The posterior capsule sustained a break during phaco which was near the capsular bag equator and not immediately noticeable to the resident surgeon. The toric IOL was injected into the capsular bag with the assumption that the capsular bag was intact, but once the surgeon removed the viscoelastic, vitreous began to prolapse. Now what?
This case is part 3 and a continuation of the same cataract surgery which was featured here:
- Part 1: The Chop failed and the phaco probe hit the capsular bag equator
- Part 2: The capsular bag collapsed during cortex removal
When the surgeon removes the viscoelastic from behind the optic, the high vacuum level entrapped vitreous which then further prolapsed and caused the capsular break to extend. Certainly, a partial vitrectomy needs to be performed, but can the toric IOL be left in place?
The toric IOL needs to be aligned with the steep axis of the cornea. These toric marks on the optic are the three dots at the haptic-optic junction. In this case the haptic of the toric IOL would need to be placed right at the site of the posterior capsule break where there is lack of support.
Remember that we cannot place this toric IOL in the sulcus because it is a single-piece acrylic lens which will lead to chronic inflammation, iris damage, and potential more issues. This toric IOL must be explanted and then replaced with a three-piece IOL designed for the sulcus.
click below to learn from this video of a cataract complication:
If the rupture was noted after implantation of the lens but prior to having significant vitreous prolapse (when the IA was performed behind the lens) what about doing an optic capture assuming the toric’s alignment is relatively good?
The reverse optic capture has been reported to work but I am not a fan of this technique with a single-piece acrylic IOL.