(h) Multiple capsular punctures or capsular relaxing incisions as the final option (Fig. 7.39): When everything has failed and a capsular tear has occurred (or perhaps, the surgeon is uncertain that there is, but is highly suspicious that it has happened), perform multiple punctures or multiple relaxing incisions, either with cystotome or with scissors. If tears are already present, perform relaxing capsular incisions to the opposite side of the tear and to many meridians as possible, in order to redistribute the forces that may cause extension of the tears to the lens equator. This is the final option when everything has failed. It will not be a nice and round CCC, but the possibility of a tear transmitted to the posterior capsule will be less.

7.1.3Avoiding Complications During Biaxial Phaco with an Incomplete Capsulorhexis

Once the surgeon is sure that he has an incomplete capsulorrhexis and doesn’t know exactly if the tear has extended to the posterior capsule, the golden rule is, to avoid transmission of forces to the capsular bag. It must be an “in the air surgery,” meaning, performing the whole procedure at the iris plane.

Some years ago, Prof. Keiki Mehta from Mumbai, India, described what he called, “The Lens Salute Technique,” that consists of a hemi-luxation of the nucleus to the iris plane, during hydrodissection and

Fig. 7.40 Nucleus placed in lens salute position

hydrodelineation (Fig. 7.40). The authors have found that during their surgical practice, this maneuver helps to decrease the transmission of forces to the capsular bag and to the zonula, even in noncomplicated cases (which means completed cases with nice, round capsulorrhexis). In cases of incomplete capsulorrhexis, this maneuver can be a safer way of performing a noncomplicated phacoemulsification. The key is to work at the iris plane.

(a)Performing gentle hydrodissection (Fig. 7.41): Because in many cases the surgeon cannot know exactly the state of the capsular bag when a capsulorrhexis is incomplete, added precaution should be taken when performing hydrodissection and hydrodelineation. The surgeon has to perform soft and slow maneuvers inside the capsular bag, separating only the layers adjacent to the anterior capsule

in the meridians, where it is possible to visualize it well. This maneuvers of hydrodissection and hydrodelineation is very similar to the approach for cases of Posterior Polar Cataracts. “To be gentle” is the key for this surgical step. Avoid maneuvers like vigorous injection of irrigating fluid and the rotation of the nucleus. Even with gentle hydrodissection, the goal should still be to take the nucleus out of the capsular bag.

(b)Searching for an easy “Lens Salute Position” (Fig. 7.42): Because the surgeon is uncertain about the integrity of the posterior capsule, it will be a tremendous mistake to perform phacoemulsification inside the capsular bag. Maneuvers like prechop, vigorous chopping and stop and chop in the bag, must be avoided. The key factor for phacoemulsification is to work outside the capsular bag. In these cases, the surgeon can apply the concept of “the safest place to work for a cataract surgeon is at the iris plane” Once the nucleus is at the iris plane, the transmission of forces to the “incomplete” capsular bag, posterior capsule and zonules should be avoided. Furthermore, while working in a biaxial approach, the irrigating cannula (or irrigating chopper) can be placed behind the nucleus (Fig. 7.43). Irrigation from the irrigating chopper helps separate the nucleus from the posterior capsule or in such cases, from the hyaloid face. If the surgeon is working in a coaxial approach, it is impossible because there is no irrigation available at his nondominant hand and worst, the coaxial irrigation pushes the nucleus back to the incomplete capsular bag. The main concept that must be learned in these cases is that the surgeon has to believe that the

Fig. 7.43 Irrigating cannula behind the nucleus

posterior capsule is broken, even if he has signs that it is not, with the goal to avoid initial or subsequent damage. There are two ways to take the nucleus outside the capsular bag:

−Perform the “Lens Salute Technique” during the hydroprocedures (Fig. 7.42): If the surgeon is uncertain about the integrity of the posterior capsule and he has to be gentle during the hydrodissection without rotating the nucleus, a small amount of solution can be injected behind the anterior capsule in a place where he can best visualize it. While injecting, gently press down the equator of the nucleus in this same position. Do not press the nucleus in the center or in the mid-periphery. It has to be pressed at the extreme periphery; otherwise, the nucleus might get

pushed into the vitreous. While injecting and at the same time pressing the equator, the solution will run behind the nucleus to the opposite side, creating a posterior fluid wave that pushes the nucleus forward. This fluid wave moves between the nucleus and the posterior capsule. Even if the posterior capsule is absent, the wave will move between the nucleus and the hyaloid face, pushing the nucleus forward. This is why this maneuver will not work if the surgeon pushes the nucleus in another location, different from the extreme periphery. Disastrous consequences may occur if this maneuver is not performed properly. Remember that the aim of this maneuver is for the nucleus to reach its final position, which is, the “tilt” position, a plane of inclination that will allow the surgeon to place his irrigating chopper or cannula behind the nucleus (Fig. 7.43) as it reaches the iris plane. The key factor is to move the nucleus out of the capsular bag. The nucleus will tilt forward easily because of the absence of a small CCC that can keep it in the capsular bag.

−If the surgeon does not have enough skills, or is afraid to perform hydroprocedure in a possible broken capsular bag, there is one technique that can help move the nucleus from the capsular bag. Gentle and soft hydrodissection without nuclear rotation can be performed, followed by the insertion of the irrigating chopper (or cannula) and the phaco needle to the anterior chamber (Fig. 7.44a). There should be enough fluid (active or passive infusion according to the gauge of preference) to avoid surge and high vacuum (according to the phaco needle and the phaco-machine parameters). Start the irrigation and impale the phaco needle with a small amount of ultrasonic power into the center of the nucleus (Fig. 7.44b). Avoid pushing the nucleus during this maneuver. Once the phaco needle is deep enough in the nucleus, stop the ultrasonic force but not the vacuum. The surgeon should avoid performing a groove, remember that he needs to work outside the capsular bag, and keep the vacuum active. Do not lose the nucleus, and keep itkept in place with only the vacuum force firmly holding it. In a single swift, but gentle movement, the surgeon should pull the phaco needle-nucleus outside the capsular bag. This maneuver is similar to that of intracapsular surgery, when the unit, cryo probe-

cataract are moved in a single but gentle movement, to remove the cataract from the eye (Fig. 7.44c). In this case, the movement is just to put the nucleus at the iris plane. Once the surgeon is at the iris plane, vacuum should not be stopped. As the nucleus is held firmly by the phaco needle, the irrigating chopper (or cannula) on the nondominant hand is slipped behind the nucleus. This instrument has irrigation, so it is easy to know that it is placed properly behind the nucleus. This irrigation, acting as the surgeon’s third hand in this situation cannot be obtained in a coaxial approach. Once the irrigating device is behind the nucleus keep it firmly held with the vacuum, and simply move the irrigating device to cut the nucleus (Fig. 7.44d). With sustained vacuum at the iris plane, from the rear to the front, the surgeon will obtain a nice division of the nucleus in two halves at the iris plane, far away from the corneal endothelium and from the possible damaged capsular bag (Fig. 7.44e).

(c)Maintaining a positive IOP with irrigation: Because the aim is to work at the iris plane, the maintenance of wide spaces in the anterior and posterior chambers plays an essential role. If the surge is present, the damage to the intraocular structures is possible. Surge can cause damage to the posterior capsule, ultimately causing nuclear material to lodge in the vitreous cavity. More importantly, it can decrease the speed of recovery of a patient suffering from corneal edema because of endothelial touch. Enough fluid to work with, will help the surgeon create space to maneuver inside the eye, thereby, avoiding touch of intraocular structures. Moreover, this fluidfilled space can support high vacuum levels during phaco. As a general rule, while using an irrigating device of 19G or wider, passive infusion (gravity force) can be utilized. But when using diameters of 20G or smaller, avoid the risk of surge . Use forced infusion, whether internal or external because it assures the surgeon success in these complicated cases.

(d)Biaxial prechop technique at the iris plane (with lens salute or with “pull the nucleus technique”):

Whichever way the nucleus is placed at the iris plane, a mechanical fracture of the nucleus performed between the phaco needle (placed in the front part of the nucleus) and irrigating device, either chopper or cannula (placed in the rear part of

Fig. 7.44 (a) Starting Bi-Axial Phaco. (b) Entering the nucleus with slow ultrasonic power. Be careful not to groove. (c) Pulling the nucleus outside the capsular bag with vacuum. (d) Mechanical

fragmentation of the nucleus at the iris plane. (e) Nuclear division in two pieces at the iris plane

the nucleus), is the key to success (Fig. 7.45). The surgeon now has the following advantages:

•Now, the surgeon works outside the capsular bag.

•There is an irrigating force separating the nucleus from the posterior chamber structures, although he is not certain of the integrity of the posterior capsule.

•It is possible to emulsify all the nuclear strands from the front to the rear, so an incomplete chop is almost difficult to occur, unless he loses vacuum force.

•Because the surgeon is firmly holding the nucleus with vacuum, it functions as a unit, as a single piece that can be managed in single movements.

•iHe has irrigation posterior to the nucleus, and hence, the pieces are pushed forward, and never to the posterior chamber.

Avoid the use of prechopper forceps, prechopping inside the capsular bag, coaxial irrigation, stop and chop techniques, and all the techniques that will take the surgery again to the posterior chamber. Extra precaution should be taken not to touch the corneal endothelium. Work at the iris plane and not at the anterior chamber. Fragment the nucleus into pieces as much as possible at the iris plane. Divide the nucleus several times with the same technique; apply vacuum force to the nucleus and vertical chop at the same time from the rear to the front.

(e) Avoiding work at the capsular bag. pulling the fragments to the iris plane (Fig. 7.46): Because of the uncertainty of the integrity of the posterior capsule, placing the irrigation behind the nucleus is the key. The surgeon has a third hand in helping to keep the nuclear fragments at the iris plane and maintaining the broken posterior capsule or the vitreous body away from the surgical space. Nevertheless, some surgeons recently have pointed out the benefits of placing a mechanical device behind the nucleus in order to have a safe phacoemulsification, when there is a damaged posterior capsule (artificial posterior capsule). The future will tell us about their real benefits and possible complications. They, however, share with us the same way of thinking, that is, in cases of phacoemulsification performed with an incomplete capsulorrhexis, the working space must be at the iris plane. Some physical force

(either fluid or mechanical) must be inserted or instilled behind the nucleus to avoid loss of nuclear fragments to the vitreous cavity, and eventually to avoid more damage to the structures located in the posterior chamber.

(f)Maintaining a positive IOP while switching to I/A mode: Because the surgeon is working in a biaxial approach, it is possible to switch from phaco mode to Irritagion/Aspiration mode, without the need to stop irrigation. In a coaxial approach, this is not possible. Once the surgeon has finished the emulsification of the nucleus, he has to switch from one handpiece to another. Irrigation is stopped between the steps, unless viscoelastic material is injected through a second incision to maintain a stable anterior and posterior chamber. If this is the case, the surgeon is very near to being converted from a coaxial to a biaxial surgeon. With the biaxial approach, the surgeon only needs to switch from the phaco probe to the aspirating cannula with the dominant hand, and with the help of his assistant holding the irrigating handpiece on the nondominant hand and keeping the eye stable, thereby maintaining the anterior and posterior chambers wide open, and the damaged capsule, hyaloid face or vitreous body far away from the incisions. It is a tremendous advantage of a micro-incisional surgery in a biaxial approach (Fig. 7.47a–c).

(g)Biaxial I/A: After switching instrumentation, I/A is performed in the usual manner. In this particular step, it is possible to review the integrity of your the capsular bag and also the presence of the vitreous, the Because of the separation between irrigation

Fig. 7.47 (a) Maintaining the irrigation on. Notice the filtration through the incision with possitive IOP. (b) Notice the hydrostatic pressure maintaining the hyaloid face in a case of posterior

capsule rupture. (c) With possitive IOP viscoelastic is applied and no vitreous loss is present