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Pop goes the weasel: Avoiding posterior capsule rupture

Premium surgeons need to be ready with various techniques and technologies so the posterior capsule does not 'pop.'

So, what makes a premium surgeon think about a nursery rhyme in the first place? Weasel means coat, and it was traditional for even poor people to own a suit, which they wore as their “Sunday best.” When times were hard, they would pawn their suit, or coat, on a Monday and claim it back before Sunday, hence the term “pop goes the weasel.”

As a premium surgeon, we do not get the opportunity to claim back anything once we “pop” the posterior capsule, so any means to avoid posterior capsule rupture should be our goal from start to finish in any cataract case, basic or premium. Below I discuss some common strategies to avoid popping the posterior capsule. A typical disregard is assuming any and every case of cataract surgery is “routine,” but unfortunately, as a premium surgeon, there are no routine cases until the case is completed.

Do not chase the strands

Due to the enhanced optics of our surgical operating microscopes (Zeiss Lumera, Leica, Alcon Luxor), we can now see every little posterior capsule strand, and as obsessive premium surgeons, we feel we must go after every single strand. And then we learn the valuable lesson of “pop goes the weasel” with a posterior capsule rupture that was clearly avoidable in the first place. Thomas Boland, MD, gave me this valuable lesson: Leave the strands. And if you do have to clean the posterior capsule due to true posterior subcapsular cataract residue, then consider using CapsuleGuard I/A handpiece (Bausch + Lomb) with its flexible 45° tip design for effective cortical material cleanup, especially along the posterior capsule centrally.

Consider femtosecond laser-assisted cataract surgery

The advantages of FLACS are widespread, from automated capsulotomy with toric IOL alignment nubs (IntelliAxis, Lensar), reduced effective phacoemulsification times, reduced total balanced salt solution volume infusion used and effective astigmatism management with controlled placement of corneal incisions to almost no need to remove epinuclear material during phacoemulsification. Typically with the autofragmentation feature with the Lensar platform, the epinucleus is rarely a remnant during phacoemulsification. Most premium surgeons say in personal discussions that posterior capsule rupture will accidentally occur during epinucleus removal as it tends to be thicker, and our phaco handpieces are not as ergonomic as our irrigation and aspiration handpieces to tackle it as efficiently, which results in another way to “pop goes the weasel.”

Dense cataracts need extra ‘love’

The dreaded brunescent no-view-of-the-retina cataract results in higher phacoemulsification times even with FLACS, but the sharp edges of nuclear quadrants truly become daggers to the posterior capsule. Extra viscoelastic, especially with a dispersive viscoelastic such as Viscoat (sodium chondroitin and sodium hyaluronate, Alcon), to sandwich these denser/sharper pieces is helpful to buffer the posterior capsule from rupture. Also, trying to break up the brunescent cataract into smaller quadrants in the event FLACS is not used will be better tolerated to avoid posterior capsule rupture. The miLOOP (Carl Zeiss Meditec) is a micro-interventional device to deliver zero-energy endocapsular lens fragmentation with a self-expanding nitinol filament technology to break up these brunescent cataracts into small fragments for easier phaco removal and less posterior capsule risk.

Readiness with appropriate tools once rupture occurs

Unfortunately, no matter what precautions we take, posterior capsule rupture does occur, but the visual outcomes with appropriate next steps can be maintained. First and foremost, try to keep the rupture from enlarging, keep the phaco tip in the eye and add a dispersive viscoelastic such as Viscoat immediately to tamponade the region. If vitreous does come forward, a two-port and/or pars plana vitrectomy should be completed to remove all vitreous from the anterior chamber, and use intracameral Kenalog (triamcinolone acetonide, Bristol-Myers Squibb) to confirm all vitreous has been evacuated. Next, do not attempt to place a one-piece IOL into the posterior capsular bag that has been compromised, but rather place a three-piece aspheric IOL into the ciliary sulcus or optic capture it in the anterior capsular opening, using IOLs such as the CT Lucia 602 (Zeiss) or LI61AO (Bausch + Lomb) due to their asphericity and nice stability in these two positions.

In summary, whenever your surgery day comes, do not try to reclaim that coat but come prepared with various techniques and technologies to avoid the ultimate “pop goes the weasel” when it comes to the posterior capsule. Bet you never realized a nursery rhyme would have relevance as a premium surgeon.

Disclosure: Jackson reports he is a consultant for Lensar, Carl Zeiss Meditec and Bausch + Lomb.

So, what makes a premium surgeon think about a nursery rhyme in the first place? Weasel means coat, and it was traditional for even poor people to own a suit, which they wore as their “Sunday best.” When times were hard, they would pawn their suit, or coat, on a Monday and claim it back before Sunday, hence the term “pop goes the weasel.”

As a premium surgeon, we do not get the opportunity to claim back anything once we “pop” the posterior capsule, so any means to avoid posterior capsule rupture should be our goal from start to finish in any cataract case, basic or premium. Below I discuss some common strategies to avoid popping the posterior capsule. A typical disregard is assuming any and every case of cataract surgery is “routine,” but unfortunately, as a premium surgeon, there are no routine cases until the case is completed.

Do not chase the strands

Due to the enhanced optics of our surgical operating microscopes (Zeiss Lumera, Leica, Alcon Luxor), we can now see every little posterior capsule strand, and as obsessive premium surgeons, we feel we must go after every single strand. And then we learn the valuable lesson of “pop goes the weasel” with a posterior capsule rupture that was clearly avoidable in the first place. Thomas Boland, MD, gave me this valuable lesson: Leave the strands. And if you do have to clean the posterior capsule due to true posterior subcapsular cataract residue, then consider using CapsuleGuard I/A handpiece (Bausch + Lomb) with its flexible 45° tip design for effective cortical material cleanup, especially along the posterior capsule centrally.

Consider femtosecond laser-assisted cataract surgery

The advantages of FLACS are widespread, from automated capsulotomy with toric IOL alignment nubs (IntelliAxis, Lensar), reduced effective phacoemulsification times, reduced total balanced salt solution volume infusion used and effective astigmatism management with controlled placement of corneal incisions to almost no need to remove epinuclear material during phacoemulsification. Typically with the autofragmentation feature with the Lensar platform, the epinucleus is rarely a remnant during phacoemulsification. Most premium surgeons say in personal discussions that posterior capsule rupture will accidentally occur during epinucleus removal as it tends to be thicker, and our phaco handpieces are not as ergonomic as our irrigation and aspiration handpieces to tackle it as efficiently, which results in another way to “pop goes the weasel.”

Dense cataracts need extra ‘love’

The dreaded brunescent no-view-of-the-retina cataract results in higher phacoemulsification times even with FLACS, but the sharp edges of nuclear quadrants truly become daggers to the posterior capsule. Extra viscoelastic, especially with a dispersive viscoelastic such as Viscoat (sodium chondroitin and sodium hyaluronate, Alcon), to sandwich these denser/sharper pieces is helpful to buffer the posterior capsule from rupture. Also, trying to break up the brunescent cataract into smaller quadrants in the event FLACS is not used will be better tolerated to avoid posterior capsule rupture. The miLOOP (Carl Zeiss Meditec) is a micro-interventional device to deliver zero-energy endocapsular lens fragmentation with a self-expanding nitinol filament technology to break up these brunescent cataracts into small fragments for easier phaco removal and less posterior capsule risk.

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Readiness with appropriate tools once rupture occurs

Unfortunately, no matter what precautions we take, posterior capsule rupture does occur, but the visual outcomes with appropriate next steps can be maintained. First and foremost, try to keep the rupture from enlarging, keep the phaco tip in the eye and add a dispersive viscoelastic such as Viscoat immediately to tamponade the region. If vitreous does come forward, a two-port and/or pars plana vitrectomy should be completed to remove all vitreous from the anterior chamber, and use intracameral Kenalog (triamcinolone acetonide, Bristol-Myers Squibb) to confirm all vitreous has been evacuated. Next, do not attempt to place a one-piece IOL into the posterior capsular bag that has been compromised, but rather place a three-piece aspheric IOL into the ciliary sulcus or optic capture it in the anterior capsular opening, using IOLs such as the CT Lucia 602 (Zeiss) or LI61AO (Bausch + Lomb) due to their asphericity and nice stability in these two positions.

In summary, whenever your surgery day comes, do not try to reclaim that coat but come prepared with various techniques and technologies to avoid the ultimate “pop goes the weasel” when it comes to the posterior capsule. Bet you never realized a nursery rhyme would have relevance as a premium surgeon.

Disclosure: Jackson reports he is a consultant for Lensar, Carl Zeiss Meditec and Bausch + Lomb.