maintaining it behind the iris plane. Avoid possible surges. If a vitrector is not available or if the surgeon wants to have an immediate complete visualization of the intraocular structures before removing the irrigating device, he should change his aspirating cannula to a viscoelastic syringe using his dominant hand, and inject viscoelastic before removing the irrigating cannula (Fig. 7.47c). Once the eye is filled completely with the viscoelastic and there is enough positive pressure, irrigation should be stopped and the irrigating cannula should be removed. Now anterior chamber is completely formed with the viscoelastic, without surge or negative pressure induced to the eye. Now, the current state of the intraocular tissues can be reviewed calmly by the surgeon.

7.1.4Avoiding Complications During IOL Insertion with an Incomplete Capsulorhexis

IOL implantation in cases of incomplete capsulorrhexis is only mentioned briefly because it is something that should be evaluated depending on each case, either coaxial or biaxial, when a lack of posterior capsular integrity is highly suspected. It is not the aim of this chapter to make an analysis of each these steps. It is sufficient to mention the decisions to be taken by the surgeon at the end of each case of incomplete capsulorhexis:

1.Perform an adequate re-evaluation of integrity of capsular bag

2.Decide on the best IOL based on the particular circumstance (absence or presence of posterior capsule)

3.Be careful with injectors in the absence of the posterior capsule; consider the use of forceps when inserting the IOL.

4.Decide on the use of a helping device such as a capsular tension ring.

5.Decide on the technique for IOL fixation (e.g., iris suture, sulcus fixation, glue implantation) according to the situation and surgical experience (Fig. 7.50).

7.1.5 Conclusions

Many advantages have been observed when performing biaxial lens surgery in the management of complicated capsular case. These advantages can be noted from the first steps wh the surgeon starts to feel the capsular tissue and to the maneuvers that can be performed in order to avoid a more complicated case. But furthermore, these advantages are more evident during the management of the chop maneuvers, phacoemulsification, I/A and biaxial anterior vitrectomy when needed. It is completely true that MICS is not only a matter of incision size. It is a whole new perspective on the utilization of new tools, new maneuvers, new forces, new fluidics inside the eye, which helps the surgeon to decrease the possible complications of cataract

surgery. But of even great importance is its value in solving complex and challenging cases like that, which was presented in this chapter.

Remember to avoid applying force to the residual capsular bag and the zonular ligament if the surgeon is unsure that the capsulorhexis is complete.

Take Home Pearls

ßMICS surgery has distinct advantages over coaxial techniques in the management of

incomplete capsulorhexis cases.

ßThe irrigation handpiece in the nondominant hand becomes a powerful tool in maintaining a

positive intraocular pressure. Moreover, it keeps the nuclear fragments away from the endothelium and from the residual posterior capsule (or even the vitreous body).

ßWith MICS, it becomes easier for the surgeon to work safely at the iris plane in these particular

cases.

References

1.Sacu S, Menapace R, Findl O (2006) Effect of optic material and haptic design on anterior capsule opacification and capsulorrhexis contraction. Am J Ophthalmol 141(3):488–493

2.Jacobs DS, Cox TA, Wagoner MD, Ariyasu RG, Karp CL (2006) Capsule staining as an adjunt to cataract surgery: a report from the american academy of ophthalmology. Ophthalmology 113(4):707–713

3.Alió J, Rodríguez-Prats JL, Galal A, Ramzy M (2005) Outcomes of microincision cataract surgery versus coaxial phacoemulsification. Ophthalmology 112(11):1997–2003

4.Garg A (2007) Dinamics of capsulorrhexis. In: Pinelli R, Fazio P (eds) Mastering the phacodynamics (tools, technology and innovations), Chapter 12. Jaypee Brothers Medical Publishers, India

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6.Brar N, Cremers SL (2007) Assessing surgery skills. Ophthalmology 114(8):1587–1587

7.Muqit MM, Menage MJ (2006) Intraoperative floppy Iris syndrome. Ophthalmology 113(10):1885–1886

8.Kawai K, Suzuki T, Hayakawa K (2005) The 23 gauge capsulorrhexis forceps having a cystotome function. Tokai J Exp Clin Med 30(1):11–13

9.Kawai K (2004) Comparison of 23 gauge and 25 gauge anterior capsulotomy forceps. Tokai J Exp Clin Med 29(3):105–110

10.Packer M., Hoffmann R., Fine H (2006) Refractive lens surgery. Ophthalmol Clin North Am 19(1):77–88

11.Wasserman D, Apple DJ, Castaneda VE, Tsai JC, Morgan RC, Assia EI (1991) Anterior capsular tears and loop fixation of posterior chamber intraocular lenses. Ophthalmology 98(4):425–431

12.Castaneda VE, Legler UF, Tsai JC, Hoggatt JP, Assia EI, Hogan C, Apple DJ (1992) Posterior continuos curvilinear capsulorrhexis. An experimental study with clinical applications. Ophthalmology 99(1):45–50

13.Sallam A, Sherafat H (2007) Intraocular lens implantation in cases with anterior capsule tears extending to the posterior capsule. J Cataract Refract Surg 33(6):938–939

14.Marques FF, Marques DM, Osher RH, Osher JM (2006)

Fate of anterior capsular tears during cataract surgery. J Cataract Refract Surg 32(10):1638–1642

15.Fishkind WJ, Discussion paper by Gimbel HV, Sun R. Ferensowics M (2001) Intraoperative management of capsular tears in phacoemulsification and intraocular lens implantation. Ophthalmology 108:2190–2192

16.Gimbel HV, Teuhann T (1990) Development, advantages and methods of continuos curvilinear capsulorhexis technique. J Cataract Refract Surg 16:31–37

17.Assia EI, Apple DJ, Tsai JC, Morgan RC (1991) Mechanism of radial tear formation after anterior capsulectomy. Ophthalmology 98:432–437

18.Vajpayee RB, Sharma N, Dada T, Gupta V, Kumar A, Dada VK (2001) Management of posterior capsule tears. Surv Ophthalmol 45(6):473–488

19.Gimbel HV, Sun R, Ferensowicz M, Anderson Penno E, Kamal A (2001) Intraoperative management of posterior capsule tears in phacoemulsification and intraocular lens implantation. Ophthalmology 108(12):2186–2189; discussion 2190–2192

20.Assia EI, Apple DJ, Barden A, Tsai JC, Castaneda VE, Hoggatt JS (1991) An experimental study comparing various anterior capsulectomy techniques. Arch Ophthalmol 109(5):642–647

21.Hettlich HJ, El-Hifnawi ES (1997) Scanning electron microssopy studies of he human lens after capsulorhexis. Ophthalmologe 94(4):300–302

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24.Sallam A, Sherafat H (2007) Intraocular lens implantation in cases with anterior capsule tears extending to he posterior capsule. J Cataract Refract Surg 33(6):938–939; author reply 939–940

25.Osher RH (2007) Reply: inraocular lens implantation in cases with anterior capsule tears extending to he posterior capsule. J Cataract Refract Surg 33(6):939–940

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7.2MICS in Special Cases (on CD): Vitreous Loss

Jerome Bovet

Core Messages

ßAs soon as the surgeon recognizes the presence of a posterior capsule rupture and vitre-

ous loss, it is best to remove all the instruments from the eye with care.

ßTriamcinolone may be injected inside the anterior chamber to visualize the vitreous.

ßBimanual anterior vitrectomy or sutureless pars plana bimanual vitrectomy can be performed.

ßBoth the techniques result in faster visual rehabilitation and better visual outcomes in patients

with posterior capsule rupture and vitreous loss during MICS.

7.2.1 Introduction (Fig. 7.51)

MICS surgery has been the preferred method of cataract extraction during the last décade [1, 2]. A major advancement in the management of cataracts is early surgery, when the nucleus is still soft and before it becomes more dense. However, there are patients who already have mature cataracts at the time of the first examination. This obviously creates difficulties during surgery. Other ocular conditions that may present alone or in combination with cataracts are pseudoexfoliation syndrome (PEX), iridodonesis-phacodonesis, zonulolysis, lens subluxation, and posterior polar cataracts. All of these may be addressed as the precursors of a probable intraoperative complication along with the mature white cataracts [3–5].

Vitreous loss is probably the most frequent serious complication encountered by cataract surgeons. A vitreous loss may increase the risk of cystoid macular