Ординатура / Офтальмология / Английские материалы / Master's Guide to Manual Small Incision Cataract Surgery (MSICS)_Garg_2009

Figure 36.4: In very small pupils a mechanical enlargement of the pupil should be made with two Kuglin hooks to avoid the dialysis of the posterior capsule

POSTOPERATIVE COMPLICATIONS

AND THEIR AVOIDANCE

Corneal Edema

Transient corneal edema can appear in the postoperative period. This edema quickly resolves and is not clinically significant. Avoiding cornea touch will prevent corneal edema. The use of high density viscoelastic material during nuclear fragmentation will prevent the endothelial cell loss and corneal edema.

Shallow Anterior Chamber

This complication is usually due to the closure of the incision. This can be managed by applying a suture.

High Intraocular Pressure

This is due to the large amount of viscoelastic material used during surgery. To prevent it the viscoelastic should be removed from the anterior chamber with great care.

Postoperative Endophthalmitis

This is a rare complication. Although its reported incidence has decreased significantly from 1 to about 0.05 to 0.1 percent, it still remains a source of dread for all eye specialists. Despite improvements in asepsia and sterilization, infectious endophthalmitis continues to persist as one of the most important sight-threatening condition.

REFERENCES

1.Gutiérrez-Carmona FJ. Manual technique allows for small incision cataract surgery. Ocular Surgery News: Surgical Maneuvers 1997;14-5.

2.Gutiérrez-Carmona FJ. Nueva técnica e instrumental de facofragmentación manual para incisiones esclárales tunelizadas de 3.5 mm Arch Soc Esp Oftalmol 1999;74:181-6.

3.Gutiérrez-Carmona FJ. Manual multi-phacofragmen- tation through a 3.2 mm clear corneal incisión. J Cataract Refract Surg 2000;26:1523-8.

4.Keener GT (Jr). The nucleus division technique for small incisión cataract extraction. In Rozakis GW (Ed): Cataract Surgery; Alternative Small-Incision Techniques. Thorofare, NJ Slack, 1990;6:163-91.

5.Kansas PG. Small incision cataract extraction and implantation surgery using a manual phacofragmentation technique. J Cataract Refract Surg 1998;14: 328-30.

6.Quintana M. Implantación de LIO plegable con facosección manual y pequeña incisión. Microcirugía ocular 1998;6(1):37-44.

7.Blumenthal M. Manual ECCE, the present state of the art. Klin Monatsbl Augenheilkd 1994;205:266-70.

8.Koch PS. Structural analysis of cataract incision construction. J Cataract Refract Surg 1991;17(Suppl):661-7.

9.Boyd BF, et al. Complicaciones Transoperatorias de la Facoemulsificación. En: El Arte y la Ciencia en la Cirugía de la Catarata; Highlights of Ophthalmology Int’l , edición en español 2001;11:249-68.

10.Davis DB. Scleral Incisions With Cataract Surgery. American Intra-Ocular Implant Society Journal, Spring 1983;9:192.

Complications are the important part of any surgery. Due to recent advances in cataract surgery the number of complication have reduced.

Thorough preoperative evaluation, immaculate operative technique and good postoperative care can minimize the rate of both intraoperative and postoperative complications.

Intraoperative complications: These include complications related to different steps of surgery.

ANESTHETIC COMPLICATIONS7

Anesthetic complications are mainly related to the type of anesthesia used. They are less common in topical and subtenon anesthesia and common in retrobulbar and peribulbar anesthesia.

The complications seen are:

a.Retrobulbar hemorrhage: This can be seen by both retrobulbar or peribulbar injection. It is recognized by:

•Proptosis

•Tensed eyeball, and

•Difficulty in separating the eyelid

Treatment: Immediate digital massage for 15-20 minutes. This allows the bleeding to stop. Then check the IOP digitally and then continue with the surgery. The intraocular pressure is also eased by lateral canthotomy. If IOP is not under control, then postpone the surgery and give antiglaucoma agents.

b.Globe Perforation: It is common complication seen during/with retrobulbar injections. Also occasionally optic nerve damage is also seen. To avoid this complication – peribulbar anesthesia with short needle is used. Early diagnosis of globe perforation

is very important. It is diagnosed by sudden hypotomy.

Treatment: It includes complete evaluation of eye to find the site of perforation. The site of perforation is accordingly sealed with cryotherapy. Evaluate the periphery to check the retinal status. If there is retinal break or detachment then treat accordingly.

c.Subconjunctival hemorrhage: This is commonly seen during or with peribulbar, subtenons anesthesia and retrobulbar injection. It is differentiated from retrobulbar hemorrhage by its fresh red color and normal intraocular pressure.

d.Chemosis: This is treated by making incision or conjunctiva and draining the fluid out of swelling.

WOUND RELATED COMPLICATIONS5

An adequate and properly constructed wound is important prerequisite for SICS (Figure 37.1). The complication related to wound depends on:

Figure 37.1: Correct incision

(Courtesy : Dr KPS Malik and Dr Ruchi Goel, New Delhi)

Figure 37.2: Shallow incision leading to buttonholing of roof of the tunnel (Courtesy: Dr KPS Malik and Dr Ruchi Goel, New Delhi)

1.Depth of incision.

2.Length of incision.

3.Width of incision

4.Shape of incision.

Depth of the Incision5

Depth refers to the thickness of the flap. External incision should be 0.3 mm deep or about one third–one half the thickness of the sclera. The problems associated with depth of incision may be:

Superficial Incision

If the incision is superficial – then it leads to buttonholing of anterior wall of tunnel. This buttonholing may also result from improper direction of blade or forward dissection (Figure 37.2).

Management

a.Proper placement of crescent knife – angle the crescent knife downwards to increase the dissection of sclera.

b.Abandon the present tunnel and reenter at a deeper plane from another site of internal incision.

Button holing can also be prevented by making scleral pockets at medial and lateral end of tunnel and then joining both the pockets.

Deep incision: Deep tunnel wound leads to:

A.Premature entry onto AC5: This would lead to prolapse of iris tissue out of the wound (Figure 37.3). Management: Reposit the iris tissue back into AC. Inject viscoelastic both in front and behind the

Figure 37.3: Premature entry

(Courtesy: Dr KPS Malik and Dr Ruchi Goel, New Delhi)

nucleus to keep iris back. Place lens glide or iris repositor behind the nucleus and try to deliver the nucleus. Wire vectis can also be used. Since it is wider, pushes back the iris more firmly. But if prolapse is large one should suture the wound and abandon the site and make new entry at another place.

B.Scleral disinsertion: The floor of the tunnel is formed by posterior half of the sclera. Deep incision would cut through the floor of tunnel – thus resulting in disinsertion of inferior sclera.

This may lead to large shift of wound downwards and flattening of vertical meridian of cornea. This will cause large against the rule astigmatism, which would continue to increase postoperatively (Figure 37.4).

Figure 37.4: Deep incision leading to scleral disinsertion (Courtesy: Dr KPS Malik and Dr Ruchi Goel, New Delhi)

Management: The tunnel is sutured with radial bites so that the two edges of floor are connected or joined.

C.Detachment of Descemets’s membrane5: The descement’s membrane may be injured or detached either while making entry into AC with keratome or while entering the AC with rough edge cannula.

Management: Descemet’s membrane must be uncurled and kept in this position so that corneal stoma is protected from aqueous. Inject viscoelastic/ air into anterior chamber. This has tamponade effect on Descemet’s membrane. The detached part settles down fast if placed under pressure for few hours.

The other option is Descemetopexy,11 a surgical technique of reattachment of stripped Descemet’s membrane.

Reopening of the central portion12 of the wound and unrolling the Descemet’s membrane with iris repositor.

Suturing of Descemet membrane if it is seen in the incisional area.

1.Width of wound5: The distance between external incision and internal entry into the AC is the width of the incision. For production of astigmatic neutral incision, the external incision should be as far as posterior as possible.

The main complications seen are increase incidence of bleeding.

Management: Proper cauterization of episcleral vessels before starting with the incision is very important. If the width is small, then valvular effect of wound is reduced and the section is no longer selfsealing. There is also increase incidence of iris prolapse.

Treatment: Close the incision with suture and make incision at longer distance than previous one.

2.Length of the incision5: It is very important part of the incision. If the incision is smaller than the size of nucleus then there is difficulty in removal of the nucleus. This may lead to further complications of damage to corneal endothelium, corneal edema and uveitis. If the length is large then there is increase in postoperative astigmatism. There is also increase incidence of postoperative shallow AC, wound gaping and iris prolapse.

Thus, the length of the incision should be around 5- 6 mm. If cataract is very hard you can increase the length to 7 mm or use any of the method of nuclear delivery in which we divide the nucleus into smaller pieces.

Iris prolapse: This is one of the important complications seen in SICS. This may be due to:

a.Improperly structured wound: due to increase in size, incision very close to the limbus and deep incision.

b.Increase positive pressure in the eye.

Management: The main principles followed are:

a.Ensure that the eyeball is soft before the surgery. This can be done by applying digital pressure after the peribulbar block.

Use of thin wire speculum is important in ensuring minimal external pressure.

If superior rectus is taken then it should be released to reduce the pressure.

b.The wound should be properly constructed with adequate size.

If length is more then proper suturing should be done to reduce the length of the wound. A small iridectomy may also help in reducing iris prolapse. Iris repositor is used to reposition the iris. Viscoelastic can also be used. Lens glide or wire vectis – may be used for delivery of nucleus in presence of iris prolapse.

3.Side port entry: Side port is created by lance tip MVR blade (19G/20G). This opening is used mainly for:

a.Anterior capsulotomy

b.Cortex aspiration

c.Injection of visco/air into AC.

Complications related to it are:

a.Bleeding if made in vascular area.

b.If opening is large–it may lead to increase leaking and shallow AC

c.Descemet’s detachment.

d.Injury to the iris.

e.Injury to the lens.

There can be prevented by using sharp instruments– inserting at avascular area. The direction should be towards center of area.

If the incision is large, it can be sutured with 10/0 nylon suture. Hydration of side ports should always be done to prevent any leak through side ports.

Descemet’s membrane detachment can be managed by injection of air bubble in anterior chamber or by suturing.

COMPLICATIONS RELATED TO

ANTERIOR CAPSULOTOMY

There are two basic types of capsulotomy used for cataract surgery.

•Continuous curvilinear capsulorhexis.

•Can opener capsulotomy.

Continuous Curvilinear Capsulorhexis5

The commonest type of capsulotomy done in SICS is continuous curvilinear capsulotomy (CCC). The ideal size of CCC should be about 0.25 mm less than that of optics of IOL. The complication related to the rhexis depends on its size, shape and position.

•Small rhexis: A small rigid rhexis can result in: -

1.Increase in zonular stress while prolapsing the nucleus into the anterior chambers. This can lead to zonular dehiscence and avulsion of bag into AC.

2.Increase incidence of PC tears and nuclear drop during hydroprocedure because of capsular blockage syndrome.

Management: Enlargement of small sized rhexis by continuation of the spiral tears.

If the CCC is small then it is converted to can opened capsulotomy by giving 1-2 relaxing cuts at rhexis margins. The cuts should not be extended away from the equator. After nucleus delivery, second rhexis can be done in order to insert the IOLs in the bags. They can be done by taking small nick with 26 no. needle and then CCC is completed with utrata forceps for 26 no. needle. Dyes such as tryptan blue are used for better visualization of the capsule.

•Large rhexis:7 If CCC is large then it may result in premature delivery of nucleus into the AC. It may also cause difficulties in placing the IOL in the bag.

•Peripheral extension of CCC: The CCC may extend into the periphery towards the equator or posterior capsule. The most common complication associated is advertent perpendicular capsule tear extending to the peripheral zonules underneath the iris. This is more common when the anterior chamber is shallow mainly when there is positive pressure on the globe.

Management:

a.The capsulorhexis is stopped when the tear develop a peripheral heading.

b.Refill the anterior chamber with viscoelastic.

c.The direction of vector force at the edge of capsular flap is changed to resume the circular tear. The following measures can be taken:

•Cut the outgoing flap of the capsule and then proceed with rhexis on the remaining capsular area.

•Use of utrata/capsular forceps to bring the capsular extension inside in path of rhexis.

•Initiate the rhexis at starting point and more in opposite directions.

•Another option is to convert the rhexis into can opener capsulotomy with multiple

perforations.

—Eccentric rhexis: There is chance of IOL decentration at later stage. This is prevented by making continuous circular rhexis and in the bag lens implantation.

•Can-opener capsulotomy: It is a technique of capsulotomy in which you make multiple perforations in anterior capsule. The most common complication associated with the procedure is creation of unequal capsular flaps. The flaps may be aspirated into the irrigation aspiration cannula. This can cause an inadvertent capsular tear towards the zonlues.

If left unrecognized it could lead to large posterior

capsular rent or some times nuclear bag may be aspirated.

Management

a.Multiple fine punctures should be created, thus eliminating large capsular flaps.

b.Continuous curvilinear rhexis should be done thus avoiding the creation of capsular tag.

c.Use of trypan blue helps in visualization of anterior capsular flaps.

COMPLICATIONS DURING

HYDROPROCEDURES5

Hydroprocedures are techniques, which are used to free the nucleus and epinucleus from the capsular bag so that nucleus could move or rotate freely in the bag. It also helps in reducing the size of nucleus, so that it could be delivered easily through the small incision. Minimum amount of fluid should be used for the procedure.

Complications

If large amount of irrigating fluid is injected vigorously there it can lead to peripheral extension of small radial tears and zonule ruptures, thus leading to rupture of posterior capsules that will lead to vitreous loss and posterior dislocation of lens.

There is high incidence of these complications in case of hard nuclear cataract in which there is minimal cortical matter and the posterior capsule in thin. In case of posterior polar cataract, hydrodissection is avoided and only hydrodelineation is done. This prevents the posterior capsular tear.

Management The following steps should be taken to prevent the complication:

a.Inject small amount of fluid beneath the capsule. About 0.1-0.2 ml is sufficient.

b.Inject the fluid by just lifting the anterior capsule. We could see fluid wave coming out of the wound if you are in proper plane.

After injecting the fluid one should tap the anterior surface of the nucleus to release the fluid out of the bag. If this is not done, then it will cause more pressure on the posterior capsule leading to rupture. One should perform hydrodissection first and then hydrodelineation so that cortical matter does not hamper the visualization. Do not inject more fluid in case of hard nucleus cataract. All there procedures can prevent the complication related to hydroprocedures.

COMPLICATIONS DURING NUCLEUS DELIVERY

All the methods of SICS except few require the delivery of nucleus into the anterior chamber. This is one of the important steps of small incision cataract surgery. The inability to prolapse the nucleus may be due to following reason:

Small CCC

The size of the rhexis should be adequate to deliver the nucleus out of the bag. In case of hard cataract one should make larger rhexis. Smaller rhexis can be managed by making another rhexis that should be of larger size. One can also give extension cuts at 2-3 sites, which help in reducing the tension on capsular bag and helps in delivery of nucleus into the anterior chamber.

Incomplete Rotation of Nucleus in the Bag

This is usually due to improper hydrodissection. This can be managed by repeating hydrodissection in a correct plane.

Small Pupil or Miosis

Miotic pupil not dilating with mydriatic may be due to presence of posterior synechiae. The synechiae makes the delivery of nucleus difficult, if one tries to rotate the nucleus – it can lead to increase in zonular stress leading to zonular dehiscence or lens displacement. It can also lead to damage of iris sphincter and bleeding.

Prevention

This can be prevented by breaking the posterior synechiae. Inject the viscoelastic into the AC8 and pass the synechiatome under the iris to break the synechiae.

One can also pass the iris repositor to separate posterior surface of iris and anterior capsule. Pupils can also be enlarged by using iris hooks. Stretching of pupil cause microsphinctrotomy which help in enlargement of pupil. Vannas scissor can also be used to make sphincterotomy by taking small nicks so that shape of pupil is maintained. These patients usually do not dilate with adrenaline injections. Pupils can become smaller during the surgery also. This is usually seen with increase iris handling or when the surgical time required is more. This can be managed by:

a.Use of adrenaline either in the irrigating fluid or directly into anterior chamber. It has to be diluted before giving intracamerally.

b.High molecular weight viscoelastic can also be used to dilate the small pupil.

c.Avoid damage to iris during AC maneuvers.

d.If pupil is not dilating then sphincterotomy or radial iris cuts can be made.

Zonular Dehiscence5

It is one of important complication seen while delivering the nucleus into the anterior chamber. Dehiscence usually occurs as result of increase stress on zonules when nucleus is rotated out of the bag. This is commonly seen in cases of hard nuclear cataract, in cases of small pupil, improper technique of rotation of the nucleus and in cases of small rhexis. This is commonly seen in beginners who start learning the basic steps of the surgery. Increase application of pressure while rotating over the nucleus forcibly can lead to zonular dialysis or delivery of whole nuclear bag (Figure 37.5).

Management In case of small rhexis opening, try to make second larger rhexis or take relaxing cuts at 2-3 places. Then after injecting viscoelastic try to deliver the

Figure 37.5: Dehiscence of superior zonules of lens (Courtesy: Dr KPS Malik and Dr Ruchi Goel, New Delhi)

nucleus out of the bag. While rotating nucleus with Sinskey hook pressure should not be applied posteriorly but it should be more anteriorly in the clockwise or anticlockwise direction. This would decrease zonular stress, thus preventing zonular dehiscence and dislocation of nucleus.

Detection of zonular dehiscence: Nucleus is freely rotating in the bag but does not prolapse into the anterior chamber. It shifts towards the left side or downward. This may be associated with vitreous loss. The management depends on vitreous loss in AC.

A.If there is no vitreous loss/no vitreous in AC First see the size of rhexis. If size is small then give relaxation cuts or convert into can opener (multiple perforation) capsulotomy. Check the size of tunnel. Inject viscoelastic above the nucleus. Try to rotate the nucleus and delivery it into anterior chamber without increasing the area of zonular dehiscence.

Now deliver the nucleus out of the wound. Aspiration of cortex should be done with little irrigation, as increase flow of irrigation can increase the area of zonular dehiscence. There should be minimal manipulation while inserting the IOL.

B.If there is vitreous in AC In this case complete automated vitrectomy is done. Then nucleus delivery and IOL implantation is proceeded. Special precaution should be taken so that there is no increase in vitreous loss.

C.If the amount of zonular dehiscence is large In this case any attempt for nuclear rotation and delivery into the anterior chamber can lead to total dislocation of nucleus into the vitreous.

Treatment

Initial step is to increase the size of tunnel. Take relaxation cuts on rhexis or convert it into can opener capsulotomy. Deliver the nucleus out of wound with the help of plain wire vectis. Cortical aspiration is done under minimal or dry aspiration. IOL is implanted into the sulcus away from area of zonular dehiscence (Figure 37.6).

The other option is to convert into manual or conventional extracapsular cataract extraction. Either end of the tunnel is cut down radially to limbus and then limbal section enlarged by corneal scissors.

Damage to Corneal Endothelium6

This is one important complication seen during nucleus delivery. Endothelial touch or damage to endothelium

Figure 37.6: Management of Zonular Dehiscence (Capsular Bag stretched by IOL Haptics) (Courtesy: Dr KPS Malik and Dr Ruchi Goel, New Delhi)

is more common in case of hard nuclear cataract. If while rotating the hard cataract into anterior chamber in presence of small tunnel there is increase chance of endothelial damage. Endothelial touch is also common when instruments are inserted through the scleral tunnel.

Management Damage to the endothelium is prevented by using large amount of viscoelastics. It should be inserted above the nucleus so that nucleus does not touch the corneal endothelium. The size of incision should also be large enough so that there is enough space for maneuvering of the instruments. If preoperative evaluation show early decompensation or corneal guttata then high viscosity agent is used so that if stays inside the AC and gives adequate support / cushion like effect to the endothelium.

Dropped Nucleus

This is one of an important complication of cataract surgery (Figure 37.7). It is commonly seen in Phacoemulsification. The common predisposing factors are:

a.Hard nuclear cataract

b.Small pupil

c.Pseudoexfoliation due to weak zonules

d.Beginners who have started doing phacoemulsification.

Dropping the part or whole nucleus in vitreous cavity is feared complication of phacoemulsification.

Protocol that should be followed in management of retained nuclear fragment.

a.Initial observation – in cases of small retained nuclear fragment and /or mild inflammation.

b.Continuous local steroid eyedrops.

c.Vitrectomy is indicated: If size of fragment is more than 25 percent of actual size of nuclear.

If inflammation is not controlled

Figure 37.7: Dropped nucleus

d.We can delay vitrectomy so that corneal edema reduces and ocular inflammation reduces.

e.Perform adequate core vitrectomy and then proceed for phaco fragmentation.

f.Implant secondary IOL if not done before.

g.Examine the periphery to look for retinal breaks or retinal detachment.

Management Initial steps depend on grade of the nuclear and size of dropped nuclear fragment. In manual SICS– usually the whole nucleus drops into the vitreous cavity. A proper and complete automated vitrectomy is very important. Any lens material and vitreous in anterior chamber should also be removed. A 3 part pars plana approach is used (Figure 37.8).

If the nucleus is soft then the fragment can be brought to the center of vitreous cavity and eaten up with vitreous cutter.

But if the nucleus is hard then, use perfluorocarbon liquid to float the nucleus and then by using fragmatome – break the nucleus into small pieces and then remove the actual fragmentation of the nucleus should be performed in the midvitreous cavity and not on or near the retinal surface.

If there is coexisting RD also then encircling scleral buckle is recommended. After nuclear is removed then endolaser is applied around retinal breaks. Then silicone oil may be injected for tamponading effect.

If nucleus is present in anterior vitreous, we can bring the nucleus in the anterior chamber and deliver it through cataract section.

Figure 37.8: Vitrectomy for dislocated nucleus + VH + Iaterogenic GRT + Total RD

After removal of dropped nucleus, one should evaluate the status of retina. The next step is implantation of IOL. The variety of IOL to be implanted depends on integrity of posterior capsule. The IOL may be implanted in the bag in the sulcus or scleral fixated PCIOL or ACIOL may be used.

Postoperatively systemic and local steroids should be given to reduce the postoperative inflammation that may occur.

COMPLICATION DURING CORTICAL ASPIRATION

The main complications seen are:

a.Retained lens matter.

b.Posterior capsular tears or rupture.

Retained Lens Matter19

Lens matter such as anterior capsule, cortical matter or nuclear fragments may be left behind in eye. Nuclear or cortical fragments of about 25 percent usually tend to absorb spontaneously without any sequelae or complications. But large amount of cortical lens matter can result in –

a.Uveitis.

b.Corneal edema.

c.Secondary glaucoma.

d.Cystoid macular edema

e.Posterior capsular opacification

f.Retinal detachment

Residual lens matter is usually left behind in

following cases:

a.Small pupil.

b.Posterior capsular tears with or without vitreous in AC

c.Small rhexis.

d.Subincisional cortex.

Management In cases of small pupil, inject adrenaline into irrigation fluid or in the anterior chamber. Lens fragments in anterior chamber should be removed preserving as much capsular bag as possible. If vitreous is seen in anterior chamber first do automated vitrectomy. This would prevent traction on the vitreous. Then corneal matter is removed with dry irrigation. Try to removal the entire cortical fragment without increasing the capsular tear. The central visual pupillary area should be clear of cortical matter.

If capsular tear is small then lens is implanted in the bag over the tear and if tear is large then lens is implanted in the sulcus or scleral fixating lens is used. Large size optics lens is used for in the bag implantation.

If the tear is large and the large cortical fragments cannot be removed then whole capsular bag is removed and anterior chamber lens or scleral fixated lens are used.

In case of small rhexis and small pupil if we try to aspirate blindly there is high chance of posterior capsular tear. The cortical matter left behind can be removed by phenomenon of water jetting in which irrigating saline is flushed. It is better to leave piece of cortical matter that is not in pupillary area rather than increase the chance of posterior capsular tear.

Adequate hydroprocedures also loosens the cortical matter and these small bits of residual cortex can get absorbed within 3-4 weeks if left behind.

In presence of posterior capsular tear, cortical matter away from area of rent is aspirated first so that the size of tear is not increased.

Posterior Capsular Rupture

Posterior capsule is very important as it provides support for posterior chamber IOL implantation. The commonest step in which posterior capsular tear occur is during cortical matter aspiration.

The other stages being:

a.Hydroprocedures

b.Delivery of nucleus.

c.IOL implantation.

Posterior capsular tear may occur as:

a.Posterior tear without vitreous loss7, i.e. with intact hyaloid face.

b.Posterior tear with vitreous loss

c.Large tear with vitreous in anterior chamber.

d.Loss of Capsular bag

Prevention

Extra precautions are taken in cases in which posterior capsular tear is suspected or cases in which posterior capsule are thin.

In case of posterior polar cataract, hydrodissection is not carried out by hydrodelineation is done.

Another important aspect is that minimal quantity of fluid is used for hydrodissection thus decreasing the pressure in the bag.

Management

If posterior capsular tear occur during cortical removal Initial step is to do a good automated vitrectomy is done. Then cortex is aspirated with dry irrigation. Try to aspirate the cortex away form the capsular tear site. Also try to remove the cortex under the cover of viscoelastics.

Inject high molecular viscoelastic. Implant the lens in bag or in the sulcus depending on size of tear. Scleral fixating lens may also be used.

Site of IOL implantation in presence of capsular tear This is very important step in case of PC tear. One should always try to implant posterior chamber lens in almost all cases. The site of implantation will depend on:

a.size of PC tear

b.size of capsule.

If the size of PC tear is small then one should implant PC IOL over the PC rent, i.e. in the bag. After implantation confirm that IOL is well placed in situ. This is done by tap test. This is done by tapping the IOL in the center and then to see for the stability of the lens. If IOL is in situ after tapping it remains stable. But if tear is not well placed after tapping it shifts its position and starts telling

If the size of PC tear is large then assess the size of rhexis. Inject viscoelastic over the out capsule. Insert IOL over the CCC in the sulcus one should see that IOL does not increase the size of PC tear and is not placed in the bag.

If the size of tear is large and the rhexis size is not sufficient – then the other alternative is of scleral fixative lens.

Anterior chamber lens can also be used. But before implanting one should remove the nuclear bag completely. We should not forget to do peripheral iridectomy, as secondary angle closure glaucoma is common after anterior chamber lens implantation.

Position of PCIOL on case of posterior capsular tears

If posterior chamber lens is implanted in the bag then direction of is very important. The position of the haptic should be such that it should not increase the size of capsular tear. The Lens implantation can be done at some setting or one can also go for lens implantation after 6-8 weeks after the inflammation of the eye subsides. If it is done at the same sitting will lead to increase postoperative inflammation.

Management of Posterior Capsular Rupture

Iridodialysis

This is another common intraoperative complication seen after manual small incision surgery. When deep scleral tunnel is made, the chance of iris getting damaged at 12 o’clock position is common. Iridodialysis can also occur while removing the nucleus with the plain wire vectus. The site of dialysis is usually is 6 o’clock position (Figure 37.9).