posterior capsular rupture vitrectomy farid karimian m d 2002 l.
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Posterior Capsular Rupture & Vitrectomy Farid Karimian M.D 2002. Capsular Anatomy . Elastic basement membrane, type IV collagen Thickness: • 2-4  at the posterior pole Thickest: 17-23  near the ant. & post equator Ant. Capsule  14  thickness increases with age

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capsular anatomy

Capsular Anatomy

Elastic basement membrane, type IV collagen

Thickness: • 2-4  at the posterior pole

Thickest: 17-23  near the ant. & post equator

Ant. Capsule  14  thickness increases with age

Fragile posterior capsule:

- Congenital post lenticonus, posterior polar

cataract

- Posterior subcapsular ( PSC): age- related,

steroid

signs of capsule rupture

Signs of Capsule Rupture

• Sudden, abrupt and dramatic posterior

displacement of iris

• Momentary pupillary dilatation

• Nucleus “ fall away” from the phaco tip

• Nucleus dose not follow toward the phaco tip

NOTE: Any time suspected of ruptured posterior capsule modify surgical plan on that suspicion

predisposing factors for capsular rupture

Predisposing Factors for Capsular Rupture

1- Position of surgeon’s hand obscuring

visibility

2- Irrigation fluid pooling

3- Torsion of the globe

4- Poor microscope illumination or alignment

5- Poor visibility secondary to pathology: dense arcus, ptryguim, band keratopathy, corneal scars, interstitial keratitis

predisposing factors cont 1
Predisposing Factors…cont.(1)
  • Long and short axial length eyes deep or shallow AC
  • Pseudoexfoliation, weak zonules, poor dilation
  • Brunescent or black cataract
  • Dense asteroid hyalosis
predisposing factors cont 2
Predisposing Factors… cont.(2)
  • Posterior polar cataracts (esp. calcified):

- cataract to post capsule adhesion,

- posterior capsule thining

  • Inexperienced surgeons
  • Poor visualization (eg. Microscope problems)
predisposing factors cont 3
Predisposing Factors… cont.(3)
  • Demented, disoriented, anxious, and addict patients: inadvertant movement
  • Equipment malfunction
  • Pre-existing trauma unseen capsular or zonular damage
  • Small pupils
when the posterior capsule is torn
When the Posterior Capsule is Torn?
  • Terminal stages of phaco for emulsification of last pieces of endonucleus
  • During posterior capsule polishing
  • During I/A
  • Hydrodissection, IOL insertion: less common
developing a surgical plan

Developing a Surgical Plan

Posterior capsule tear suspicion  Alternate surgical plan

Goal to minimize prolonged or damaging

Procedures damaging retina and/or cornea

Planning 

Timing (when in the procedure)

 Location (where in posterior capsule)

Size (small, medium, large, or extra large)

posterior capsular rupture during nucleus emulsification

Posterior Capsular Rupture During Nucleus Emulsification

Two main questions:

1. Is vitreous present in A/C?

2. Is Conversion to ECCE indicated?

Conversion decision:

1. Hardness and size of nucleus

2. Size of pupil

3. Maintain adequate deep A/C

4. Ease of access to anterior segment

5. Level of surgical experience

conversion to ecce
Conversion to ECCE
  • Support the lens nucleus with a dispersive viscoelastic (injection underneath)
  • Extend peritomy and corneoscleral incision
  • Open the wound larger than expected
  • Use lens loop or manipulator
  • No limbal pressure  vitreous will be

expelled

continued phacoemulsification
Continued Phacoemulsification
  • Inject viscoelastic below fragment
  • Protect the endothelium
  • Lower bottle height, vacuum and flow
  • Emulsify the nucleus in A/C in one piece
  • Use second instrument to feed phaco tip
  • Do notcreate multiple fragments
the pseudo posterior capsule sheet s glide after viscoelastic injection under nucleus

The Pseudo-posterior Capsule:Sheet’s glide after viscoelastic injection under nucleus

Support nucleus fragments

Prevent excess loss of vitreous

Both ECCE and phaco can be done

over Sheet’s glide

Finally I/A and vitrectomy over glide

principles of managing an open posterior capsule

Principles of managing an open posterior capsule

1- Do not mix cataract with vitreous

- Mixture of lens material will cause inflammation

- Isolated cortex in the eye is absorbed with low

reaction

- Cortex- vitreous mixture  variable course 

from tolerance to severe inflammation

principles of managing an open posterior capsule cont

Principles of managing an open posterior capsule…(cont)

- Nucleus left in the eye  variable clinical

outcome

- Small nucleus fragment in A/C  inferior angle

 endothelium rubbing  cell loss

Should be removed

1 do not mix cont
1- Do not mix… cont.
  • Nucleus fragments behind iris and above anterior capsule  fairly harmless
  • Nucleus fragments in vitreous  significant inflammation
  • Increased inflammation:

- personal Physiology and response,

- Central nucleus > peripheral chips

  • About 1/3 of cases with dropped nucleus chips develop uveitis and glaucoma
2 do not stretch the slinky

2- Do not stretch the slinky

Vitreous has natural elasticity  extending down to

macula (not necessarily)

-Tensions on anterior vitreous  exertion through

entire vitreous body  pulling on the macula and

vitreous base

During phacoemulsification  small incisions plugged

by instruments 

If pressure A/C is kept sufficient Prevent vitreous prolapse

Forces remained in anterior vitreous

No transmission to macula or vitreous base

posterior assisted levitation
Posterior Assisted Levitation
  • When stabilization of nucleus is impossible
  • Distal zonular dehiscence  Distal pole of nucleus falling into the vitreous
  • Pars plana stab incision 3.5mm posterior to limbus
  • Site of incision  wherever zonular hinge occurs
  • Cyclodialysis spatula  lever the nucleus into the A/C
  • Removal by phaco or extracapsular approach (preferred)
specific clinical situations

Specific Clinical Situations

Posterior capsule rupture and vitreous loss situations

1- During Capsulotomy and Hydrodissection

-poorly directed anterior capsule  peripheral extension

Tear usually stops by zonule network

High volume with rapid injection  extends radial tear into equator and back to posterior capsule

specific clinical situations cont
Specific Clinical Situations cont…
  • Small capsulorrhexis  phaco needle

trauma

  • Sharp hydrodissection needle  radial tear formation
  • Presence of posterior polar cataract or post capsule defect
  • High MW viscoelastic injection under capsular

 wound extension  nucleus delivery

2 during sculpting

2- During Sculpting

•Hard nucleus insufficient power-

- blunt needle tip

- low machine power settings

- low power generation

• Nudging nucleus toward 6 o’clock  pushing

inferior capsule

Pulling on superior zonules

• Superior zonular dehiscence  whole

nucleus moved down

Failure of nucleus to return

•Conversion into ECCE after anterior capsule relaxing

incisions

slide22

2- During Sculpting…cont.

  • Peripheral sculpting  capsular trauma
  • High vacuum sculpting  sudden

emulsification of posterior nuclear

plate and cortex  capsular rupture

  • Inferior capsulorrhexis rim trauma 

posterior extension

  • Improper focusing on sculpting depth
3 during rotation of the nucleus

3- During Rotation of the Nucleus

Causes: - inadequate hydrodissection (nucleus adhered to capsule)  shearing off zonules

- Second instrument- capsule trauma

- Unstable zonules e.g. pseudexfoliation

 bimanual rotation

• If shearing of zonules is complete  ICCE

removal must be done

• Zonular dehiscence

- <90°  complete hydrodissection  PE

- 90°- 270°  capsular tension ring  PE

- >270°  ECCE with radial tears in anterior

capsule or ICCE

4 during emulsification

4- During Emulsification

Causes:

- Small capsulorrhexis and during division

- Sudden flattened A/C and capsular bag

- Uncontrolled surge during emulsification

nucleus particle

- Sharp ends of nuclear fragments

Management:

- Protection of remaining PC with viscoelastic

- Sheet’s glide support of nucleus fragment-

pushing back PC and vitreous

- Emulsification of nucleus fragments over glide

in A/C

5 during cortical aspiration

5- During Cortical Aspiration

Causes:

•Post capsule trauma by I&A tip: Flat AC, excess

aspiration

• Anterior capsule entrapment in aspiration port 

traction

• Inadequate hydrodissection

Management:

- Place dispersive viscoelastic over the vent

- Embed I&A tip into the cortex  apply vacuum

(not aspirating vitreous)

- Stripping toward capsule tear

- Lower infusion bottle  inflow,  turbulence

- Vitrectomy tip can be used for cortical removal

- Leave cortical material: if not too much!

slide26

6- During or After IOL Implantation

 More complicated than earlier phases

 First: secure IOL to prevent sinking

 Use viscoelastic to hold vitreous back

 By clockwise rotation bring IOL into

sulcus or AC

 If capsulorrhexis is intact  sulcus

fixation

slide27

During or After IOL Implantation… cont.(1)

  • Close the wound  to prevent flat AC, further endothelial damage
  • Bimanual vitrectomy over and under the IOL
  • Constrict pupil by intraocular miotic injection over IOL  check vitreous clearance
  • If no sufficient capsular support  transscleral fixation, or ACIOL
slide28

Vitrectomy Following Vitreous Loss: Principles

  • Keep AC as closed as possible: instruments, suture
  • Maintain IOP stable: keep foot pedal at stage I, use viscoelastics
  • Loss of anterior segment  forward displacement of vitreous
  • Vitrectomy setting: suction 60mmHg, cut: 360-400 cpm
  • Do vitrectomy adequately
  • Keep capsule rent as small as possible
vitrectomy with coaxial infusion

Vitrectomy with Coaxial Infusion

- Special tip to-reduce no. of entrances

- Easily placed through phaco incision

- It fails,because stretches the slinky

1. The coaxial infusion strikes posterior capsule 

 rupture size

More vitreous comes forward

2. Coaxial cannula reaching the body of vitreous  hydration of vitreous

Increase vitreous volume

 Forward movement

3. Flow moves the vitreous around  wiggling and shaking vitreous  flush it forward

Recommendation: Don’t use coaxial infusion cannula

slide30

Two-handed (port) Vitrectomy

  • Close the entrance wounds for vitrectomy tip  i.e. make a closed system
  • Procedure will be performed rapidly and conveniently
  • Perform small vitrectomy without irrigation
  • Prevent eye softening by repeated injection of viscoelastic  push vitreous back
  • Chamber-maintainer through side-port forms AC
  • Remove the vitreous to below the level of posterior capsule
postoperative care

Postoperative Care

At conclusion of surgery:

- Betamethasone 4mg (short-acting)

- Antibiotic e.g. Gentamicin 20mg

- Trimcinolone (kenalog) 20mg or Methyl-

prednisolone 40mg (longer anti-inflammatory

action)

- Take care of IOP rise, endophthalmitis, and

other complications of vitreous loss

- Systemic steroid, prednisolone 1-1.5 mg/kg

PO for 7-14 days