Focal lens opacity after intra-vitreal injection

This patient had multiple prior intra-vitreal injections for macular disease and now presents to you for cataract surgery. Upon examination there is moderate nuclear sclerosis and another small, focal lens opacity. What should we do differently in this case?

Penetration of the lens capsule by the intra-vitreal injection will cause either a total white cataract due to liquefaction of the cortex or a small focal defect like we see here. There is even a needle tract leading up to the focal opacity.

The best approach to this case is to treat it like a posterior polar case. This means avoiding hydro-dissection because that will cause pressure which will blow out the posterior capsule. Instead, do just hydro-delineation and remove the lens endo-nucleus, then use a dispersive visco-elastic to perform visco-dissection. This slow wave of dispersive visco-elastic will slowly dissect the epi-nucleus and cortex from the capsule and will tamponade any break in the posterior capsule.

In this anonymously submitted video, the surgeon proceeds normally and does hydro-dissection. This causes a wide-open posterior capsule and retained lens fragments in the vitreous which necessitate a pars plana vitrectomy. The patient ultimately does well.

Click below to learn from this important complication: