When the Capsule Breaks …

Five pearls for managing posterior capsule rupture and vitreous loss during cataract surgery.

BY UDAY DEVGAN, M.D., F.A.C.S.

You're doing your routine cataract surgery and all seems well — then suddenly, there's a deepening of the posterior chamber, the fluidics don't seem as effective, and the nucleus starts to go south. A feeling of heaviness sets in as you realize that the posterior capsule just broke and that this will be a complex case. What can you do to minimize the vitreous prolapse, preserve the remaining capsule, implant the IOL and complete the case?

A broken posterior capsule during cataract puts the patient at higher risk for cystoid macular edema, endophthalmitis, retained cataract fragments, vitreous traction, retinal detachment, displaced IOL position and a host of other sight-threatening complications. However, if properly managed, an eye with a ruptured posterior capsule can also have a very good visual outcome.

How can we optimize the situation in order to prevent or minimize vitreous loss and give the patient the best outcome? Using the appropriate technique and settings on our phaco platforms can allow complete removal of the cataract and minimize vitreous loss in the presence of a ruptured posterior capsule. From my experience over the last decade of teaching the UCLA ophthalmology residents, I have distilled my recommendations to five simple pearls, covered below.

The Sooner the Better

We can only manage the complications of a broken capsule when we realize that it is broken. The earlier we detect the posterior capsule rupture, the earlier we can safely address the surgical challenges. Dr. Howard Fine taught me the three cardinal signs of a ruptured posterior capsule, which I remember as the three R's: room, rebound loss and resistance to phaco. "Room" refers to the increase in room within the eye due to a deepening of the posterior chamber after capsule rupture. "Rebound loss" refers to the inability of the nucleus to rebound back to its central location after manipulation with the phaco probe or second instrument. "Resistance to phaco" refers to the phaco probe's inability to emulsify the cataract due to prolapsed vitreous blocking the phaco tip.

When we notice any of these cardinal signs of a ruptured posterior capsule, it is important to immediately change both our technique and phaco settings in order to minimize or prevent vitreous prolapse.

Pearl 1: Do Not let the Anterior Chamber Collapse

If you remember one thing from this article, remember to keep your phaco probe in the eye and avoid collapsing the anterior chamber. The first step must be moving to foot position one (irrigation without aspiration) and keeping the phaco probe inside the eye (Figure 1). While maintaining irrigation, viscoelastic can then be injected via the paracentesis to prevent collapse of the anterior chamber when the phaco probe is withdrawn. The most common mistake that surgeons make is allowing collapse of the anterior chamber when they notice a break in the posterior capsule.

Figure 1: Do not pull the phaco probe out of the eye yet!

By inadvertently creating a pressure gradient with low pressure in the anterior chamber and higher pressure in the vitreous chamber, prematurely withdrawing the phaco probe causes an increase in the vitreous prolapse. To prevent this pressure gradient, it is important to fill the eye with viscoelastic, preferably under the remaining nuclear pieces, in order to create a barrier effect and more importantly to increase the anterior chamber pressure to prevent vitreous prolapse (Figure 2).

Figure 2: First, inject viscoelastic to pressurize the AC.

This one simple move, injecting viscoelastic under the remaining nuclear pieces before pulling the phaco probe out of the eye, is the most important step to prevent or minimize vitreous loss in the presence of a compromised posterior capsule.

Pearl 2: Viscoelastic is Cheaper Than Vitreous

I would much rather use a few extra tubes of viscoelastic than have vitreous prolapsed throughout the anterior segment. As soon as I notice a posterior capsule rupture, I ask the nursing staff for two new tubes of viscoelastic, preferably dispersive. The viscoelastic keeps the anterior chamber pressurized, prevents the cataract pieces from falling back into the vitreous and can safely float smaller nuclear fragments out of the incisions.

The goal is to remove any remaining cataract pieces, clear the anterior segment of any prolapsed vitreous and securely implant the IOL. Using plenty of viscoelastic to support the nuclear pieces is helpful to prevent losing them in the vitreous. Should a nuclear piece fall posterior, do not chase after it. It is far better to refer the patient to a retinal colleague for a pars plana lensectomy than risk a giant retinal tear or retinal detachment.

Once all of the prolapsed vitreous has been removed from the anterior segment, we can prepare to inject the posterior chamber IOL. While the main incision is still sutured shut, it is important to inject viscoelastic via the paracentesis to prepare for IOL implantation and maintain the pressure within the anterior chamber. In most cases, injecting viscoelastic directly under the iris will expose sufficient capsular support to place a sulcus IOL. At this point, the main incision can be opened and the IOL can be implanted, ideally with the haptics in the sulcus and the optic captured by the capsulorrhexis (Figure 3). There are other ways of securing the IOL, as described by Howard Gimbel, M.D. However, the technique of optic capture by pushing it back through the anterior capsulorrhexis is the most secure in my hands.

Pearl 3: Use Triamcinolone to Stain the Vitreous

Consider staining the prolapsed vitreous with diluted preservative-free triamcinolone, as this will improve visualization and provide somewhat of an anti-inflammatory effect postoperatively. Currently, at least one manufacturer makes sterile, preservative-free triamcinolone for intraocular use. If this is not available to you, you can certainly prepare it.

Draw 1 cc of triamcinolone (10 mg/cc) into a syringe, then attach a micro-filter and push the plunger to discard the solvent and trap the triamcinolone particles in the filter. Now, re-suspend the triamcinolone particles by drawing up 2 cc of sterile balanced salt solution through the micro-filter. These steps can be repeated for further washing. Then the filter can be removed and a 25- or 27-gauge cannula can be attached. Additionally, the resultant triamcinolone suspension (now 5 mg/cc and preservative-free) can be injected via the paracentesis to stain the vitreous.

Figure 3: IOL haptics in the ciliary sulcus. IOL optic captured behind the anterior capsulorrhexis

Inject a small aliquot of the triamcinolone into the anterior chamber, then follow it with a small amount of balanced salt solution to disperse it evenly throughout the anterior segment. The triamcinolone particles will stain vitreous and make it visible to facilitate clean up. Keep in mind that for a large tongue of vitreous, only the outer part is stained by the triamcinolone, so re-staining may be required periodically.

Due to pressure gradients, the vitreous will tend to gravitate toward sites of wound leakage at the main incision and the paracentesis. Sweeping these areas with a second instrument or cyclodialysis spatula is helpful to draw the vitreous strands posterior. Once the anterior vitrectomy is complete, more of the triamcinolone suspension can be injected to double-check for the presence of residual strands of vitreous.

Pearl 4: Understand Your Foot-Pedal Settings

The key for an anterior vitrectomy is taking your time and doing a thorough cleanup of any prolapsed vitreous. Lower the bottle height, the flow rate and the vacuum level to achieve a slow-motion effect. Set the vitreous cutting rate at the highest allowed on your machine, as this will exert the least traction on the vitreous.

Most phaco machines allow a choice of anterior vitrectomy modes, performing the cutting action either before or after aspiration (Figures 4 and 5). With an anterior chamber full of vitreous, it is important to set the mode so that vitreous cutting is performed before aspirating. When the goal is removal of residual cortex or small cataract pieces, a mode where aspiration occurs before cutting is helpful.

Figure 4: Irrigation, Vitrector, Aspiration

Figure 5: Irrigation, Aspiration, Vitrector

Keep the infusion cannula in the anterior chamber, above the vitreous cutter at all times, as this will prevent hydrating the vitreous. Performing a vitrectomy is a slow process for cataract surgeons who are used to quick surgical procedures. Patience is key to thoroughly remove the prolapsed vitreous. Stay central in the posterior chamber and avoid contact with the remaining lens capsule.

Pearl 5: Use New, Separate Incisions for the Vitrectomy

It is critical to avoid using your primary cataract incision for the anterior vitrectomy. Using the large clear corneal incision is a mistake because it is too large for the vitrector and the ensuing leakage from the incision will only draw more vitreous anteriorly. Close the primary incision and put a suture through it. Split the anterior vitrector into two components: the irrigator and the vitreous cutter. Using a 20- or 21-g cannula on the irrigating line and inserting it via the paracentesis will maintain the anterior chamber while creating a fluid current to push the vitreous back.

A second incision for the vitreous cutter can be created at the limbus into the anterior chamber or via the pars plana into the anterior vitreous. Placing the vitreous cutter via the pars plana is more physiologic, as it will draw the prolapsed vitreous posterior where it belongs (Figure 6). With the vitreous cutter via a second paracentesis incision, care must be taken to avoid drawing vitreous into the anterior chamber (Figure 7). Surgeons who choose to make a pars plana incision must take care to properly close this incision and to have the patient follow-up with a retinal colleague in the postoperative period.

Once the vitreous has been cleared from the anterior segment and the IOL has been secured, make sure that all of the incisions are properly sealed. Eyes that have suffered a broken posterior capsule are at higher risk for post-operative complications such as wound leakage and endophthalmitis. Suturing all incisions is recommended to ensure proper closure and sealing, and supplementation with additional injections of antibiotic medications may be warranted.

Figure 6: Pars Plana Anterior Vitrectomy

Figure 7: Paracentesis Anterior Vitrectomy

Final Thoughts

In the postoperative period, the patient should be using a fourth-generation fluoroquinolone as well as topical steroids and non-steroidal anti-inflammatory drugs. A longer course of the anti-inflammatories is usually indicated due to the higher risk of cystoid macular edema in these patients.

All surgeons who operate will experience complications every once in a while. But by using the appropriate technique and settings on our phaco platforms, we can optimize the situation and minimize vitreous loss to give the patient the best outcome. OM

Uday Devgan, M.D., F.A.C.S., is in private practice at the Maloney Vision Institute in Los Angeles and Chief of Ophthalmology at Olive View UCLA Medical Center. He is a consultant for Allergan, AMO, Bausch & Lomb, eyeonics, Ista Pharmaceuticals, and STAAR Surgical. You can contact him via email at Devgan@ucla.edu.