FEATURE 8 EWAP DECEMBER 2023 Creation of a peripheral corneal relaxing incision with a pre-set 600-micron diamond blade. Peripheral corneal relaxing incision completed. Precise placement and subsequent stability of a toric IOL are of the utmost importance for success in correcting astigmatism. Capsule tears can threaten both factors. So what do you do when a capsule tear occurs during cataract surgery when you planned to implant a toric IOL? Amandeep Rai, MD, FRCSC, said recognition is the first step with any case of capsule rent, whether or not a toric IOL is planned. “Once recognized, the surgeon should try to immediately tamponade the vitreous behind the compromised capsule with a dispersive viscoelastic device. It is incumbent on the surgeon to ensure that the anterior chamber remains formed; sudden shallowing may cause the rent to suddenly enlarge,” Dr. Rai said. “Depending on the stage of the surgery, the surgeon should attempt to keep all lens material anterior to the rent and remove the cataract with altered fluidics. Generous use of viscoelastic can help compartmentalize the lens fragments in the anterior chamber and keep the vitreous posterior. “A surgeon should alter the fluidics by reducing the flow rate, irrigation pressure, and vacuum,” Dr. Rai continued. “Irrigation and aspiration may be done manually or at low flow settings. Surgeons should ensure that there is no vitreous prolapse, and this may be aided by the use of diluted triamcinolone intracamerally. Any vitreous should be removed using a vitrector, and the Contact information Rai: amandeep.rai@mail.utoronto.ca Rubenstein: jonathan_rubenstein@rush.edu What to do? A compromised capsule when a toric IOL was planned by Liz Hillman Editorial Co - Director This article originally appeared in the September 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. surgeon should be vigilant and check for vitreous regularly through the remainder of the case. Suturing the main wound is suggested, as this patient may require a vitrectomy and is also at increased risk of postoperative endophthalmitis. Intracameral antibiotics should also be considered.” When it comes to IOL selection, Dr. Rai said it depends on capsular support and the type of rent. If it is an anterior capsule (AC) rent, Dr. Rai said that a single-piece IOL can be placed if the surgeon is confident in the long-term axial and rotational stability. “This depends on appropriate placement of the haptics so that a haptic does not tilt forward; if a single haptic is in the bag and the other haptic tilts forward into the sulcus, the patient is
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