2984: Quiz: Big hole in the posterior capsule – Why?
It is time for group knowledge because I am genuinely not sure why this surgical complication happened. In this case, an anonymous resident surgeon ends up with a huge hole in the posterior capsule. To figure out the root cause, we need to leverage the collective brains of all ophthalmologists in our global community. Was it an issue with fluidics, a sudden chamber surge, or perhaps an unnoticed mechanical touch from an instrument during nuclear division or cortex removal? Sometimes these posterior capsule tears can happen in a fraction of a second, leaving us questioning the exact mechanism. Please watch the video closely, analyze the steps leading up to the complication, and comment your thoughts and theories below to help us all learn from this case.
At approximately 3 min and 15.08 sec into the video, radial wrinkles in the posterior capsule are visible for one frame. This is when the PCR happens. The wrinkles appear to center on where I’d imagine the very tip of the phaco needle to be: burrowed in just a little too deeply into the remaining nuclear material. In this split-second, it is hard for the surgeon to know exactly where the phaco tip is and how far down the chopper is. This is in part due to the three Purkinje 1 reflections of the microscope’s illumination system appearing directly at the midpoint between the phaco tip and the chopper tip, limiting the surgeon’s ability to gauge the position of these instruments.
I have found that keeping the oblique illumination as dim as possible (I keep it at zero for my routine phaco cases) can help by suppressing or eliminating the topmost P1 reflection. The other piece of advice is to always keep the chopper in the “safe position” when you know you are gobbling up the last piece of nucleus.
It was the last part of the sculpting of the groove in the middle+the chopper in there during the first cracking.