s side, these include too much pressure when hydrodissecting, issues when chopping the nucleus, and using an unfamiliar machine or suboptimal machine settings. Care should be taken during nucleus disassembly and removal to prevent post-occlusion surge, a common cause for PCR during phacoemulsification. Techniques and IOL options Dr. Al-Mohtaseb stressed that it’s not the end of the world if there is a posterior capsular tear. These patients can still do well. Early recognition is key because the surgeon wants to try to avoid postoperative complications, like decentration or subluxation of the lens, inyammation, cystoid macular edema, and macular tear or detachment. The surgeon should use surgical techniques that avoid shallowing of the chamber, which means always placing OVD into the eye before removing the phaco tip or the I/A, Dr. Al-Mohtaseb said. At no point should the surgeon let the chamber shallow to prevent vitreous from prolapsing forward. She also stressed the importance of doing a good anterior vitrectomy. She recommended a pars plana approach to the anterior vitrectomy, so the surgeon is bringing vitreous back and avoids traction. She uses triamcinolone to highlight any remnant vitreous in the anterior chamber and for its anti-inyammatory properties. Dr. Venkateswaran noted that it’s important to assess how large the posterior capsular tear is, when in the case it occurred, and what the next steps are. “I think the best-case scenario is when there is a very small posterior rupture with no vitreous loss,” she said. “You may still be able to safely place a one-piece lens in the capsular bag.” But if there is a large radial posterior capsular tear or an anterior capsular tear that extended posteriorly, the options are more limited, she said. She added that if there is an intact anterior capsule despite loss of a significant amount of the posterior capsule, the best option is to perform primary optic capture, where the surgeon places a three-piece Posterior dislocation of the entire lens nucleus in a post-vitrectomized eye after a large posterior capsular rupture. Source: Nandini Venkateswaran, MD
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