Our CataractCoach.com readers understand the challenges of white cataracts and in particular, intumescent white cataracts. With a capsular bag that is filled with liquefied lens cortex, it becomes pressurized and can cause great difficulty in creating a capsulorhexis. In this case, the resident surgeon ran into trouble and the capsulorhexis radialized out to the zonular attachments. What should you do now?
The danger of having just one area of radialized anterior capsule is that any forces on the capsular bag will all be directly transmitted to this area which can cause it to rip all the way to the posterior capsule. Then the wide open posterior capsule greatly increases the risk of vitreous prolapse into the anterior segment and then nucleus displacement into the vitreous cavity. In this case, the resident is able to use the small scissors to start another point for tearing the capsulorhexis and complete the case. Note that care is taken to avoid stress on the capsular bag to prevent further tear out of the capsule.
For a review of the challenges and techniques for white cataracts, please see this comprehensive guide.
Click the video below to learn how to rescue this run-out capsulorhexis:
Dr. Devgan,
I like the concept of performing a capsulorhexis with a pressurized anterior chamber and a small initial rhexis size. In practice, I think this is difficult to perform if the surgeon is not experienced with creating a cystotome only capsulorhexis in a small incision since the rhexis has to be performed relatively quickly.
I find that Healon 5 is a great viscoelastic since it is “heavy.” In these situations, it stays inside the anterior chamber and flattens the anterior capsule. Using a soft-shell technique with viscoat may have helped prevent the tear out.
Why not aspirate with the cystotome to decompress the milky cortex? It has a lumen like a needle and is already placed on a syringe.
Most of the time, the nucleus is soft and relatively easy to remove in these liquified white cataracts. Getting the lens out of capsular bag is a good option. Have you ever experienced a large nucleus that is pulled through the anterior rhexis to cause propagation of the tear? Another option is to use a V-groove that Thomas Oetting discusses in this video: https://www.youtube.com/watch?v=GpTC1OaLrIQ
This technique allows you to remove the nucleus without hydrodissection and minimal lens rotation.
Thanks for sharing this difficult case.
Great points. Yes you can aspirate lens milk with a needle or even using the phaco probe to puncture the lens capsule. We have shown these techniques here before. Also good thoughts with the specialty viscoelastics. Many options for these intumescent white cataracts.