offers an alternative to sutured posterior chamber, or anterior chamber, IOLs. Zonular problems are discussed in greater detail in Chapter 17.

POSTOPERATIVE CAPSULAR

COMPLICATIONS

Migration and proliferation of residual lens epithelial cells following phacoemulsification and planned extracapsular cataract extraction (ECCE) are responsible for posterior capsular opacification, asymmetric capsular contraction with optic decentration, phacotoxis, Soemmering’s ring, capsular phimosis, and anterior inflammatory membranes (Fig. 5–10).23–26

Anterior capsular contraction syndromes and capsular block syndromes may occur months after the initial surgery. Anterior capsular contraction requires YAG excision of the phimotic and fibrotic anterior capsular ring. Capsular block syndrome requires posterior capsulotomy.

In pediatric patients, creation of an anterior and primary posterior CCC with or without anterior vitrectomy and optic capture has been found to both provide stable support for lens implantation and reduce secondary posterior capsular opacification (Fig. 5–8).12–14 As noted previously, to minimize the risk of decentration resulting from capsular contraction, the CCC should be symmetric and well centered (Fig. 5–10). If the capsulorrhexis is asymmetric or irregular, the haptics should be aligned parallel to the irregularity in an attempt to provide a counterforce to capsular contraction.23 In addition, as mentioned previously, anterior tears should be matched at 180 degrees and the IOL haptics placed perpendicular to the tears (Fig. 5–6).

YAG CAPSULOTOMY

Posterior capsular fibrosis/haze occurs in approximately 10% of postoperative cataract cases per year. Over time treatment may be required in up to 50% of all patients undergoing cataract extraction with an intact posterior capsule.21 Certain lens designs and materials may reduce this incidence. Pediatric patients are at particularly high risk for this complication. It has become standard to treat posterior capsular opacification with the Nd:YAG laser. Silicone plate haptic lenses, however, represent a special circumstance. Improper capsulotomy techniques in these cases may pose a risk for posterior subluxation of the lens implant. It is recommended that the anterior capsule be released and posterior capsulotomy be performed in a circumferential manner such that asymmetric contraction forces are neutralized and tears do not extend posteriorly, squeezing the IOL into the vitreous.23

Although the use of Nd:YAG capsulotomy is commonly performed and yields excellent results, there are risks associated with its use. Transient intraocular pressure (IOP) spikes, iris hemorrhage, damage to the lens implant, CME, and increased risks for retinal detachments have been reported following Nd:YAG capsulotomy.40–42 Therefore, every effort should be made, using the operative techniques described above, to minimize the risk of developing postoperative complications related to capsular contraction and opacification.

We found that, after YAG capsulotomy, CCC with bag fixation resulted in a statistically significant decrease in IOP spikes, anterior chamber flare, and particulate matter in the anterior chamber as compared to sulcus fixated lenses.6 Our review of 218 consecu-

tive Nd:YAG cases revealed a 1% rate of RD over 49.5 months of follow-up as compared to 0.5% of 198 matched controls who underwent phacoemulsification but no Nd:YAG capsulotomy.6 Our published results were lower than previously reported rates.40–42 This decreased incidence of RD was felt to be related to the techniques of CCC and in-the-bag IOL placement, which were used during phacoemulsification.

CONCLUSION

Avoidance of capsular complications during phacoemulsification and postoperatively begins with proper CCC techniques. Furthermore, in the majority of cases of intraoperative complications, if managed appropriately, an excellent visual outcome may be obtained.

With experience in the technique of capsulorrhexis and phaco, in over 10,494 cases, the incidence of anterior capsular tears in our center was 0.70% for the senior surgeon (H.V.G). Over the last 1246 cases the rate of posterior capsular tears was 0.32%, and the rate of posterior capsule fibrosis within the first year following surgery was 1.5%.

REFERENCES

1.Gimbel HV, Kaye GB. Forceps-puncture continuous curvilinear capsulorrhexis. J Cataract Refract Surg 1997;23:473–475.

2.Gimbel HV, Neuhann T. Development, advantages, and methods of the continuous circular capsulorrhexis technique. J Cataract Refract Surg 1990;16:31–37.

3.Arshinoff S. Mechanics of capsulorrhexis. J Cataract Refract Surg 1992;18:623–628.

4.Pande M. Continuous curvilinear (circular) capsulorrhexis and planned extracapsular cataract extraction: are they compatible? Br J Ophthalmol 1993;77:152–157.

5.Thim K, Krag S, Corydon L. Stretching capacity of capsulorrhexis and nucleus delivery. J Cataract Refract Surg 1991;17:27–31.

6.Gimbel HV, van Westenbrugge JA, Sanders DR, et al. Effect of sulcus vs. capsular fixation on YAG-induced pressure rises following posterior capsulotomy. Arch Ophthalmol 1990;108:1126–1129.

7.Gimbel HV. Two-stage capsulorhexis for endocapsular phacoemulsification. J Cataract Refract Surg 1990;16: 246–249.

8.Jaffe N. Cataract Surgery and Its Complications. 3rd ed. St. Louis: CV Mosby; 1981:368, 576–579.

9.Gimbel HV. Posterior capsule tears using phacoemulsification: causes, prevention and management. Eur J Implant Ref Surg 1990;2:63–69.

10.Gimbel HV. The prevention and management of capsule complications. Asia-Pacific J Ophthalmol 1995;7: 5–8.

11.Gimbel HV, DeBroff BM. Posterior capsulorrhexis with optic capture: maintaining a clear visual axis after pediatric cataract surgery. J Cataract Refract Surg 1994;20:658–664.

12.Gimbel HV. Posterior capsulorrhexis with optic capture in pediatric cataract and intraocular lens surgery. Ophthalmology 1996;103:1871–1875.

13.Gimbel HV. Posterior continuous curvilinear capsulorrhexis and optic capture of the intraocular lens to prevent secondary opacification in pediatric cataract surgery. J Cataract Refract Surg 1997;23:652–656.

14.Gimbel HV, DeBroff BM. Management of lens implant and posterior capsule with respect to prevention of secondary cataract. Oper Tech Cataract Refract Surg 1998;1:185–190.

15.Gimbel HV, Sun R, Heston JP. Management of zonular dialysis in phacoemulsification and IOL implantation using the capsular tension ring. Ophthalmic Surg Lasers 1997;28:273–281.

16.Hara T, Hara T, Yamada Y. “Equator ring” for maintenance of the completely circular contour of the capsular bag equator after cataract removal. Ophthalmic Surg 1991;22:358–359.

17.Nagamoto T, Bissen-Miyuajima H. A ring to support the capsular bag after continuous curvilinear capsulorhexis. J Cataract Refract Surg 1994;20:417–420.

18.Hara T, Hara T, Sakanishi K, et al. Efficacy of equator rings in an experimental rabbit study. Arch Ophthalmol 1995;113:1060–1065.

19.Cionni RJ, Osher RH. Endocapsular ring approach to the subluxed cataractous lens. Cataract Refract Surg 1995;21:245–249.

20.American Academy of Ophthalmology. Nd:YAG laser capsulotomy. In: Lens and Cataract: Basic and Clinical Science Course, 1996–1997. San Francisco: American Academy of Ophthalmology; 1996:135–136.

21.van Westenbrugge JA, Gimbel HV, Souchek J. Incidence of retinal detachment following Nd:YAG capsulotomy after cataract surgery. J Cataract Refract Surg 1992;18:352–355.

22.Gills JP. Cataract Surgery: The State of the Art. Thorofare, NJ: Slack; 1998.

23.Apple DJ, Solomon KD, Tetz MR, et al. Posterior capsule opacification. Surv Ophthalmol 1992;37:73– 114.

24.Apple DJ, Kincaid MC, Mamalis N, et al. Intraocular Lenses. Baltimore: Williams & Wilkins; 1989.

25.Masket S. Post-operative complications of capsulorrhexis. J Cataract Refract Surg 1993;19:721–724.

26.American Academy of Ophthalmology. Lens and Cataract: Basic and Clinical Science Course, 1996– 1997. San Francisco: American Academy of Ophthalmology; 1996.

27.Kuszak JR, Deutsch TA, Brown HG. Anatomy of aged and senile cataractous lenses. In: Albert DM, Jakobiec FA, eds. Principles and Practice of Ophthalmology: Clinical Practice. Philadelphia: WB Saunders; 1994: 564–575.

28.Brierley L. Vacuum capsulorrhexis. J Cataract Refract Surg 1995;21:13–15.

29.Luck J, Brahma AK, Noble BA. A comparative study of the elastic properties of continuous tear curvilinear capsulorrhexis versus capsulorrhexis produced by radio frequency endodiathermy. Br J Ophthalmol 1994;78:392–396.

30.Wilson ME, Bluestein EC, Wang X-H, et al. Comparison of mechanized anterior capsulectomy and manual continuous capsulorrhexis in pediatric eyes. J Cataract Refract Surg 1994;20:602–606.

31.Koch PS. Forceps capsulotomy. In: Koch PS, Davison JA, eds. Textbook of Advanced Phacoemulsification Techniques. Thorofare, NJ: Slack; 1991:49–56.

32.Gimbel HV. Continuous curvilinear capsulorrhexis and nucleus fracturing: evolution, technique and complications. Ophthalmol Clin North Am 1991;4:235–249.

33.Chen V, Shochot Y, Blumenthal M. Anterior capsulotomy through a small pupil. Am J Ophthalmol 1987; 104:666–667.

34.Coonan P, Fung WE, Webster RG Jr, et al. The incidence of retinal detachment following extracapsular cataract extraction: a ten-year study. Ophthalmology 1985;92:1096–1101.

35.Davison JA. Capsular contraction syndrome. J Cataract Refract Surg 1993;19;582–589.

36.Davison JA. Capsular bag distention after endophacoemulsification and posterior chamber intraocular lens implantation. J Cataract Refract Surg 1990;16:99– 108.

37.Horiguchi M, Miyake K, Ohta I, et al. Staining the lens capsule for circular continuous capsulorrhexis in eyes with white cataract. Arch Ophthalmol 1998;116:535– 537.

38.Melles GRJ, de Waard PWT, Pameyer JH, Beekhuis WH. Trypan blue capsule staining to visualize the capsulorrhexis in cataract surgery. J Cataract Refract Surg 1999;25:7–9.

39.Akashoshi T, Chang DF. A demonstration of two staining agents to facilitate visualization in white cataracts. Video J Ophthalmol 2000;16(3).

40.Smith PW, Startk WJ, Maumenee AE, et al. Retinal detachment after extracapsular cataract extraction with posterior chamber intraocular lens. Ophthalmology 1987;94:495–504.

41.Dardenne M-U, Gerten G-J, Kokkas K, et al. Retrospective study of retinal detachment following neodymium:YAG laser posterior capsulotomy. J Cataract Refract Surg 1989;15:676–680.

42.Rickman-Barger L, Florine CW, Larson RS, et al. Retinal detachment after neuodymium:YAG laser posterior capsulotomy. Am J Ophthalmol 1989;107:531–536

MANAGEMENT OF A SMALL PUPIL

DURING CATARACT SURGERY

The meiotic pupil is a relatively common problem. It is defined by Howard Fine1 as a pupil smaller than 4 mm. Gimbel reported an incidence of 1.6% patients with small pupils out of 1880 consecutive phaco surgeries.2 The presence of a small pupil has been established as a significant risk factor for the development of complications during cataract surgery. Therefore, the surgeon is compelled to acquire skills to effectively manage a small pupil. A small pupil makes visualization of the anterior chamber difficult and diminishes depth perception while working deep to the iris. It can make all the significant steps of phacoemulsification difficult, including capsulorrhexis, hydrosteps, phaco, irrigation and aspiration (I&A), and intraocular lens (IOL) insertion.

ETIOLOGY

There are many causes of a small pupil. The most common is pseudoexfoliation.3 These patients have fibrotic pupillary sphincters as well as weak capsules and friable zonules.4 Patients with anterior uveitis may have posterior synechiae. Previous trauma with iris scarring or posterior synechiae may cause a small pupil. The incidence of combined cataract and glaucoma increases with age; many of these patients will be on long-term mitotic drops with secondary pupillary fibroses and extremely small pupils. Finally, some older patients just don’t dilate well.

The primary goal of managing the meiotic pupil is to achieve an adequate pupillary aperture to per-

form safe phacoemulsification. This size will vary with the experience of each surgeon. In addition, there is an important secondary goal of pupil man- agement—the maintenance of both pupillary function and cosmetic appearance after pupillary dilation (Tables 6–1 and 6–2).

PREOPERATIVE MANAGEMENT

If possible, discontinue the use of miotic agents such as pilocarpine at least 2 weeks prior to surgery. On the day of surgery one protocol is the following:

1% cyclopentolate hydrochloride (Cyclogyl)

1% tropicamide (Mydriacyl)

2.5% phenylephrine (Neo-Synephrine)

Topical nonsteroidal antiinflammatory drugs (NSAIDs) such as ketorolac tromethamine 0.5% (Acular)

Each is given every 5 to 15 minutes for four times prior to surgery. If the pupil does not dilate well, add one drop of phenylephrine (Neo-Synephrine) 10% viscous. It is inadvisable to use aqueous phenylephrine in this concentration, as intractible cardiac arrhythmias have been associated with systemic absorption of the liquid form.

SURGICAL TECHNIQUE—

LYSIS OF SYNECHIAE

Topical anesthesia can be performed even in cases with small pupils. However, the following can also be performed with retro/peribulbar anesthesia. With topical anesthesia, after creation of the paracentesis, 49