Posterior Capsular Rupture

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Posterior Capsular Rupture Vitrectomy
Farid Karimian M.D 2002
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Capsular Anatomy

• Elastic basement membrane, type IV collagen
• Thickness 2-4 ? at the posterior pole
• Thickest 17-23 ? near the ant. post equator
  
• Ant. Capsule ? 14 ? thickness increases with
  age
• Fragile posterior capsule
• - Congenital post lenticonus, posterior
  polar
• cataract
• - Posterior subcapsular ( PSC) age-
  related,
• steroid

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Signs of Capsule Rupture

• Sudden, abrupt and dramatic posterior
• displacement of iris
• Momentary pupillary dilatation
• Nucleus fall away from the phaco tip
• Nucleus dose not follow toward the phaco tip
• NOTE Any time suspected of ruptured posterior
  capsule modify surgical plan on that
  suspicion

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Predisposing Factors for Capsular Rupture

• 1- Position of surgeons hand obscuring
• 
  visibility
• 2- Irrigation fluid pooling
• 3- Torsion of the globe
• 4- Poor microscope illumination or alignment
• 5- Poor visibility secondary to pathology dense
  arcus, ptryguim, band keratopathy, corneal scars,
  interstitial keratitis

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Predisposing Factorscont.(1)

• Long and short axial length eyes deep or
  shallow AC
• Pseudoexfoliation, weak zonules, poor dilation
• Brunescent or black cataract
• Dense asteroid hyalosis

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Predisposing Factors cont.(2)

• Posterior polar cataracts (esp. calcified)
• - cataract to post capsule adhesion,
• - posterior capsule thining
• Inexperienced surgeons
• Poor visualization (eg. Microscope problems)

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Predisposing Factors cont.(3)

• Demented, disoriented, anxious, and addict
  patients inadvertant movement
• Equipment malfunction
• Pre-existing trauma unseen capsular or
  zonular damage
• Small pupils

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When the Posterior Capsule is Torn?

• Terminal stages of phaco for emulsification of
  last pieces of endonucleus
• During posterior capsule polishing
• During I/A
• Hydrodissection, IOL insertion less common

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Developing a Surgical Plan

• Posterior capsule tear suspicion ? Alternate
  surgical plan
• ?
• Goal to minimize prolonged or damaging
• Procedures damaging retina and/or cornea
• Planning ?
• ? Timing (when in the procedure)
• ? Location (where in posterior capsule)
• ? Size (small, medium, large, or extra
  large)

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Posterior Capsular Rupture During Nucleus
Emulsification

• Two main questions
• 1. Is vitreous present in A/C?
• 2. Is Conversion to ECCE indicated?
• Conversion decision
• 1. Hardness and size of nucleus
• 2. Size of pupil
• 3. Maintain adequate deep A/C
• 4. Ease of access to anterior segment
• 5. Level of surgical experience

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Conversion to ECCE

• Support the lens nucleus with a dispersive
  viscoelastic (injection underneath)
• Extend peritomy and corneoscleral incision
• Open the wound larger than expected
• Use lens loop or manipulator
• No limbal pressure ? vitreous will be
• 
  expelled

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Continued Phacoemulsification

• Inject viscoelastic below fragment
• Protect the endothelium
• Lower bottle height, vacuum and flow
• Emulsify the nucleus in A/C in one piece
• Use second instrument to feed phaco tip
• Do not create multiple fragments

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The Pseudo-posterior Capsule Sheets glide after
viscoelastic injection under nucleus

• Support nucleus fragments
• Prevent excess loss of vitreous
• Both ECCE and phaco can be done
• over Sheets glide
• Finally I/A and vitrectomy over glide

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Principles of managing an open posterior capsule

• 1- Do not mix cataract with vitreous
• - Mixture of lens material will cause
  inflammation
• - Isolated cortex in the eye is absorbed
  with low
• reaction
• - Cortex- vitreous mixture ? variable course
  ?
• from tolerance to severe inflammation

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Principles of managing an open posterior
capsule(cont)

• - Nucleus left in the eye ? variable clinical
• 
  outcome
• - Small nucleus fragment in A/C ? inferior angle
• ? endothelium rubbing ? cell loss
• ?
• Should be removed

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1- Do not mix cont.

• Nucleus fragments behind iris and above anterior
  capsule ? fairly harmless
• Nucleus fragments in vitreous ? significant
  inflammation
• Increased inflammation
• - personal Physiology and response,
• - Central nucleus gt peripheral chips
• About 1/3 of cases with dropped nucleus chips
  develop uveitis and glaucoma

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2- Do not stretch the slinky

• Vitreous has natural elasticity ? extending down
  to
• macula (not necessarily)
• -Tensions on anterior vitreous ? exertion through
  
• entire vitreous body ? pulling on the macula and
• vitreous base
• During phacoemulsification ? small incisions
  plugged
• by instruments ?
• If pressure A/C is kept sufficient ?Prevent
  vitreous prolapse
• ?
• Forces remained in anterior vitreous
• ?
• No transmission to macula or vitreous base

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Posterior Assisted Levitation

• When stabilization of nucleus is impossible
• Distal zonular dehiscence ? Distal pole of
  nucleus falling into the vitreous
• Pars plana stab incision 3.5mm posterior to
  limbus
• Site of incision ? wherever zonular hinge occurs
• Cyclodialysis spatula ? lever the nucleus into
  the A/C
• Removal by phaco or extracapsular approach
  (preferred)

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Specific Clinical Situations

• Posterior capsule rupture and vitreous loss
  situations
• 1- During Capsulotomy and Hydrodissection
• -poorly directed anterior capsule ? peripheral
  extension
• ?
• Tear usually stops by zonule network
• High volume with rapid injection ? extends radial
  tear into equator and back to posterior capsule

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Specific Clinical Situations cont

• Small capsulorrhexis ? phaco needle
• 
  trauma
• Sharp hydrodissection needle ? radial tear
  formation
• Presence of posterior polar cataract or post
  capsule defect
• High MW viscoelastic injection under capsular
• ? wound extension ? nucleus delivery

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2- During Sculpting

• Hard nucleus ? insufficient power-
• - blunt needle tip
• - low machine power settings
• - low power generation
• Nudging nucleus toward 6 oclock ? pushing
• inferior capsule
• ?Pulling on superior zonules
• Superior zonular dehiscence ? whole
• nucleus moved down
• ?Failure of nucleus to return
• Conversion into ECCE after anterior capsule
  relaxing
• incisions

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2- During Sculptingcont.

• Peripheral sculpting ? capsular trauma
• High vacuum sculpting ? sudden
• emulsification of posterior nuclear
• plate and cortex ? capsular rupture
• Inferior capsulorrhexis rim trauma ?
• posterior extension
• Improper focusing on sculpting depth

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3- During Rotation of the Nucleus

• Causes - inadequate hydrodissection (nucleus
  adhered to capsule) ? shearing off zonules
• - Second instrument- capsule
  trauma
• - Unstable zonules e.g.
  pseudexfoliation
• ? bimanual
  rotation
• If shearing of zonules is complete ? ICCE
• 
  removal must be done
• Zonular dehiscence
• - lt90 ? complete hydrodissection ? PE
• - 90- 270 ? capsular tension ring ? PE
• - gt270 ? ECCE with radial tears in
  anterior
• capsule or ICCE

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4- During Emulsification

• Causes
• - Small capsulorrhexis and during
  division
• - Sudden flattened A/C and capsular
  bag
• - Uncontrolled surge during
  emulsification
• nucleus particle
• - Sharp ends of nuclear fragments
• Management
• - Protection of remaining PC with
  viscoelastic
• - Sheets glide support of nucleus
  fragment-
• pushing back PC and vitreous
• - Emulsification of nucleus fragments
  over glide
• in A/C

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5- During Cortical Aspiration

• Causes
• Post capsule trauma by IA tip
  Flat AC, excess
• 
  aspiration
• Anterior capsule entrapment in
  aspiration port ?
• 
  traction
• Inadequate hydrodissection
• Management
• - Place dispersive viscoelastic over the
  vent
• - Embed IA tip into the cortex ? apply
  vacuum
• (not
  aspirating vitreous)
• - Stripping toward capsule tear
• - Lower infusion bottle ?? inflow, ?
  turbulence
• - Vitrectomy tip can be used for
  cortical removal
• - Leave cortical material if not too
  much!

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6- During or After IOL Implantation
? More complicated than earlier phases ? First
secure IOL to prevent sinking ? Use viscoelastic
to hold vitreous back ? By clockwise rotation
bring IOL into sulcus or
AC ? If capsulorrhexis is intact ? sulcus
fixation
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During or After IOL Implantation cont.(1)

• Close the wound ? to prevent flat AC, further
  endothelial damage
• Bimanual vitrectomy over and under the IOL
• Constrict pupil by intraocular miotic injection
  over IOL ? check vitreous clearance
• If no sufficient capsular support ? transscleral
  fixation, or ACIOL

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Vitrectomy Following Vitreous Loss Principles

• Keep AC as closed as possible instruments,
  suture
• Maintain IOP stable keep foot pedal at stage I,
  use viscoelastics
• Loss of anterior segment ? forward displacement
  of vitreous
• Vitrectomy setting suction 60mmHg, cut 360-400
  cpm
• Do vitrectomy adequately
• Keep capsule rent as small as possible

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Vitrectomy with Coaxial Infusion

• - Special tip to-reduce no. of entrances
• - Easily placed through phaco incision
• - It fails, because stretches the slinky
• 1. The coaxial infusion strikes posterior capsule
  ?
• ? rupture size
• ?
• More vitreous comes forward
• 2. Coaxial cannula reaching the body of vitreous
  ? hydration of vitreous
• ?
• Increase vitreous volume
• ?
• ? Forward movement
• 3. Flow moves the vitreous around ? wiggling and
  shaking vitreous ? flush it forward
• Recommendation Dont use coaxial infusion
  cannula

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Two-handed (port) Vitrectomy

• Close the entrance wounds for vitrectomy tip ?
  i.e. make a closed system
• Procedure will be performed rapidly and
  conveniently
• Perform small vitrectomy without irrigation
• Prevent eye softening by repeated injection of
  viscoelastic ? push vitreous back
• Chamber-maintainer through side-port forms AC
• Remove the vitreous to below the level of
  posterior capsule

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Postoperative Care

• At conclusion of surgery
• - Betamethasone 4mg (short-acting)
• - Antibiotic e.g. Gentamicin 20mg
• - Trimcinolone (kenalog) 20mg or Methyl-
• prednisolone 40mg (longer anti-inflammatory
• action)
• - Take care of IOP rise, endophthalmitis, and
• other complications of vitreous loss
• - Systemic steroid, prednisolone 1-1.5 mg/kg
• PO for 7-14 days