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Posterior Capsular Rupture & Vitrectomy Farid Karimian M.D 2002.

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Presentation on theme: "Posterior Capsular Rupture & Vitrectomy Farid Karimian M.D 2002."— Presentation transcript:

1 Posterior Capsular Rupture & Vitrectomy Farid Karimian M.D 2002

2 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

3 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

4 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

5 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

6 Predisposing Factors … cont.(2) Posterior polar cataracts (esp. calcified): - cataract to post capsule adhesion, - posterior capsule thining Inexperienced surgeons Poor visualization (eg. Microscope problems)

7 Predisposing Factors … cont.(3) Demented, disoriented, anxious, and addict patients: inadvertant movement Equipment malfunction Pre-existing trauma unseen capsular or zonular damage Small pupils

8 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

9 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)

10 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

11 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

12 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 not create multiple fragments

13 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

14 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

15 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

16 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

17 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

18 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)

19 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

20 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

21 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

22 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

23 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

24 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

25 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!

26 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

27 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

28 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

29 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

30 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

31 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

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