Phacoemulsification has come a long way in both technological advances
and newer surgical techniques that increase efficiency, cut down total surgical
time and improve the visual outcome for patients.
Unfortunately, one factor cannot be eliminated from the surgical scene
potential surgical complications. One such complication that the
ophthalmic surgeon dreads most is an accidental tear in the posterior capsule
during phacoemulsification of a cataractous nucleus. Depending on the timing of
the posterior capsular tear, the degree of difficulty can vary from relatively
easy to handle to an extremely difficult, complex situation that the surgeon
has to recover for a relatively good postoperative outcome. Associated with
capsular tear is the inherent concern of dropping the remaining lens material
into the vitreous cavity and possibly on to the retina. It would be nice to
have a surgical technique that can help insulate the surgeon from dropping the
lens material into the vitreous.
In this column, Drs. Agarwal and Jacob describe a new technique that
utilizes a pre-placed IOL within the anterior chamber as a scaffold to prevent
dropping the lens material posteriorly during phacoemulsification in the
presence of a posterior capsular rent.
Thomas John, MD
OSN Surgical Maneuvers Editor
by Amar Agarwal, MS, FRCS, FRCOphth, and Soosan Jacob, MS, FRCS, DNB
Posterior capsular rupture is one of the major problems encountered by
any cataract surgeon and is an especially daunting task when it occurs in the
presence of retained nucleus, epinucleus and cortex. The aim is to remove all
these components completely while causing the least amount of vitreous traction
and without allowing any fragment drop into the posterior segment. At the same
time, it is ideal to be able to complete the entire surgery through small
incisions, thus negating complications associated with large incisions, such as
wound leak, shallow anterior chamber, endophthalmitis and postoperative
The normal trend is to bring the nuclear fragments out of the bag into
the anterior chamber and to keep them supported temporarily on the iris until
they are emulsified in the anterior chamber or, in case of the entire nucleus,
to bring the nucleus out through a corneoscleral section. One of the problems
in emulsifying nucleus in the presence of a posterior capsular rupture is that
fragments can fall posteriorly through the posterior capsular rupture into the
vitreous cavity, necessitating a pars plana vitrectomy for their removal.
Various techniques and materials have been proposed to prevent this
complication from happening, including the use of a Sheets glide, a Hema
contact lens lifeboat by Dr. Keiki Mehta, and phacoemulsification after
injecting perfluorocarbon liquid in collaboration with a vitreoretinal surgeon.
While it is still advisable to bring the nucleus out in toto by
enlarging the incision in case of posterior capsular rupture with the entire
hard nucleus in situ or an entire hard nucleus that has been dropped into the
vitreous, we describe a new technique for tackling lens fragments up to hard
hemi-nuclei and soft, clear whole nuclei. This was devised by Dr. Agarwal and
involves using an IOL as a scaffold to prevent nuclear fragments from falling
down into the vitreous cavity.
Anterior vitrectomy is performed in case of vitreous loss, and the
nucleus is brought on to the iris surface (Figures 1a and 2). A dispersive
viscoelastic is injected into the anterior chamber to protect the cornea.
Anterior vitrectomy is performed, and the epinucleus and cortex are removed,
alternating between cutting and aspiration modes of the vitrector. A foldable
three-piece IOL is then injected into the anterior chamber, taking care to
allow the IOL to gently unfold in the anterior chamber. Wound-assisted
implantation should not be performed in order to prevent the IOL from entering
in an uncontrolled manner and accidentally falling into the vitreous cavity.
|Figure 1. The
nuclear fragment is brought above the iris (a). The IOL is injected so as to
insert the leading haptic above the iris and the optic covering the pupillary
area (b). The nucleus is emulsified using the phaco probe while using the IOL
as a scaffold to prevent the lens pieces from falling into the vitreous cavity
(c). The IOL is dialed into the sulcus (d).
Images: Agarwal A, Jacob S
|Figure 2. Posterior
capsular rent with retained nucleus (a). The nucleus is brought out of the bag
into the anterior chamber. The IOL is then injected into the anterior chamber
with the leading haptic over the iris and under the nuclear fragments (b). The
trailing haptic is left outside the wound (c). The nucleus is emulsified over
the surface of the IOL using the IOL as a scaffold to prevent nuclear fragments
from falling down into the vitreous cavity (d).
The leading haptic is maneuvered over the iris and the second haptic is
left trailing outside the wound (Figures 1b and 2). If required, the wound may
be enlarged minimally for this step. The rest of the procedure can be carried
out with the second haptic left trailing outside the wound, especially in case
of atonic pupils. But if the pupil has a good tone, is not floppy, and is
between 5 mm to 6 mm in size, the trailing haptic can also be gently positioned
over the iris so that the entire IOL now lies on the iris surface and the optic
sits over the pupil.
Once the IOL is stable in this position, the nuclear fragments are
emulsified in the anterior chamber (Figures 1c and 2). If the trailing haptic
has been left outside the wound, the optic-haptic junction on the trailing side
is then maneuvered using a dialer in the nondominant hand so that the IOL
blocks the pupil. Gas-forced infusion in the form of an external air pump or an
inbuilt air pump, as present in many newer phaco machines, allows the anterior
chamber depth to be well maintained. The nucleus is then emulsified using low
vacuum settings. The optic of the IOL acts as a scaffold and prevents nuclear
fragments from dropping into the vitreous cavity. It also prevents vitreous
from prolapsing into the anterior chamber and getting aspirated into the phaco
probe. After nucleus removal, the completeness of anterior vitrectomy and
cortex removal and the capsular support are again assessed. If adequate
capsular support exists, the IOL is dialed into the sulcus (Figures 1d and 2).
If not, it is glued into place using the glued IOL technique.
This technique not only prevents dropping nuclear fragments into the
vitreous, but also compartmentalizes the eye, thus preventing hydration of the
vitreous that can result in more vitreous prolapse. There is also no need for
extending the phaco incisions, neither any need to insert a temporary device or
substance for nuclear support that then needs to be removed, causing additional
trauma. The insertion of an IOL that is going to eventually be implanted is
merely pre-placed by this technique. If both haptics of the IOL are over the
iris, more space is created in the anterior chamber for easy emulsification of
the nuclear pieces. If the second haptic is left trailing out, the dialer held
by the nondominant hand manipulates the optic to lie low flush against the
pupil as well as centered over the pupil to create adequate space in the
anterior chamber, as well as to avoid nuclear fragment drop.
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- Amar Agarwal, MS, FRCS, FRCOphth, and Soosan Jacob, MS, FRCS, DNB,
can be reached at Dr. Agarwals Eye Hospital, 19 Cathedral Road, Chennai,
India 600086; 91-44-28116233; fax: 91-44-28115871; email:
- Edited by Thomas John, MD, clinical associate professor at Loyola
University at Chicago and in private practice in Oak Brook, Tinley Park and Oak
Lawn, Ill. He can be reached at 708-429-2223; fax: 708-429-2226; email:
- Disclosure: Drs. John, Agarwal and Jacob have no relevant financial