Unplanned Vitrectomy Expecting, Recognizing and Strategizing for Surprises.

1
Unplanned VitrectomyExpecting, Recognizing and
Strategizing for Surprises.

• Aron D. Rose, MD
• Associate Clinical Professor
• Yale University School of Medicine
• Yale University School of Nursing

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Note danger signs

• Change in pupil size or bounce
• Change in AC depth
• New peripheral red reflex
• Loss of followability
• Tilt or peripheral movement of nucleus
• Presence of vitreous

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PC tear does not ant. hyaloid face rupture.
Reflexively withdrawing phaco instrument will
rupture ant. hyaloid face.
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When a problem is noted

• Go to foot position 1
• Create () AC pressure with viscoelastic
• Go to foot position 0
• Gently withdraw phaco handpiece

5
When things typically go wrong

• The drape
• The incision(s)
• The capsulotomy
• Hydrodissection
• Introducing the phaco tip
• Phacoemulsification
• I/A
• IOL insertion

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Complications Associated With Construction of the
Capsulotomy

• Generally arise from
• Poor visibility
• Size of rhexis

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Poor Visibility

• Poor corneal transparency
• Thin capsule
• Too anterior an AC entry
• Lack of red reflex

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Capsulorhexis Size

• Too small beware nicking
• Too wide beware lens prolapse

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Incomplete Capsulorhexis

• Can complete by reversing direction from the
  origin and re-connecting, or (not preferred) with
  a can-opener technique.
• Consider non-endocapsular technique!

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Escape of the capsulorhexis

• Injecting more (high MW) viscoelastic will reduce
  the forces which induce centrifugal tearing.
• Increase magnification and try re-grasping.
• Start the tear in the opposite direction.

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Complications of Hydrodissection

• Be careful not to extend a non-intact rhexis when
  hydrodissecting.
• Decompress the capsular bag after each 1 ml
  injected.

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Hydrodissection, cont.

• Insufficient hydrodissection doesnt allow
  nuclear rotation and stresses zonules.
• Overly aggressive hydrodissection can blow out
  the posterior capsule.
• Beware posterior polar cataracts.

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Complications During Endocapsular Phaco

• Tear and extension of the capsulorhexis
• Perforation of the posterior capsule
• Zonular disinsertion during nucleus rotation

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Tearing of the Rhexis During Phaco

• Avoid foot position O as repeated reinflation
  of the bag can lead to equatorial tears.
• Consider a supracapsular approach.

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Tearing of the Rhexis During I/A

• Usually originally torn prior to I/A.
• Avoid torn area.
• Use dispersive viscoelastic and do not come on
  and off irrigating pedal.
• Consider side port I/A, or dry I/A.

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Zonular Rupture

• Management dependent upon loss is noted
• Capsular hooks can be used to stabilize.
• If tension ring.
• If 3-4 clock hours and nucleus removed,
  consider modified CTR and suture.

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Rupture of the Posterior Capsule

• If anterior hyaloid face is intact
• Dispersive viscoelastic tamponade (/- use of
  Sheets glide).
• Convert rent to CCC (/- paint post. capsule with
  dye to highlight)
• Convert to ECCE.

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Rupture of the Posterior Capsule

• If theres vitreous present
• Consider conversion to ECCE if nuclear remnant is
  large.
• Sheets glide / visco-tamponade.
• Separate remnant and remove manually if the
  fragment is small.

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Luxation of the Nucleus

• May occur at any point in the procedure, and the
  management is different at different points!
• If there is partial luxation, time is of the
  essence. Save the nucleus by use of spatula,
  cystotome, or viscoelastic support.

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If nucleus begins to descend

• Remember that formed vitreous is keeping the lens
  in place!
• Avoid expanding defect and pushing nucleus
  posteriorly
• Consider Sheets glide
• NEVER chase and attempt to phaco

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Advantages to a bimanual approach

• Separation of aspirating and irrigating ports
  advantageous for vitrectomy
• Bimanual anterior vitrectomy far more efficacious
  than the coaxial approach
• Watertight incisions stabilize chamber
• Use low flow/vacuum and high cutting speeds
• Separation of aspirating and irrigating ports
  best for I/A too!

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Do not exceed your surgical comfort level

• Ant. segment surgeons role is to
• Remove lens safely
• Remove prolapsing vitreous
• Place secure IOL
• Close incisions
• Refer to vitreoretinal specialist if necessary