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BY

PROF. HISHAM FAWZY

POSTERIOR CAPSULAR RENT

PHACO NIGHTMARES

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

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(PCR), reported to occur in 0.5% to4.5%

Any breach in the continuity of posterior capsule

Posterior capsule tears (PCT) can be pre-existing (congenital or traumatic), spontaneous, or intrasurgical

Vitreous loss appears to be the most crucial factor determining the eventual visual outcome

Depends upon equipment, setup, and surgeon’s experience and skill

Posterior Capsular tear

Highest incidence towards the end during last piece removal.

Then during P/C polishing

Then During I/A.

During early to mid-phaco.

Least during hydrodissection and IOL insertion

Incidence-wise

With NEWER machines with excellent FLUIDICS the incidence is much lower

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PCR with / without vitreous

disturbances ?

Once vitreous is lost, the postoperative course is complicated in 30% of patients with an increased incidence of hyphaema, retained cortex, corneal edema, blurred vision and long term retinal problems including chronic CME, macular holes ,retinal detachment and choroidal detachment.

In spite of a steady improvement in the safety of

cataract surgery since the inception of

phacoemulsification, diagnosing and managing

posterior capsular rent still remains a challenge.

ANTICIPATION

EVALUATION

RECOGNITION

. appropriate managemntcan have excellent outcomes.

modifications Could be doneDuring surgery to prevent this complication.

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COMMON RISK Factors

Patient selection

Extreme esotropia

Deep set Small eye

Exaggerated Bell’s phenomenon

Types of Cataract

Posterior Polar Cataract Traumatic Cataract

Post vitrectomy Cataract White Cataract

Post Lenticonus

Black Cataract

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Difficuit situation

A. Extra ocular

Bizarre eye movements

Improper positioning: (Respiratory or Musculo-skeletal problems)

Proper patient positioning

Peribulbar Block (especially for 2nd eye – if the 1st eye had PC Rent)

Shift to temporal side

Prevention

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COMMON RISK FACTORS FOR (PCR)

• Intraoperative factors:

Extra ocular

MECHANISM OF PCR

1. Wound construction: Poor visibility

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MECHANISM OF PCR

1. Wound construction:

leaky wounds are the most important factor for

unstable AC

MECHANISM OF PCR

1. Wound construction:conjunctival balooning

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MECHANISM OF PCR2. Anterior continuous curvilinear

capsulorhexis (CCC):

It can withstand turbulence,

pressure and mechanical

stress created by the fluid,

nucleus, chopper, IOL, etc.,

during phacoemulsification

Rhexis margin tear (RMT)

can extend posterioly to

cause posterior capsular tear.

MECHANISM OF PCR

2. Anterior continuous curvilinear

capsulorhexis (CCC):

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MECHANISM OF PCR

3. During Hydrodissection:

Block to outflow: The outflow may be blocked due to increased resistance offered by viscoelastic in the chamber or a small. CCC/small pupil

Injection of too much fluidInherent weakness

MECHANISM OF PCR

4.During Nuclear management

• posterior extension of the anterior capsular opening •direct damage to the edge of the rhexis by ultrasound tip• zonular disinsertion through traction linked to the manipulations performed on the nucleus • insufficient phaco power used to emulsify a very hard cataract • mechanical trauma to the capsule during various nuclear maneuvers

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MECHANISM OF PCR

4.During Nuclear management

Surgeon should use the second instrument to move the remaining nucleus away from the tear to complete the emulsification in high myopia

Procedure should be slowed down by reducing the aspiration flow rate, decreasing the vacuum and by lowering the infusion bottle

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MECHANISM OF PCR

5. During irrigation-aspiration

especially in the subincisional

area due to poor access and

decreased visibility • use of

excessive vacuum • Aspiration

done with port close to the

posterior capsule • Aspiration

done in the presence of a

shallow chamber

MECHANISM OF PCR

6.During capsular polishing:

During polishing, a well-focused PC in retro-illumination view under high magnification and a bag filled with visco-elastic substances is a must to prevent posterior capsular tear.

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Early recognition of posterior capsular rupture

Sudden deepening of the anterior chamber with momentary dilatationof the pupil .

Sudden transitory appearance of a clear red reflex peripherally

Excessive lateral mobility or displacement of the nucleus and lossof nucleus followability

Excessive tipping of one pole of the nucleus

Inability to rotate a previously mobile nucleus

Partial descent of the nucleus into the

anterior vitreous space

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Early response to PCR

Sudden unplugging of the incision will

result in emptying and collapse of the

anterior chamber.

The surgeon should stay in foot pedal

position 1, and as the viscoelastic is injected

he should change to foot position (0) and

the handpiece can then be safely removed

after the anterior chamber is filled

DAMAGE

CONTROL

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GOALS OF MANAGEMENT OF PCR

To avoid posterior dislocation of nucleus, nuclear fragments, epinucleus or cortical matter into

the vitreous cavity.

Prevent enlargement of tear.

Prevent damage to capsulorhexis

Minimize size of vitrectomy, avoiding traction

Removal of left over cortex.

Maintain the wound size

Proper positioning of the IOL

Categories:

▪ Broken capsule with an intact anterior hyaloid.

▪ Vitreous prolapse into AC

▪ Vitreous loss through the incision

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Developing a Surgical

PlanPOSTERIOR 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)

MANAGEMENT STRATEGIES

Extent of PCTIntactness of hyaloid faceLocation of the nucleus – whether dislodged into the

vitreous cavityAvailability of equipment – vitreous cutter, vitrectomy

machine Availability of alternative IOLsKnowledge about anterior vitrectomy Availability of VR surgeon

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Tear is redirected to a posterior

capsulorrhexis

If the rent in the posterior capsule is small & central,this must be converted to a

circular posteriorr capsulorhexisand IOL placed in the bag

WHEN PCR IS SUSPECTED:

STOP ULTRASOUND &STABELZE THE AC

Only after OVD injection can the

phaco tip be withdrawn from the

eye.

If not, the chamber will collapse

and the stage of complication

may progress from capsular

rupture to vitreous prolapse or to

vitreous loss.

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DRY VITRECTOMY

Useful technique in performing a small vitrectomy

If the eye softens the pressure in the eye can be equalized by putting more viscoelastic in to the anterior chamber

Advantage of pushing vitreous towards the back of the eye andreducing the amount of vitrectomythat has to be performed

Conversion to ECC

PCR is suspected during hydrodissection

or early phacoemulsification and if there

is a significant amount of residual nucleus

Sclerocorneal tunnel incision is

constructed temporally or superiorly

While expelling the nucleus the vectis

should apply pressure against the

posterior lip of the wound, rather than

lifting and dragging the nucleus against

the cornea.

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To Phaco or convert to ECCE

Situation with posterior capsular

defect and retained nuclear material

without vitreous prolapse

Depends on the bulk of the residual

nucleus material, the degree of

nuclear sclerosis, the size of the

rent,size of pupil and surgeons

experience

If the nucleus is soft, and if only a

small residual amount remains,

continuing with phacoemulsification

may be a reasonable option

PCT WITH PARTIALLY DESCENDED

NUCLEU

Posterior assisted leviation (PAL):Viscoat cannula inserted through a parsplana stab incision located 3.5 mm behind the limbus Injecting Viscoat and maneuvering the cannula tip itself, the nucleus can be elevated through the capsulorhexis and pupil and into the anterior chamber.

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VITRECTOMY

Microsurgical (20G) advanced vitrectomy cutter with high performance proportional linear suction control is a necessity for anterior vitrectomy • Use of the maximum possible cutting rate, lowest vacuum and flow rates reduces traction on the retina • The vitrectomy cutter should be advanced or held stationary during anterior vitrectomy and never pulled away while cutting

TECHNIQUE OF PERFORMING ANTERIOR

VITRECTOMY; Place the cutter through

the PC Rent with the cutting port facing

upwards. The strategy is to pull the

vitreous from the anterior chamber down

to the cutter

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PCR with hyaloid face ruptured without

luxation of nuclear matter into vitreous

If the residual nuclear material is

small in volume, dry

anterior vitrectomy is performed and

the residual

nucleus is emulsified after it has been

cleaned of the

vitreous

Phacoemulsification is performed

using high vacuum (150–200 mm

Hg), low flow (10–15 cc/min) and low

ultrasound (30–50%

IOL IMPLANTATION

If the IOL shows signs of

poor fixation it can be

repositioned from the

capsular bag into the ciliary

sulcus, sutured into the ciliary

sulcus or exchanged for an

anterior chamber IOL

Be sure pupil is round Be certain

incisions are sealable Evaluate the

intactness of CCC Evaluate the

extent of posterior capsular tear and

residual sulcus support.

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Vitrectomy in pcr &IOL implantation

The best strategy

when performing a

vitrectomy is to

avoid violating more

vitreous than is

actually needed,

without disturbing

the rest of the

vitreous especially

that which overlies

the vitreous base

Posterior Capsule Tear with Hyaloid

Face Intact and Nuclear Material

Present

Dispersive viscoelastic agent should be injected to plug

the posterior capsule tear.

Nuclear material is moved into the anterior chamber

with a spatula and emulsified with short bursts.

Low bottle height (20–40 cm above the patient’s

head), low flow rate (10–15 cc/min), high vacuum (120–

200 mm Hg) and low ultrasound (20–40%).

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PCT with hyaloid face ruptured

&luxation of nuclear matter into

vitreous

Attempts at retrieval of dislocated nucleus carry high

risk of creating peripheral tears Removal of the

remaining cortical material should be attempted with

preservation of the anterior and posterior capsule

Anterior vitrectomy should be performed so as to allow

closure of the wound without vitreous incarceration

Secondary removal of dislocated nucleus through

three port pars plana vitrectomy

TAKE HOME MASSAGE

MANAGEMENT OF PCR:

Don’t panec and withdrow the brobe

Injection of high molecular wight thought

the side port.

Gently withdrow the probe from the eye

Reducing the bottle hight

Appropriatemaagement of the nucleus

Bimanual IA.

Thorough anterior vitrectomy’

Assess the integrity of the capsule integrity

Apprpriate IOL

implantation:

In the bag

In the sulcus

Glued IOL

Scleral fixation

Yamani

technique

AC IOL

Anticipate PCR in:

traumatic cataract ,

post vitrectomy

cataract ,brown

cataract

,psudoexopholiation

Early signs of PCR:

Loss of lens followability.

Sudden change of AC or

PC depth.

Pupil snap sign during

hydrodisication

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