Posterior assisted levitation: Long-term follow-up data

Modified posterior-assisted levitation with intraocular lens scaffold and glued IOL for sinking nucleus in eyes with inadequate sulcus support

Posterior-assisted levitation is used to retrieve and levitate a sinking nucleus in cataract surgery associated with posterior capsule rupture. After the nucleus is levitated in the anterior chamber, the intraocular lens (IOL) scaffold procedure helps emulsify the nuclear remnants with the phacoemulsification probe and glue-assisted intrascleral haptic fixation (glued IOL) enables appropriate placement of an IOL in cases with insufficient capsule support. We describe a triumvirate procedure for a sinking nucleus in the absence of capsule support that combines modified posterior-assisted levitation, in which the nucleus is levitated from the existing sclerotomy sites of glued IOL surgery, with the IOL scaffold technique, enabling a closed-chamber approach when performed concurrently.

Posterior capsular rent: Prevention and management

This review article deals with a potentially sight threatening complication – rupture of the posterior capsule – during cataract surgery. Cataract surgery is the most commonly performed surgical procedure in ophthalmology and despite tremendous technical and technological advancements, posterior capsular rent (PCR) still occurs. PCR occurs both in the hands of experienced senior surgeons and the neophyte surgeons, although with a higher frequency in the latter group. Additionally, certain types of cataracts are prone to this development. If managed properly in a timely manner the eventual outcome may be no different from that of an uncomplicated case. However, improper management may lead to serious complications with a higher incidence of permanent visual disability. The article covers the management of posterior capsular rent from two perspectives: 1. Identifying patients at higher risk and measures to manage such patients by surgical discipline, and 2. Intraoperative management of posterior capsular rent and various case scenarios to minimize long-term complications. This review is written for experienced and not-so-experienced eye surgeons alike to understand and manage PCR.

Intraoperative management of posterior capsular rupture

PURPOSE OF REVIEW

Posterior capsular rupture (PCR) and vitreous loss are inevitable complications encountered in cataract surgery across all levels of surgical experience and in spite of technological advances to improve safety. Thus, cataract surgeons must always be prepared to practice safe and effective intraoperative management strategies for capsular rupture.

RECENT FINDINGS

Novel approaches for lens fragment removal, vitrectomy, and lens implantation have expanded the available options for cataract surgery in the setting of an open posterior capsule. Intraoperative PCR management strategies should prioritize safety and strive to minimize vitreous traction, stabilize anterior chamber volume, maintain capsular and zonular integrity, and protect the corneal endothelium and other anterior segment structures.

SUMMARY

With appropriate management of PCR and vitreous, surgeons may still deliver safe and satisfactory visual outcomes for modern cataract surgery.

2013 update on the management of posterior capsular rupture during cataract surgery

PURPOSE OF REVIEW

Posterior capsular rupture (PCR) is an infrequent complication of cataract surgery that can lead to significant ocular morbidity and permanent vision loss. In the setting of PCR, the primary objective is the safe and thorough evacuation of vitreous and lens fragments from the anterior segment. The secondary objective is the stable placement of an intraocular lens (IOL) selected for best refractive outcomes. Expedited referral to vitreoretinal specialists is recommended for management of posteriorly dislocated lens material and surveillance for retinal injury. It is the intention of this review to present current guidelines for the management of PCR.

RECENT FINDINGS

There are new techniques available to anterior and posterior segment surgeons in the setting of PCR. Endoillumination may facilitate visualization during anterior vitrectomy and the IOL may be used as a pupillary barrier to prevent loss of lens fragments. When secondary procedures are needed, early return to the operating room and small-gauge pars plana techniques may reduce patient morbidity.

SUMMARY

When approached carefully and systematically, patients may have good outcomes in the setting of PCR. Recent advancements in instrumentation and technique encourage further study and may lead to new standards of care.

Planned posterior assisted levitation in severe subluxated cataract: surgical technique and clinical results

We report the surgical technique and outcome of planned posterior assisted levitation (P-PAL) in four cases of subluxated cataract. P-PAL was planned as the preferred approach in all cases. A spatula was inserted via the pars plana, the whole lens was lifted to the anterior chamber and then removed through a scleral tunnel incision. Anterior chamber intraocular lenses were implanted in all cases. All four eyes had severe subluxation of the crystalline lenses with marked phacodonesis. Two eyes had history of blunt trauma, and the other two eyes had severe pseudoexfoliation with spontaneous lens subluxation. Follow-up ranged from 1 to 2 years in three cases. The postoperative visual acuity was 20/80 or better. No intraoperative complications were observed. In conclusion, the P-PAL technique was successfully performed during cataract surgery in four eyes with severe subluxated cataracts. There were no complications over the long-term follow-up.

Posterior-assisted levitation in cataract surgery

PURPOSE OF REVIEW

Posterior-assisted levitation (PAL) is a surgical maneuver for dealing with rupture of the posterior capsule or zonular dehiscence with threatened or actual subluxation of the nucleus or entire lens into the vitreous during phacoemulsification. PAL is often unknown or overlooked, especially by young or inexperienced surgeons.

RECENT FINDINGS

The advantages of PAL are, first, that it often enables completion of phacoemulsification and intraocular lens placement without conversion to an open eye with nuclear expression and second, it prevents luxation of nucleus, nuclear fragments, or the lens into the vitreous avoiding the necessity for trans pars plana vitrectomy (TPPV)-lensectomy. PAL has recently been criticized by vitreoretinal surgeons as dangerous and to be avoided. However, there is no large series or controlled study showing that the PAL maneuver is associated with an excessive complication rate as compared to cases of nuclear or lens subluxation in the vitreous managed by TPPV-lensectomy with or without previous PAL.

SUMMARY

PAL is a simple technique that can be extremely helpful. In cases in which the PAL maneuver is unsuccessful and in cases with complete luxation of nucleus or lens into the vitreous, the patient should be referred for TPPV-lensectomy.

Vitreous loss during cataract surgery: prevention and optimal management

Vitreous loss during cataract surgery is associated with a poor visual outcome. Experienced surgeons and those performing a high volume of cataract operations have lower rates of vitreous loss. Risk stratification systems, which allow prediction of intraoperative complications from preoperative criteria exist, so that less experienced surgeons can avoid higher risk cases. The management of vitreous loss includes counselling patients before surgery of the potential risks and complications. When vitreous loss occurs, it is important for the surgeon to avoid actions [corrected] which increase the chance of disaster for the eye. These include phacoemulsification in the presence of vitreous and attempts to recover dropped lens fragments from the posterior segment without vitrectomy. There are advantages in performing an anterior vitrectomy by the pars plana route rather than through the anterior chamber and this approach is facilitated by sutureless 23-gauge instruments. Dislocation of lens nuclear fragments into the vitreous is associated with a high incidence of retinal detachment as well as secondary glaucoma and cystoid macular oedema. Early involvement of a retinal surgeon in the management of these eyes is recommended.

Posterior-assisted levitation: Outcomes in the retrieval of nuclear fragments and subluxated intraocular lenses

PURPOSE

To report the outcomes of posterior-assisted levitation (PAL) to retrieve nuclear fragments and subluxated intraocular lenses (IOLs).

SETTING

Singapore National Eye Centre, Singapore, Singapore.

METHODS

In a retrospective series, the case notes of consecutive surgeries performed by a single surgeon between 1999 and 2006 were reviewed. Posterior-assisted levitation was performed for intraoperative posterior capsule rupture with nucleus-IOL dislocation or for late subluxation of posterior chamber intraocular lenses (PC IOLs). This was accomplished by the pars plana insertion of a needle followed by levitation of the subluxated object. Ophthalmic viscosurgical device injection was not used as an adjunct for levitation.

RESULTS

Fourteen patients with PAL were followed for a mean of 18.71 months (range 1 to 79 months). There were 3 cases of dropped nucleus/nuclear fragments, 1 case of intraoperative subluxated PC IOL, and 10 cases of late subluxated PC IOLs. Complications included 1 case of retinal detachment occurring 20 months after PAL and 1 case of cystoid macular edema in a patient with previous anterior uveitis. Best corrected visual acuity was 20/40 or better in all except 3 patients (1 retinal detachment, 1 corneal edema/scarring, 1 unspecified).

CONCLUSION

Posterior-assisted levitation provided an effective, relatively noninvasive means of levitating nuclear fragments and PC IOLs with few complications.