Management of posterior capsule rupture during phacoemulsification using the dry technique

Deadbolt cataract due to misplanted minishunt

A 62-year-old woman with stable unilateral glaucoma in the left eye presented for a cataract consultation. In 2010, laser peripheral iridotomies (LPI) were performed on both eyes by a different provider. Her postoperative course was complicated by a recalcitrant steroid response with a highest intraocular pressure (IOP) of 65 mm Hg in the left eye. A trabeculectomy with a glaucoma minishunt (EX-PRESS, Alcon) was then performed by that provider (Supplemental Figure 1, http://links.lww.com/JRS/A603). Thereafter, IOP control of the left eye was normalized and maintained without topical antiglaucoma medications. Historically, her right eye has been always her better eye. Recently, she noticed metamorphopsia in her left eye. Her ocular history was also notable for high refractive errors requiring continuous spectacles wear, possible mild refractive amblyopia of the left eye, history of submacular choroidal nevus with drusen in the right eye, and an epiretinal membrane (ERM) with macular pucker in the left eye. Her husband is an optician. Both inquire about refractive cataract surgery options to correct astigmatism and presbyopia; both have reservations regarding cost and visual quality associated with diffractive optic intraocular lenses (IOLs). Her deteriorating visual acuity in both eyes affects her ability to work. Her corrected distance visual acuity was 20/40 in both eyes (pinhole, no help) while wearing spectacles according to a prescription of -8.50 diopters (D) +1.50 D × 106 for the right eye and -13.00 D +3.25 D × 057 for the left eye. Her corrected near visual acuity was 14/14 in both eyes with the abovementioned prescription and a +3.00 D add. Central corneal thickness was 618 µm in the right eye and 631 µm in the left eye. IOP was 20 mm Hg in the right eye and 10 mm Hg in the left eye on no antiglaucoma medications. Pertinent findings on slitlamp examination included bilateral dermatochalasis, a shallow diffuse thick bleb superiorly in the left eye only, patent LPI superiorly in both eyes, nuclear sclerotic and cortical cataracts in both eyes (with prominent focal spoke superiorly left eye only) (Figure 1, A-C). Fundus photos show posterior vitreous detachment in both eyes, ERM with macular pucker in the left eye, and submacular choroidal nevus (2.5 × 3.0 disc diameter size) with overlying drusen in the right eye (Supplemental Figure 2, A, http://links.lww.com/JRS/A604). Gonioscopy revealed open angles in both eyes, albeit with focal narrowing without synechiae superiorly in the left eye only (Figure 1, D-FJOURNAL/jcrs/04.03/02158034-202207000-00020/figure1/v/2022-06-24T130746Z/r/image-tiff). Most importantly, however, the distal tip of the minishunt was not positioned as expected in the anterior chamber; rather, it was noted to pierce the peripheral iris near the iris root superiorly. Most of the minishunt shaft and spur were positioned in the posterior chamber with the distal tip penetrating into the superior aspect of the capsular bag and cataract in the left eye-like a deadbolt. Visual field testing showed a full field in the right eye and an inferior nasal step in the left eye (Supplemental Figure 2, B, http://links.lww.com/JRS/A604). In addition to slitlamp, gonioscopic, and fundus photos, we also obtained optical coherence tomography of the macula and nerve (Supplemental Figure 2, C, http://links.lww.com/JRS/A604), optical biometry, ultrasound biomicroscopy, endothelial cell counts, and corneal topography (Supplemental Figure 3, http://links.lww.com/JRS/A605). How would you counsel this patient regarding her glaucoma condition, the misplanted minishunt, and her cataract surgery and IOL options? How would you manage the misplanted minishunt? What surgical approaches or specific techniques would you consider for cataract removal and visual rehabilitation?

Evaluation of the capsular safety of a new hybrid phacoemulsification tip in a cadaver eye model

PURPOSE

To evaluate the use of a new hybrid phacoemulsification tip made with a high strength polymer overmold designed to prevent posterior capsule rupture (PCR) compared with a metal tip.

SETTING

John A. Moran Eye Center, University of Utah, USA.

DESIGN

Experimental study.

METHODS

This ex vivo crossover study compared a new phacoemulsification tip to a metal tip. After a preliminary experiment applying the tips to the posterior capsule with the bevel down, 10 phakic cadaver eyes were prepared using the Miyake-Apple technique, after which each tip was tested in a series. After lensectomy, the posterior capsule was subjected to direct contact from the tip with the bevel up. The vacuum limit was set to 150 mm Hg, and the aspiration flow rate to 30 cc/min, after which the torsional power was increased by increments of 5% up to a maximum amplitude of 60%. The primary endpoint was the torsional power required to produce PCR.

RESULTS

Vacuum alone did not cause PCR with either tip. All tests showed that a higher torsional power was required for PCR with the hybrid tip. With the bevel directed upward, the hybrid tip required higher torsional power before PCR than the metal tip (55% ± 10.0% [SD] versus 15% ± 4.1%, respectively) (P value < .001). This indicates that there is a lower likelihood for PCR with the hybrid tip.

CONCLUSION

The hybrid tip used in this study can be an effective means of preventing surgical complications such as PCR. This tip would be useful for experienced surgeons as well as for those who are in training.

Vitreous Wiping, a new technique for removal of vitreous cortex remnants during vitrectomy

PURPOSE

Unremoved vitreoschisis-induced vitreous cortex remnants (VCR) are associated with macular pathology. When present on the retinal periphery, they may play a role in proliferative vitreoretinopathy and retinal detachment after vitrectomy. Existing instruments for their removal involve substantial risk of iatrogenic retinal damage. Purpose of this study was to evaluate the use of a new technique, Vitreous Wiping, for removal of VCR during vitrectomy.

METHODS

Proof-of-concept case series of six eyes (six patients) treated with vitrectomy for various pathologies (macula-on and macula-off retinal detachment, macular hole, macular pucker and vitreous floaters). Vitreous cortex remnants on the surface of the retina were visualized with triamcinolone and removed by Vitreous Wiping with a rectangular piece of polyvinyl alcohol (PVA) held with intra-ocular forceps. Visual acuity and clinical course were assessed during a follow-up of 6 months. All eyes underwent postoperative macular optical coherence tomography. Eyes without preoperative macular pathology, underwent retinal sensitivity testing and eyes without paracentral pathology underwent visual field analysis.

RESULTS

Vitreous cortex remnants could be removed completely in all eyes. There were no intra- or postoperative complications. We observed that PVA is soft like a sponge and vitreous sticks to it, making Vitreous Wiping easier and safer, compared to alternative instruments. Visual acuity improved in all eyes. Microperimetry and visual field analysis revealed no abnormalities related to Vitreous Wiping.

CONCLUSION

Vitreoschisis-induced VCR can be removed effectively and safely from the retinal surface by Vitreous Wiping. Larger studies are needed to confirm this promising finding and its potential impact.

Management of Vitreous Loss during Cataract Surgery under Topical Anesthesia with Transconjunctival Vitrectomy System

PURPOSE

A new technique to manage posterior capsular rupture with vitreous prolapse into the anterior chamber during phacoemulsification under topical anesthesia using the sutureless self-sealing 25-gauge transconjuctival vitrectomy system.

METHOD

In the event of vitreous prolapse into the anterior chamber, the corneal wound is sutured and cleared of vitreous. A trans conjunctival 25-gauge sclerotomy through the pars plana is made. The high speed 25-guage trans-conjunctival vitrectomy system (TVS-25) under topical anesthesia is introduced and vitrectomy is performed to clear the anterior chamber of vitreous. An anterior vitrectomy is also done. A foldable intraocular lens is subsequently inserted.

RESULTS

The vitrectomy is performed in a closed chamber maintaining normal intraocular pressure. The high-speed cutter exerts minimal traction on the vitreous. The accessibility to vitreous improves through the pars plana route ensuring more complete removal of the vitreous and restoration of normal anatomy. Topical anesthesia avoids the risks of globe perforation, retrobulbar hemorrhage, and prolonged postoperative akinesia of the eye.

CONCLUSIONS

The 25-gauge pars plana incision is small and self-sealing. This makes the procedure fast, effective, painless and safe.

Remnant extraction by using an intraocular lens injector with essential flow

PURPOSE

To describe a new technique for remnant removal in cases of posterior capsular rupture during cataract surgery and Soemmering ring extraction during intraocular lens (IOL) removal.

METHODS

An IOL injector, inserted into the anterior chamber, provides a new exit for residual lens fragments. Passive fluid flow, supplied by an anterior chamber maintainer or some ocular viscoelastic device (OVD) injection, delivers the residual fragments into a lumen of the injector in assistance with a second device such as a phaco-chopper and vitreous cutter.

RESULTS

Soemmering rings can be removed safely through small incisions even when under the iris. Nucleus fragments in anterior chamber can be removed safely. Fragments that fall into the vitreous cavity can float up for removal by passive flow.

CONCLUSIONS

This new technique, remnant extraction through lens injector with essential flow, has several practical advantages over existing methods including reduced OVD injection and smaller incision size. It may offer an alternative to existing methods of remnant removal in cases of posterior capsular rupture during cataract surgery and Soemmering ring extraction.

Trimanual Anterior Vitrectomy: A Novel Technique to Manage Vitreous Loss during Phacoemulsification

We report 2 cases illustrating the use of a new technique to manage vitreous loss during phacoemulsification, which we have termed 'trimanual' anterior vitrectomy. In each case, after recognizing posterior capsule tear, the remaining nuclear pieces were removed with low-parameter phacoemulsification. The remaining cortical material was then removed using bimanual irrigation and aspiration handpieces while the assistant surgeon inserted the vitrectomy probe through a separate 1-mm limbal incision. The vitrectomy probe was held below the plane of the posterior capsule tear, used to cut the vitreous and to provide a mechanical blockade to potentially descending lens material. While this technique involves the potentially awkward simultaneous use of 3 intraocular instruments, we believe that there are several advantages over standard bimanual anterior vitrectomy.

Clinical outcomes of intraocular lens scaffold surgery: a one-year study

PURPOSE

To evaluate the safety and 1-year outcome of the intraocular lens (IOL) scaffold technique in eyes with soft to moderate nuclear remnants after intraoperative posterior capsule rupture (PCR).

DESIGN

Single-center, retrospective, interventional, noncomparative, consecutive case series.

PARTICIPANTS

A total of 20 eyes of 20 patients who had intraoperative PCR underwent IOL scaffold surgery in a tertiary clinic.

METHODS

A retrospective analysis of medical records of a consecutive series of patients who underwent IOL scaffold surgery from August 2011 to February 2013 was reviewed. All surgeries were performed by a single surgeon, and a 3-piece, 6.0-mm optic, acrylic, foldable IOL with a modified C-loop haptic configuration was implanted in all eyes.

MAIN OUTCOME MEASURES

The preoperative and postoperative parameters evaluated were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), specular microscopy, gonioscopy, ultrasound biomicroscopy, central macular thickness, intraocular pressure (IOP), and anterior and posterior segment inflammation. The final visual outcome at 1 year was evaluated.

RESULTS

At 1-year follow-up, the mean postoperative UDVA and CDVA in Snellen's decimal equivalent was 0.58 ± 0.15 and 0.90 ± 0.17, respectively. The IOL was placed in the sulcus for 14 eyes and in the capsular bag for 3 eyes, and glued intrascleral fixation of IOL was performed in 3 eyes. The mean postoperative refractive error at the final examination was -0.4 ± 0.05 diopter (standard error of mean). Postoperative CDVA of 20/20 and 20/30 was achieved in 75% (15 eyes) and 25% (5 eyes), respectively. There was no correlation between preoperative specular count and percentage loss of cells (P = 0.602; r(2)=0.015). The mean central macular thickness at 1 year was 182.5 ± 11.79 μm. Clinical macular edema was observed in 1 of 20 eyes (5%).

CONCLUSIONS

The IOL scaffold provided an effective, relatively noninvasive means of emulsifying moderate to soft nuclear remnants in eyes with intraoperative PCR, with a good visual outcome and a favorable complication rate.

Reverse optic capture of the single-piece acrylic intraocular lens in eyes with posterior capsule rupture

BACKGROUND AND OBJECTIVE

To evaluate the clinical results of reverse optic capture (ROC) with single-piece posterior chamber intraocular lenses (PC-IOLs) in cases of phacoemulsification cataract and IOL surgery with posterior capsular rupture.

PATIENTS AND METHODS

Preoperative diagnosis, intraoperative events, surgical parameters, intraoperative and postoperative complications, and preoperative and postoperative visual acuity and refraction of 16 eyes that underwent ROC were reviewed and analyzed. The fellow eye of 12 patients undergoing uneventful phacoemulsification without optic capture served as the control group.

RESULTS

Over a mean of 19 months' follow-up, 94% of eyes in the ROC group and 92% in the control group achieved a best-corrected visual acuity of 20/25 or better. Ninety-four percent of eyes in the ROC group and 100% in the control group had postoperative spherical equivalent ± 1.00 D of the intended refraction. Refraction was stable between 1 month and final follow-up in both groups. In all eyes with ROC, the IOL remained well centered with a securely captured optic. There were no vision-threatening complications throughout the follow-up.

CONCLUSION

The comparable outcomes in both groups suggests that optic capture of a single-piece acrylic IOL through an anterior capsulorhexis merits consideration for IOL placement in selected cases of insufficient posterior capsule support.

Clinical application of 11-deoxycortisol in visualizing prolapsed vitreous body after posterior capsule rupture in cataract surgery

PURPOSE

To evaluate the clinical usefulness of 11-deoxycortisol, a precursor of cortisol in steroid metabolism, in visualizing the vitreous body in the anterior chamber after posterior capsule rupture during cataract surgery.

SETTING

Department of Ophthalmology, Tsukuba University Hospital, Ibaraki, Japan.

METHODS

Eight eyes had anterior vitrectomy during cataract surgery using this new technique. A suspension of 11-deoxycortisol was prepared by dilution in balanced salt solution without preservatives or emulsifying agents. After a posterior capsule rupture, the suspension was injected into the anterior chamber. The visual and anatomical outcomes of surgery were evaluated during a follow-up of 7 to 9 months.

RESULTS

After the 11-deoxycortisol injection, the vitreous body that had prolapsed through the torn posterior capsule, with white particles entrapped on its surface, became clearly visible. Complete removal of the prolapsed vitreous body was achieved easily and safely using an anterior vitrectomy system. No postoperative complications related to the use of 11-deoxycortisol were observed.

CONCLUSION

Injection of 11-deoxycortisol helped visualize the vitreous body in the anterior chamber after posterior capsule rupture. The technique minimized intraoperative and postoperative complications related to posterior capsule rupture and vitreous loss during cataract surgery [corrected]

Scheimpflug imaging of pediatric posterior capsule rupture

We report a case of an 11-year-old boy who presented two days after blunt trauma to the left eye with a slingshot. On examination his best corrected visual acuity (BCVA) was 20/20 in the right eye and 20/400 in the left eye. Slit-lamp examination of the left eye revealed a Vossius ring, traumatic cataract, traumatic posterior capsule tear (PCT). The contour of the posterior capsule bulge corresponded to the edges of the PCT. Rotating Scheimpflug imaging (Pentacam 70700:Oculus, Wetzlar Germany) confirmed the traumatic cataract in the region of the PCT visualized as increased lens density at the cortex-vitreous interface. The extent of the PCT in the greatest and least dimensions was documented before and after intraocular lens (IOL) implantation. Intra-operatively, the PCT was evident and phaco-emulsification with an IOL implant was performed. Postoperatively, his BCVA improved to 20/20 in the left eye with a well-centered in-the-bag IOL as found on slit-lamp and Scheimpflug images.

[Phacoemulsification in eyes with white cataracts: results and complications]

PURPOSE

To compare visual acuity and complications in phacoemulsification in eyes with white cataract and in eyes with immature senile cataract.

PATIENTS AND METHODS

This was a prospective study on 36 eyes in 34 patients with white cataract (group 1) and 36 eyes in 36 patients with immature senile cataract (group 2).

RESULTS

In group 1, mean preoperative visual acuity was 1/100 and mean postoperative visual acuity was 5/10 at 1 month. Posterior capsule tears occurred in four eyes (11%). In group 2, mean preoperative visual acuity was 2/10 and mean postoperative visual acuity was 7/10 at 1 month. No posterior capsule tear was observed. The preoperative visual acuity was significantly lower in group 1 (p=1.8x10(-14)). Postoperative visual acuities were not significantly different between the two groups (p=0.07). The increase in visual acuity was significantly higher in group 1 (p=2.2x10(-11)).

DISCUSSION

Our study shows that white cataract is not a risk factor of poor postoperative visual acuity and the increase in visual acuity is greater in the white cataract group than in the immature cataract group.

CONCLUSION

The results of phacoemulsification in white cataracts are satisfactory in spite of a high rate of posterior capsule rupture in our study.

Single-piece foldable acrylic intraocular lens implantation in the sulcus in eyes with posterior capsule tear during phacoemulsification

PURPOSE

To evaluate early and late period results of the implantation of single-piece foldable acrylic intraocular lens (IOL) in the sulcus in eyes developing a posterior capsule tear (PCT) during phacoemulsification (PE).

SETTING

S.S.K. Vakif Gureba Training Hospital Eye Clinic, Istanbul, Turkey.

METHODS

This prospective and noncomparative study consisted of 89 eyes of 88 patients in which PCT developed, with or without vitreous loss, and that were followed up for at least 1 year. The IOL was implanted in the sulcus in all eyes with sufficient capsule support. Postoperative best corrected visual acuity (BCVA), anterior segment biomicroscopy, intraocular pressure (IOP), IOL centralization, and fundus were analyzed.

RESULTS

Temporary corneal edema, the most frequently observed cause of reduced vision in the early period, appeared in 33 eyes; high IOP in 17 eyes; anterior chamber inflammatory reaction in 5 eyes; clinical cystoid macular edema in 7 eyes; and retinal detachment in 1 eye. The IOL was decentered in 4 eyes and dislocated in 1 eye. Repositioning was performed in 2 eyes. No IOL was removed. In the early period, BCVA was 5/10 and above in 41 eyes; the final BCVA was 4/10 and below in 16 eyes and of 5/10 and above in 73 eyes.

CONCLUSIONS

The implantation of foldable acrylic IOL in the sulcus in eyes developing posterior capsule tear during phacoemulsification surgery maintains the advantages of a small incision. Postoperative visual results were good, complications were few, and IOLs were centered.

The incidence of posterior capsule disruption during phacoemulsification and associated postoperative complication rates in dogs: 244 eyes (1995-2002)

OBJECTIVE

The objective of this retrospective study was to report the incidence of posterior capsule disruption during routine phacoemulsification and to document the postoperative outcomes and complications in eyes with posterior capsule disruption compared with eyes with intact posterior capsules.

PROCEDURES

Records of 143 dogs (244 eyes) were reviewed. Data collected included whether the posterior capsule was disrupted, whether the disruption was planned or accidental, whether an intraocular lens was implanted, and visual outcome. Records were reviewed for postoperative complications. Intraocular lens implantation rates, complication rates, and visual outcomes were compared between intact and disrupted posterior capsule groups using Chi-square analyses.

RESULTS

The posterior capsule was disrupted in 33/244 eyes (14%). Planned capsulotomies accounted for 36% of the disruptions. Intraocular lenses were implanted in 76% of eyes without a disruption of the posterior capsule and in 31% of eyes with a posterior capsule disruption. Intraocular lenses were more likely to be implanted in eyes with a planned disruption of the posterior capsule (7/12; 58%) than in eyes with an accidental disruption (3/20; 15%). There were no significant differences in postoperative complications or visual outcome between eyes with posterior capsule disruption and those without.

CONCLUSIONS

The most significant complication of posterior capsule disruption during phacoemulsification is the inability to implant an intraocular lens. Intraocular lenses are more likely to be placed in eyes with intentional disruptions of the posterior capsule than those with accidental ruptures.

Successful management of cataract surgery associated vitreous loss with sutureless small-gauge pars plana vitrectomy

PURPOSE

To investigate the efficacy of 25-gauge self-sealing sutureless pars plana vitrectomy (PPV) in the management of vitreous loss associated with phacoemulsification.

DESIGN

Retrospective noncomparative case series.

METHODS

We conducted a retrospective chart review of 29 patients who underwent a newly described surgical technique, self-sealing sutureless PPV for the management of vitreous loss during phacoemulsification. The 29 eyes included in the study were analyzed for age, sex, race, posterior segment pathology, systemic illness, laterality of the eye, type of anesthesia used during surgery, placement of intraocular lens, visual acuity (pre- and postoperative), and postoperative complications. All patients had a minimum follow-up of 3 months. Self-sealing sutureless PPV was not performed in eyes with visually significant posterior segment pathology, in monocular patients, or in eyes in which there was posterior dislocation of nuclear fragments during cataract surgery.

RESULTS

The final best-corrected visual acuity was 20/40 or better in 96.5% of the patients. The complication rate compared favorably with previous studies of visual outcomes after cataract surgery.

CONCLUSION

Self-sealing sutureless PPV is a safe, reliable adjunct for managing vitreous loss during phacoemulsification and leads to rapid visual recovery.

Posterior assisted levitation for nucleus retrieval using Viscoat after posterior capsule rupture

A pars plana injection of Viscoat (sodium hyaluronate 3%-chondroitin sulfate 4%) was used to stabilize and elevate a descending nucleus in 8 patients with posterior capsule rupture. The nucleus or nuclear remnants were successfully removed in all 8 patients.

Small-gauge, sutureless pars plana vitrectomy to manage vitreous loss during phacoemulsification

This technique manages vitreous prolapse associated with posterior capsule rupture during phacoemulsification by performing small-gauge pars plana vitrectomy with a sutureless, self-sealing incision performed in a closed chamber, maintaining normal intraocular pressure. A high-speed cutter exerts minimal traction on the vitreous. Accessibility to the vitreous through the pars plana is better, ensuring more complete removal of the vitreous and restoration of normal anatomy.

Posterior capsule dehiscence during phacoemulsification and manual extracapsular cataract extraction: comparison of outcomes

PURPOSE

To compare the intraoperative behavior and postoperative outcomes of posterior capsule dehiscence during phacoemulsification and during manual extracapsular cataract extraction (ECCE).

SETTING

L.V. Prasad Eye Institute, Hyderabad, India.

METHODS

This study was a retrospective chart review of consecutive cases of posterior capsule dehiscence over 2 years in patients having phacoemulsification or manual ECCE. A chi-square test was used for statistical comparison of the results in the 2 groups.

RESULTS

In the 127 eyes with posterior capsule dehiscence, the incidence of vitreous prolapse was comparable between the 2 groups (phacoemulsification, 61.6%; ECCE, 62.7%). In the phacoemulsification group, vitreous prolapse occurred more frequently if nuclear fragments were present at the time of posterior capsule dehiscence than if they were present during cortex removal (P =.05). Posterior dislocation of nuclear fragments occurred in 4 eyes in the phacoemulsification group. Increased anterior uveitis in the early postoperative period occurred more frequently in the ECCE group (P =.02). The visual outcomes were similar between the 2 groups.

CONCLUSIONS

Even though differences existed between the intraoperative factors influencing the management of posterior capsule dehiscence during phacoemulsification and ECCE, the final anatomic and visual outcomes were comparable.