Weakened or missing zonules present a serious challenge to the cataract surgeon. Every step of the procedure from the capsulotomy to the final removal of the viscoelastic is more challenging due to the lack of zonular integrity. Intraoperative complications are more likely, such as vitreous loss and nucleus subluxation. Intraoperative centration of the intraocular lens (IOL) and its long-term stability are also of concern. Techniques that utilize the healthy zonules yet minimize the stress on the compromised zonules will decrease the risk of complications in these patients.

ANATOMIC AND ETIOLOGIC

CONSIDERATIONS

The crystalline lens is described as dislocated or luxated when it lies outside the lens space (the patellar fossa), in the anterior chamber, in the posterior segment, or even on the retina. It is partially dislocated or subluxed when it remains within the lens space but is out of position.

Table 17–1 lists the causes of lens dislocation.1 The most common cause is trauma.2 The second most common cause is pseudoexfoliation. As many as 5% of these patients have subluxation, although it may often be occult. Iridodonesis and phacodonesis may not be visible as the iris is infiltrated with pseudoexfoliative material, causing it to be stiff and immobile. The zonules are infiltrated with the pseudoexfoliative material, causing them to be fragile. They tend to break in the middle or at their attachment at the ciliary body.

The few remaining common causes of lens dislocation are hereditary. They include Marfan’s syndrome, homocystinuria, and Weill-Marchesani syn-

drome. In Marfan’s, lens dislocation may be present at birth, remain stationary, or progress slowly up, or up and out. The zonules appear to be the cause of lens movement as they are thin and poorly aggregated. In homocystinuria the lens is spherophakic, with a crenated boarder. The zonules are weak and rupture at their midpoint. The lens may dislocate into the anterior chamber and precipitate glaucoma. Finally in Weill-Marchesani syndrome the lens tends to dislocate downward or centrally. Episodes of pupillary block are frequent as the small lens comes forward to occlude the pupil.

In consideration of the above, trauma, pseudoexfoliation, and Marfan’s syndrome are the most common etiologies producing both cataracts and partial lens dislocation.1,3

PATIENT EVALUATION

A successful outcome is more likely when the surgery is preceded by a comprehensive preoperative examination. The surgeon should characterize and draw the zonular defect, describing the weakness in terms of degrees of loss, location of the defect, and presence or absence of vitreous within the anterior segment. He should make note of whether phacodonesis is present or absent. It is important to identify an angle recession and the existence of synechiae as implantation of an anterior chamber IOL may become necessary should capsular bag support become insufficient.

Informed consent should be modified from that for the routine cataract. The patient should be specifically informed about the possibility of either a

TABLE 17–1 CAUSES OF LENS DISLOCATION

Trauma, perforating, and nonperforating Secondary to ocular processes (“consecutive”)

AD, Autosomal dominant; AR, autosomal recessive.

sutured posterior chamber IOL or a capsular tension ring.

SURGICAL TECHNIQUE

It is of great importance not to overpressurize the eye at any time during the procedure, which might stress already weakened zonules, leading to unzip-

ping of zonules and lens subluxation. Preoperatively, therefore, a Honan balloon or digital pressure should be gently applied after perior retrobulbar anesthesia administration.

In the operating room a number of surgical principles must be observed. Placing the incision away from the area of zonular weakness will reduce the stress caused by necessary movements of the phacoemulsification tip. An appropriate volume of highly retentive and cohesive viscoelastic material, or a reverse soft shell technique as described in Chapter 24, should be injected over the area of zonular dialysis to partition the area of dialysis from the anterior chamber. This should help to prevent or limit vitreous prolapse. Overfilling the anterior chamber with viscoelastic should be avoided as this could cause damage to already weakened zonules. Working through a small, tight, incision will minimize chamber collapse and forward vitreous movements due to the egress of fluid or viscoelastic.

The capsulorrhexis should be initiated in an area remote from the dialysis. Due to weakness of the zonules it may be difficult to perforate the anterior capsule. The use of a sharp needle or sharp-tipped capsulorrhexis forceps to initiate the tear may be of assistance. Minimum downward pressure on the lens should be applied. In cases with extensive zonular loss or with severe generalized weakness, it may be necessary to begin the tear by cutting the anterior capsule with a sharp-tip, 15-degree steel blade or a diamond blade. The use of a second blunt instrument for countertraction may be necessary to initiate the rhexis. Rarely, a second stabilizing instrument may be needed to complete the rhexis. This technique has been described by Neuhann.4 In this situation, the edge of the tearing anterior capsule is held by the rhexis forceps introduced through the main incision. A hook, introduced through the paracentesis, is used to make the tear using the forceps to apply countertraction (Fig. 17–1). The resultant capsulotomy should be large enough to allow for easy nucleus manipulation. In addition, it should be large enough so that the optical opening will remain adequate if the capsule should contract postoperatively. Patients with pseudoexfoliation are subject to postoperative capsular phimosis (shrinkage) due to the unopposed fibrosis of the anterior capsular ring stretching the weakened and lax zonules. Therefore, a capsulotomy of 6 to 6.5 mm should be ideal.

Careful and thorough cortical cleaving hydrodissection or even visco separation will loosen the nucleus as well as the cortex. The hydrodissection should be performed gently, especially if applying downward force to the nucleus to decompress the bag after passage of the posterior fluid wave. Multiple sites of cannula application will assure thorough

FIGURE 17–1 Large zonular dehiscence. A forceps is used to apply countertraction. The capsulorrhexis is created by a hook placed through the paracentesis.

cortical cleavage. This is important to reduce zonular stress during nucleus removal and cortical aspiration. During the hydrodissection it is helpful to depress the wound lip gently to produce adequate fluid egress. This will prevent overfilling of the anterior chamber (AC) with resultant increased downward pressure on the lens and vitreous.

The emulsification of the nucleus should be performed using low vacuum and aspiration settings. This will allow a lower bottle height. Excessive infusion is to be avoided, as infusion fluid will increase the intraocular pressure. This will result in irrigation fluid being forced through the weakened zonules. The fluid will then hydrate the vitreous result, which in turn will increase vitreous volume, resulting in posterior positive pressure, chamber shallowing, and vitreous prolapse (see Chapter 8). The bottle height, however, should not be too low, resulting in inadequate infusion with subsequent hypotony and chamber collapse. This also can lead to vitreous prolapse. The stop and chop and phaco chop techniques diminish zonular stress during the emulsification. During the creation of the groove, adequate power must be utilized to cut the nucleus without displacing it. If power is inadequate, the nucleus will be pushed ahead of the phaco tip, transferring additional stress to the already weakened remaining zonules. In an effort to manipulate the nuclear halves or quadrants forward with minimal zonular stress, a viscoelastic agent may be injected between the nuclear quadrants and the peripheral capsular bag. The viscoelastic will lift the nuclear fragment while providing volume to expand and stabilize the capsular bag.

Cortical removal can be a cause of significant damage to the remaining zonules due to adhesions be-

tween the cortex and the equatorial capsular bag. Cortical viscodissection prior to aspiration will limit the stress on remaining zonules without requiring the countertraction of an unstable capsular bag5 (Fig. 17–2). Applying traction to the cortex tangential to the bag is helpful. Performing irrigation and aspiration (I&A) after implantation of the IOL will allow the lens to stretch the bag and act as barrier between the I&A tip and the posterior capsule. A capsular tension ring, discussed below, is advantageous. It may be useful to aspirate the cortex manually using a 24to 27-gauge cannula within an anterior segment filled with viscoelastic material because automated I&A can lead to vitreous hydration and positive pressure.6 Finally, when removing the viscoelastic material at the end of the procedure, a 27-gauge cannula introduced through the side port incision can help to prevent late vitreous prolapse by manually aspirating small aliquots of viscoelastic and refilling with BSS. This will allow for maintenance and stability of the anterior chamber, decreasing the risk of vitreous prolapse.

VITREOUS MANAGEMENT

A small amount of vitreous that presents during the procedure can be removed from the anterior chamber using a “dry” vitrectomy technique with an automated vitrector and a viscoelastic-filled chamber.7 Significant vitreous prolapse is effectively managed by a bimanual vitrectomy using a side port incision for irrigation with a 27or 25-gauge cannula. The vitrectomy handpiece can be inserted through the main incision, through a new paracentesis, or

through a pars plana sclerotomy.8

FIGURE 17–2 Large zonular dehiscence. After nucleus removal, cortical viscodissection is employed to ease cortical removal without placing additional stress on the remaining bag and zonules.

Germany) in 1993. The ring is made of polymethylmethacrylate (PMMA) and has expanded tips with positioning holes. It comes in two sizes: the 10 mm (type 14) is for routine use, and the 12 mm (type 14A) is for high myopes (Fig. 17–4). The ring can be inserted into the capsular bag at any point after the capsulorrhexis has been completed.10 However, it is probably most advantageous to insert the ring after the capsulorrhexis and before the hydrodissection. The ring is implanted either using dull forceps or a shooter designed specifically for the insertion of this ring. The leading end is placed through the paracentesis and under the capsulorrhexis. The ring is then slowly advanced using the forceps outside the eye or the shooter, and an intraocular hook to provide guidance within the AC, until the trailing end is within the AC. The trailing end is then placed under the rhexis. The effect is a dramatic expansion and stabilization of the capsular bag. It should be noted that early insertion of the ring makes the removal of peripheral cortex more difficult. It will be trapped under the ring and require tangential stripping. Cortical removal in this situation can be assisted by performing cortical viscodissection prior to the CTR

FIGURE 17–5 Cionni modified ring model 1L with elevated hook and eyelet.

FIGURE 17–6 One end of double armed CIF-4 needle is passed through the eyelet on the Cionni modified ring.

placement. Despite the widespread availability of this device throughout the world, at the time of this writing the CTR is undergoing a FDA study and is not yet approved for use in the United States.

Although the CTR usually provides adequate expansion and improved stabilization of the bag, in more severe cases the bag may remain loose or decentered. Pseudophacodonesis may be present postoperatively. This can result in pigment dispersion and chronic inflammation. Additionally, long-term centration, in patients with progressive generalized zonular weakness such as that caused by pseudoexfoliation, is uncertain. We have seen several cases of complete posterior subluxation of the IOL within the capsular bag that have occurred years following the original surgery.

To prevent these problems, several techniques have been devised to secure the CTR and the capsular bag to the scleral wall. Robert H. Osher11 and Vladimer Pfeifer12 have independently developed techniques of sewing the CTR ring to the scleral wall. A modified CTR (Cionni ring model 1L, 11 mm) has been designed. It has an angled hook with an eyelet extending up and off the ring. This eyelet allows suture fixation to the scleral wall without violating capsular bag integrity13 (Fig. 17–5). Like the regular CTR, the Cionni ring can be placed into the capsular bag any time after completion of the capsulorrhexis. However, the presence of a large, dense nucleus makes implantation of the ring more difficult. The insertion begins by the passage of one arm of a double-armed 9-0 Prolene suture on CIF-4 needles through the eyelet of the fixation hook (Fig. 17–6). The Cionni ring is then inserted into the capsular bag. The hook is positioned anterior to the capsulorrhexis and is used to dial the Cionni ring until the eyelet is adjacent to the intended site of suture

FIGURE 17–7 Once positioned, CIF-4 needles are passed and the double-armed sutures are cinched up, correctly positioning the bag with the eyelet reliably secured.

ously prepared scleral flap (Fig. 17–8). After placement of the Cionni ring, the remainder of the procedure is simplified and usually will proceed smoothly due to the markedly improved stability of the capsular bag. The Cionni ring is also available with two fixation hooks for use in patients with very severe zonular damage. Each variation of the Cionni ring is undergoing FDA trials at the present time.

CTRs of any model should not be used if a complete continuous capsulorrhexis is not attained or if, during the procedure, a posterior capsule tear occurs. In this setting the expansile forces of the ring may cause the capsular bag to completely rupture. If a CTR or Cionni ring cannot be used, if the cataract is removed with the capsular bag, or if it is determined there is inadequate stability of the capsular bag for future IOL stability, a sulcus fixated IOL, as discussed in Chapter 22, or an anterior chamber IOL can be implanted.

placement (Fig. 17–7). The needles are then passed through the incision, into the pupil, behind the iris, and through the ciliary sulcus and scleral wall. The needle placement will be adjacent to the area of greatest zonular weakness. The suture must stay anterior to the anterior capsule at all times. This will ensure sulcus placement. The needles should exit the scleral wall approximately 1.5 mm posterior to the corneoscleral junction. It is important to position the fixation hook posterior enough to prevent postoperative iris chafing. The double-armed sutures are cinched-up and tied. The suture knot is then either rotated beneath the sclera or buried beneath a previ-

FIGURE 17–8 The suture knot is tied under the scleral flap.

CONCLUSION

Cases of zonular weakness or absence represent the most difficult procedures we can encounter. New devices have significantly improved the operative management and surgical outcome of these eyes. The surgeon must become familiar with each of these advanced surgical techniques. Skilled and knowledgeable management will reap the reward of excellent surgical results with the subsequent satisfying outcome for both patient and surgeon.

REFERENCES

1.Jaffee NS, Jaffee MS, Jaffee GF. Cataract Surgery and Its Complications. St. Louis: CV Mosby; 1990:303.

2.Nirankari MS, Chaddah R. Displaced lens. Am J Ophthalmol 1967;63:1719–1723.

3.Sahel JA, Brini A, Albert D. Pathology of the lens. In: Albert DM, Jakobiec FA, eds. Principles and Practice of Ophthalmology. Philadelphia: WB Saunders; 1994: 2225–2228.

4.Neuhann TE. Capsulorrhexis. In: Steinert RF, ed. Cataract Surgery: Technique, Complications, and Management. Philadelphia: WB Saunders; 1995:134–142.

5.Cionni R, Osher R. Complications of phacoemulsification. In: Weinstock F, ed. Management and Care of the Cataract Patient. Cambridge, MA: Blackwell Scientific; 1992:198–211.

6.Osher R, Cionni R. The torn posterior capsule: its intraoperative behavior, surgical management and longterm consequences. J Cataract Refract Surg 1990;16: 157–162.

7.Cionni R, Osher R. Complications of phacoemulsification surgery. In: Steinert R, ed. Cataract Surgery: Techniques, Complications, and Management. Philadelphia: WB Saunders; 1995:327–340.

8.Eller A, Barad R. Miyake analysis of anterior vitrectomy techniques. J Cataract Refract Surg 1996;22:213– 217.

9.Novak J. Flexible iris hooks for phacoemulsification. J Cataract Refract Surg 1997;23:828–831.

10.Cionni R, Osher R. Management of zonular dialysis with the endocapsular ring. J Cataract Refract Surg 1995;21:245–249.

11.Osher R. New approach: synthetic zonules. Video J Cataract Refract Surg 1997;13.

12.Pfeifer V. Suturing the ring. Video J Cataract Refract Surg 1998;14.

13.Cionni R, Osher R. Management of profound zonular dialysis or weakness with a new endocapsular ring designed for scleral fixation. J Cataract Refract Surg 1998;24:1299–1306.

Phacoemulsification of the human lens requires the preservation of the posterior capsule for successful lens removal and subsequent intraocular lens (IOL) implantation. Rupture of the posterior capsule during phacoemulsification, however, is a potentially serious intraoperative complication and carries the risk of precipitating additional problems that require vitrectomy and present the possibility of loss of lens material into the vitreous cavity. In addition, postoperative complications including chronic inflammation, cystoid macular edema, IOL dislocation, and a retinal detachment may be engendered by an intraoperative tear in the posterior capsule. The incidence of posterior capsule rupture in extracapsular cataract extraction and phacoemulsification has been reported to range from 0.05 to 10%.1–3 The outcome of the complicated operation, however, will be determined by the surgeon’s skills in recognizing when the posterior capsule ruptures and in managing it.

CAPSULAR ANATOMY

It is helpful to consider the key anatomic features of the lens capsule and to keep them in mind while performing phacoemulsification. The capsule is an elastic basement membrane made up of type IV collagen. It is laid down by the lens epithelial cells that reside just inside the capsule (see Chapter 5, Fig. 5–1). Interestingly, electron microscopic examination of the capsule fails to reveal elastic fibers despite the clinical elastic nature of this structure. The zonules insert on the anterior capsule approximately 3 mm from the anterior pole and on the posterior capsule approximately 4

mm from the posterior pole.4 The capsule has variable thickness. It is 2 to 4 m thick at the posterior pole. It is thickest (17 to 23 m) near the anterior and posterior equator where the zonular fibers attach.5 The anterior capsule can be as thick as 14 m in adults and it continues to increase in thickness with age. The posterior capsule may be particularly fragile in patients with congenital posterior lenticonus and posterior polar cataract; age-related or corticosteroid-related posterior subcapsular cataracts (PSCs) involve migration and enlargement of the lens epithelial cells posteriorly where the capsule is thinnest.6

The surgeon must also consider factors such as age, disease (such as pseudoexfoliation or Marfan’s syndrome), or a history of ocular trauma, which may predispose to zonular weakness or dehiscence. Zonular dehiscence is also discussed in Chapter 17.

SIGNS OF CAPSULE RUPTURE

(TABLE 18–1)

During phacoemulsification the hydrostatic pressure in the anterior chamber is elevated but stable. This is the result of the balance of hydrostatic pressure created by (1) the height of the infusion bottle (11 mm for every 15 cm of bottle height) opposed to (2) the evacuation of fluid as controlled by the machinecommanded vacuum and flow settings and (3) the controlled egress of fluid through the wound determined by wound size and configuration. Fluid flow is partitioned within the compartment created by the cornea and posterior capsule. When the posterior capsule unexpectedly ruptures, there is a sudden

TABLE 18–1 RECOGNITION OF THE TORN

POSTERIOR CAPSULE

Sudden deepening of the anterior chamber Momentary pupillary dilatation

Nucleus does not follow toward the phaco tip Nucleus falls away from the phaco tip

equalization of the hydrostatic pressure between the anterior chamber and the vitreous cavity. This will cause an abrupt and dramatic posterior displacement of the iris and dilation of the pupil as the posterior capsule opens. This is the first warning of capsular rupture that the surgeon may see. In addition the nucleus seems to “fall away” from the phaco tip. This is due to the loss of the support of the posterior capsule. Although subtle, these events should intensify the surgeon’s suspicion that the capsule may not be intact. This is especially important when the pupil is small, or the cataract is dense and the posterior capsule is not well visualized. These signs are not only the first to be observed when the capsule tears, but may be the only initial evidence of capsular rupture before more serious signs and events develop. Generally, if the surgeon is suspicious that the posterior capsule has ruptured, it probably has. The surgeon is therefore justified in modifying the surgical plan on the suspicion of a tear of the posterior capsule.

These signs of posterior capsule rupture occur not only during lens emulsification or irrigation and aspiration (I&A) of the cortex, but also during hydrodissection. Overzealous hydrodissection, especially in the presence of a small capsulorrhexis or an undisclosed noncontinuous capsulorrhexis, may result in a posterior capsular blowout. Once again, the anterior chamber will exhibit a sudden deepening as the posterior capsule opens, allowing pressure equalization between the anterior chamber and the vitreous cavity. If not recognized immediately, the next opportunity to realize that the capsule is torn will be when the phaco tip is introduced. Upon depressing the phaco foot pedal, without the support of the intact posterior capsule, the fluid infusion pressure may propel the entire contents of the capsular bag into the vitreous cavity.7

PREDISPOSING FACTORS FOR

CAPSULAR RUPTURE8

Significant predisposing factors leading to the torn posterior capsule with subsequent management dilemmas are (1) the relationship of the surgeon’s hand position to the patient’s brow with ensuing visibility problems, (2) irrigation fluid pooling, and

(3) torsion of the globe. The surgeon must attempt

to minimize torsion of the globe during surgery as this impedes adequate visualization. If the brow is prominent (e.g., a deep-set eye), a temporal approach rather than a superior approach will minimize the inferior torsion of the globe. If there is pooling of fluid, turning the head temporally will allow fluid to drain. The use of a speculum, which allows easy access to the globe and will not get in the way during phacoemulsification, cannot be underestimated. Although, in general, one would like to operate in the axis of the plus cylinder, this cannot be done when the plus cylinder is at 90 degrees in the presence of a large brow and deep-set eye. The surgeon is wiser to forgo the issue of astigmatism and operate temporally, for access and exposure, rather than risk a capsular tear.

Poor microscope illumination or alignment is another cause of poor visualization. Once recognized, this should be simple to remedy. Other factors that impede visualization include dense arcus senilus, dense nasal or temporal pterygia, severe Fuchs’ corneal dystrophy with or without associated corneal edema, band keratopathy, old corneal scars, and interstitial keratitis. Faced with these challenges to visualization, the surgeon can do nothing more than slow down, pay more attention to detail and visualization, and be more careful about focusing through the corneal problem to allow visualization of the anterior segment.

Patients with long and short axial length eyes, with associated deep or shallow anterior chambers, represent predisposing factors for torn capsules. In high myopia, the anterior chamber is deeper with more trampolining of the posterior capsule due to the thinner, more resilient tissues. Eyes that have undergone previous vitrectomy behave in a similar manner. Lowering the infusion bottle, and machine vacuum and flow settings, lessens this tendency. In high hyperopia, the anterior chamber is crowded, making the posterior capsule closer to the area of phaco and increasing the risk of a torn capsule. In these situations the early use of pulsed phaco will assist in deepening the anterior chamber. Other causes of the shallow anterior chamber are considered below.

Pseudoexfoliation is known to cause weak zonules and poor dilation secondary to fibrosis of the pupillary sphincter. These problems lead to an increased incidence of torn posterior capsules or dehiscence of the zonules. These problems are discussed fully in Chapters 6 and 17. In addition markedly brunescent or black cataracts as well as mature or white cataracts make capsulorrhexis more difficult. These problems are discussed in Chapters 16 and 17.

Dense asteroid hyalosis may make it difficult it to visualize the posterior capsule during phaco. The surgeon must again exercise due caution, and if necessary viscoelastics, to stay away from the posterior capsule, thus avoiding inadvertent tears (Table 18–2).

TABLE 18–2 GENERAL PREDISPOSING FACTORS

FOR THE TORN POSTERIOR CAPSULE

Poor visibility secondary to physical problems: hand position, brow, fluid pooling

Poor visibility secondary to pathology: dense arcus, pterygium, band keratopathy, corneal scars

Long and short axial length Pseudoexfoliation

Black cataract White cataract

Dense asteroid hyalosis Small pupil

Previous trauma

Additional predisposing factors to complications could include (1) posterior polar cataracts (especially those that are calcified) due to an increased incidence of posterior capsular holes attributable to adherence of the cataract to the posterior capsule, as well as thinning of the posterior capsule in the region deep to the cataractous lens changes; (2) inexperienced surgeons (e.g., residents); (3) poor visualization, due to the microscope, as noted above; (4) demented, disoriented, or anxious patients with subsequent inadvertent patient movement; (5) equipment malfunction; and (6) preexisting trauma with unseen capsular rupture or zonular damage.

Small pupils are the final significant predisposing factor for tearing the posterior capsule during surgery. There are many regimens to provide adequate pharmacologic dilation in all patients. One recommended guideline is cyclopentolate (Cyclogel) 1%, neosynephrine (Mydfrin) 2.5%, and ketorolac tromethamine 0.5% (Acular) given every 5 minutes for four doses prior to surgery. In those patients who have not dilated adequately, an additional dose of neosynephrine 10% gel is applied. Neosynephrine 10% solution is avoided as there have been reports in the past of the development of recalcitrant cardiac arrhythmias in patients receiving this medication.

If the pupil does not dilate to a size deemed adequate for the surgeon to provide safe phaco, or even convert to extracapsular cataract extraction (ECCE), the surgeon is obligated to further dilate surgically. This can be accomplished by stretching with iris hooks, using the Beehler dilator made by Moria, performing multiple sphincterotomies with microscissors, using iris retractors, or using the Graether pupil expander8 (see Chapter 6).

WHEN DOES THE POSTERIOR

CAPSULE TEAR?

The highest incidence of posterior capsule rupture during phacoemulsification occurs (1) toward the

end of emulsification when the last pieces of endonucleus are to be emulsified, (2) during posterior capsule polishing, and (3) during I&A. The tear in each of the above situations occurs when the posterior capsule is directly exposed to the phaco or I&A tip and thus can be more easily and inadvertently aspirated and torn. The next highest incidence of capsular tear is during early to mid-phaco when the phaco tip is inadvertently passed through the nucleus and tears the posterior capsule or capsular equator. The least common times to tear the capsule are during hydrodissection, capsule polishing, and IOL insertion.2,7

In all cases, once the vitreous face is ruptured and vitreous is detected above the plane of the posterior capsule, in the anterior chamber, or at the wound, an anterior vitrectomy is mandatory. Most tears in the posterior capsule are small when they first occur. The surgeon should endeavor to keep them from enlarging or tearing anteriorally, destroying the integrity of the anterior capsular rim, which will enhance the potential for a posterior chamber IOL placement in the bag or sulcus.

DEVELOP A SURGICAL PLAN

If the surgeon is suspicious that the posterior capsule may be torn, a concise alternative surgical plan must be initiated and adhered to. The primary goal of the surgeon should be to minimize subsequent prolonged, damaging, and unnecessary procedures that may lead to injury of the cornea or retina and subject the patient to protracted recovery. This plan should also encompass methods of nuclear remnant extraction, cortex removal, and vitrectomy techniques, and provide for adequate removal of the nucleus, cortex, and vitreous while preserving the residual lens capsule for posterior chamber IOL placement. If the nucleus is lost into the vitreous, the plan should include prior consultation with retinal specialists who might suggest whether IOL implantation should be accomplished prior to second-stage lensectomy and vitrectomy.

Therefore, timing (at what point in the procedure), location (whether the tear is central or peripheral, or has zonular dehiscence), and size (small, medium, large, or very large) of the tear should also be evaluated and incorporated into the developing alternative surgical plan.

In actuality, the surgeon needs two plans: one, when the posterior capsule ruptures but the tear cannot be visualized consequent to the presence of the nucleus, cortex, or a small pupil; and two, when the posterior capsule ruptures and the surgeon can readily see and analyze it, for example during cortical aspiration or capsule polishing.