Fig. 7.57 23-Gauge vitrectomy

Fig. 7.58 23-Gauge vitrectomy & IOL in sulcus position

7.2.3Vitreous and the Epinucleus or Cortex

Before any manipulation, the surgeon has to inject triamcinolone acetate inside the anterior chamber to assess the gravity of the problem and to plan the next step. If vitreous prolapse is already present and the nuclear fragments are admixed in the vitreous, then the vitreous should be addressed first.

Particular attention must be paid to limit the borders of the tear and to aspirate the cortex carefully. A

Fig. 7.59 Pars plana vitrectomy

Fig. 7.60 Vitrectomy with phacofragmentation

gentle, low-flow automated irrigation aspiration may be used with caution stripping the cortex under the viscoelastic from the equator toward the tear, avoiding any stress which may extend the tear.

It is also possible to use the new air-vitrector to aspirate the cortex without cutting through the tear. If the tear is small and central, it may be possible for the surgeon to carefully convert the tear into a continuous posterior capsulorhexis [27–31].

7.2.4Different Techniques Other than Pars Plana Vitrectomy for Nuclear Loss in Vitreous

If nuclear material remains, it should be removed either with phacoemulsification or by converting to an extracapsular procedure. Converting to an extracapsular technique is suited for cases in which one or two large pieces remain. If the surgeon chooses to enlarge the wound, it must be large enough to remove the largest fragment in one piece.

Viscoelastic should be placed under the nuclear fragments, which are retrieved by a lens loop. Attempted nuclear expression will likely result in more vitreous prolapse and increases the risk of posterior dislocation of the nuclear material.

Converting MICS to a larger, extracapsular wound is challenging. First, a groove should be extended to the maximum length of the intended enlarged incision, while maintaining a triplanar incision. When closing the wound, care should likewise be taken to prevent a leakage particularly at the main MICS incision.

When the anterior hyaloid face has been ruptured but the nuclear material has not yet luxated into the vitreous, it is recommended to convert to conventional ECCE. Elevating the nucleus with an instrument inserted through the phaco incision is often difficult because of the steep and anterior angle of the approach [43–45]. If total zonulolysis more than 180° is noticed, it will be useful to convert the MICS phaco technique to the old efficient IEC, using dispersive sodium hyaluronate to protect the endothelium.

The posterior assisted levitation (PAL) technique may prevent many complications of a dropped nucleus. It may also prevent the need for three-port pars plana vitrectomy to remove posteriorly dislocated lens fragments. PAL consists of inserting a spatula downward via the pars plana with its tip inclined to the posterior pole of the eye, placing it underneath the nucleus. The spatula then lifts the partially dropped nucleus forward into the anterior chamber. Surgery is completed by extending the wound and expressing the nucleus or by phacoemulsification with a sheet glide behind the nucleus fragments to protect it from falling into the vitreous. A modified PAL technique using sodium hyaluronate 3.0% – chondroitin sulfate 4.0% (Viscoat, Alcon Inc., Fort Worth) was described. The Viscoat PAL may be performed for a partially descended

nucleus after posterior capsule rupture. Following pars plana sclerotomy, the nucleus can be elevated by combining posteriorly directed Viscoat viscoelastic injection and manipulation of its cannula tip. If successful, this can help prevent a retained nucleus or subsequent posterior segment surgery to retrieve it [46–48].

7.2.5 Pars Plana Vitrectomy

If the nuclear material has dislocated posteriorly into the vitreous cavity, attempts to float the nucleus upward following a generous vitrectomy are frequently successful. However, there are cases in which it may be best to temporarily leave the lost nucleus behind, clean up the prolapsed vitreous, remove the cortex, and implant an intraocular lens. Consultation with a retina specialist is recommended for the secondary removal of the lens material via a three-port pars plana vitrectomy with phacofragmentation, and it can be scheduled in the early postoperative period. Heroic efforts to “catch” a falling nucleus or retrieve a fallen nucleus from the anterior segment have been associated with an increased risk of retinal complications and ultimately, poorer visual outcomes.

7.2.6 Zonulolysis (Figs. 7.61 and 7.62)

Zonulolysis is the most challenging complication that an anterior surgeon can encounter. It may be present naturally, prior to surgery, either as a result of trauma or in association with Marfan Syndrome, WeilMarchesani Syndrome, or homocystinuria, phacodonesis and iridodonesis. Vitreous in the anterior chamber or visibility of the lens equator may provide important clues to zonular instability. Exfoliation syndrome also results in weakened zonules. Zonulolysis also occurs from intraocular manipulations during surgery. Prompt recognition and avoidance of further trauma is the best initial management.

The capsulorhexis may be more difficult when loose zonules are present and slow movements assisted by a viscoelastic are recommended. The capsular bag can be locally stabilized in the meridian of dehiscence by placing flexible iris retractors around the capsulorhexis

Fig. 7.61 Zonulolysis

Fig. 7.62 Zonulolysis, vitreous meshwork

After implanting the lens, the surgeons inject triamcinolone acetate inside the anterior chamber to visualize any vitreous meshwork. If there remains any, an anterior bimanual vitrectomy is recommended.

Take Home Pearls

ßEarly identification, and successful management of intraoperative complications are the

keys to the success of the surgery.

ßThe triamcinolone stain provides a direct observation of the vitreous and assists surgeons in

identifying and completely removing vitreous in the anterior segment, intraoperatively.

ßVitreous visualization by using triamcinolone is useful in minimally invasive surgical

techniques to clear the vitreous and to avoid excessive surgical intervention during the management of posterior capsule rupture. However, visualizing the vitreous body using triamcinolone has a potential risk for postoperative steroid-related complications such as glaucoma and infection [36–39].

ßThe 23 gauge anterior bimanual vitrector is useful to cut a few vitreous strands, but the pars

plana sutureless vitrectomy is far more superior in managing vitreous loss after posterior capsular rupture during phacoemulsification [40–42].

margin or placing the Malugin ring [32–34]. The chop phacoemulsification technique will usually allow safe removal of the nucleus.

A highly retentive viscoelastic agent may tamponade the hyaloid face, helping to prevent vitreous prolapse into the anterior chamber. A low bottle height will limit the tendency towards vitreous overhydration. Also, low aspiration settings may help prevent chamber fluctuations, vitreous prolapse, and unintentional traction on the remaining zonules. When zonulolysis is present, cortical aspiration should be performed by gentle irrigation and aspiration with the aid of a viscoelastic, directing all forces tangentially. A capsular tension ring keeps the capsular bag open and evenly distributes the forces on the zonules, making implantation of an intraocular lens into the capsular bag possible [35].

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7.3How to Deal with Very Hard and Intumescent Cataracts

L. Felipe Vejarano

Core Messages

ßHard and intumescent cataracts are challenging and difficult cases for the surgeon and so spe-

cial care must always be taken.

ßIt is essential to know the size of each instrument that will be used, and to plan the incision

size carefully so as to avoid too tight incisions that would compromise maneuvrability, or too large incisions that would cause leakage and anterior chamber instability.

ßDuring capsulorhexis, it is recommended to stain the anterior capsule with a dye in order to

best visualize it and then minimize the tension within the capsular bag by extracting the milky cortical substance.

ßHydrodissection is an important step that should be done carefully in order to avoid

“Capsular Block syndrome.”

ßKnowledge of the fluidics of the machine and proper instrumentation is essential to perform

phacoemulsification in these cases.