In this anonymous video from a surgeon in training, we have quite the challenge: a dense white cataract surgery where a rupture in the posterior capsule is noted while there is still an entire hemi-nucleus remaining in the eye!
- What is the next step?
- How can we remove the rest of the nucleus without having it drop into the vitreous cavity?
- Will we need to do an anterior vitrectomy?
- How will we securely place an IOL for great long-term stability?
- What is the prognosis for this patient?
- Do we need to place a suture even though the incision is well-constructed?
The bimanual 23g anterior vitrectomy instrumentation is used to do both the cortical clean-up as well as the anterior vitrectomy. There is an important distinction between the two anterior vitrectomy modes on your phaco machine:
- I/A Cut: This means that your foot pedal does: position 1 irrigation, position 2 aspiration, position 3 the mechanical cutting action. This is great for aspirating cortex material or removing viscoleastic at the end of the case. Do not use this mode for removing vitreous since it will put traction on the vitreous and that could damage the retina. If you hear the ding sound that the machine makes when it is occluded, you likely have vitreous blocking the port and you should not be using this mode.
- Anterior Vitrectomy: This means that your foot pedal does: position 1 irrigation, position 2 mechanical cutting action, position 3 aspiration. This is great for removing prolapsed vitreous, but it does not work well for stripping away cortex material. Also, be careful as this mode can easily damage the remaining capsular support or even the iris.
Triamcinolone is also used to help visualize the prolapsed vitreous because it sticks to the surface of the vitreous strands. It also has a good anti-inflammatory activity which is helpful in healing after cataract surgery with complications like this.
The Optic Capture Technique: The IOL haptics are in the suclus, but the 6-mm optic has been placed behind the 5-mm capsulorhexis, similar to placing a button through a buttonhole in your shirt. Technically, the optic is in a similar to position compared to being “in the bag”, so we do not need to drop the IOL power as we would when the optic is in the sulcus. We must convert from the single-piece lens (A-constant of 119.2 and IOL power of +21.0) to the three-piece lens (A-constant of 118.7 and thus IOL power should be 0.5 D less, so +20.5).
Click below to learn how to rescue this tough case and survive this complication:
Can we try IOL scaffold technique in this case. As almost half of the nucleus has been removed and remaining half of the nucleus has been prolapsed into AC we can easily put a multipiece lens over the inatact capsulorrhexis and can cotinue Phaco .
Yes, excellent point. That technique does work well, however in this case there is already vitreous prolapse. If you insert the IOL first as a scaffold, then it may be entrapped in vitreous. Either option is reasonable — it is the surgeon’s decision