Managing Posterior Capsule Rupture
This is a case of posterior capsular rupture. Steps are described to minimize complications and maximize safety. 1. Early recognition. If you don’t recognize it, you can’t fix it. And before you know it, there could be more vitreous in the AC and loss of lens material into the vitreous space. Certainly, this can still happen with early recognition, but early recognition will limit the problems. 2. Keep the phaco tip in the AC under continuous irrigation. Allowing the AC to collapse will cause fluid to flow out of the eye and invite vitreous into the anterior chamber and out of the incision. 3. Inject dispersive OVD into the area of the posterior capsule defect then withdraw the phaco tip when the AC looks stable. Dispersive OVD will tamponade vitreous from coming into the AC. 4. Pause and decide your game plan. In this case, there was a few lens fragments and all the cortex remained. 5. Under low irrigation setting (lower the bottle height or reduce IOP), place the I&A port right up and against the cortex and slowly increase AFR and vacuum to remove cortical material. Avoid aspirating aqueous, BSS, OVD. 6. Dry aspiration of the cortex is very controlled and effective. It minimizes the risk of vitreous coming forward. 7. Use dispersive OVD to push lens fragments to the incision to burp out. 8. Preplace a 10-0 nylon suture for the main temporal incision before the vitrectomy. Placing the suture after vitrectomy will collapse the AC and can invite more vitreous. 9. Pars plana vitrectomy is superior to anterior vitrectomy because vitreous will flow posteriorly rather than anteriorly. This allows more efficient vitreous removal and reduces vitreous manipulation. Pars plana infusion should only be done with training and experience. Anterior infusion through a paracentesis is adequate and effective as this encourages flow away from the AC. 10. Plan which type of IOL, IOL power target, and location of IOL placement. Remember single-piece acrylic IOLs should not be placed into the ciliary sulcus. 10. Inject miostat, miochol, or intraocular triamcinolone to ensure there is no vitreous in the AC or to the wound. 11. Tie off incisions with 10-0 nylon suture to reduce the risk for postop vitreous prolapse. 12. Inject subconj antibiotics to reduce risk for endophthalmitis.