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Management of per operative capsular ruptures

dimanche 17 août 2008 par Jean Paul Amar

This complex subject is mostly interesting due to the huge difference between the obvious ease of cataract surgery and the bad prognosis of complicated cataract surgery.
If the seriousness of the cases is obviously due to the capsular rupture itself, the worsening of the initial situation can also be a consequence of the surgical management of the accident.
In any case, there is no spontaneous resolution of the crisis.
An inflammatory, painful eye with bad visual acuity is usually leading to an angry patient.

The Subject has to be studied in 2 parts

  • What does the anterior segment surgeon have to do when the accident occurs ?
    • First of all, the initial situation shouldn’t be worsened.
    • Secondly, the eye should be prepared to facilitate the repair by the Posterior Segment Surgeon.
  • What is the vitreo-retinal surgeon’s goal ?
    The only way to obtain a good visual result is to restore the hemato-ocular barrier by repairing the surgical anatomy.

ATTITUDE OF THE ANTERIOR SEGMENT SURGEON

Rupture during phako

Firstly, we are going to talk about the most frequent and most complicated case which is the capsular rupture with luxated lens in the vitreous gel, the other clinical forms will be studied later.

The traps to avoid

  • The anterior rhexis integrity should be preserved ; surely to place the lens in, but also to restore a capsular plane video3.
  • The size of the corneal incision should not be enlarged nor should be left any vitreous strands or iris in the incision ; it leads to hypotonia and therefore to choroïdal hematoma complicating ulteriorly the vitreo-retinal surgery video2.
  • One should not try to remove the luxated lens pieces behind the capsular plane. No vitreous gel or iris should be left in the surgical incision
  • Because of hemorrhages, no iridectomy should be done
  • The surgery should be ended with an isotonic and watertight globe video1.

Principles of a good anterior vitrectomy :

A good anterior vitrectomy has to follow exactly the same principles as a posterior vitrectomy

  • The infusion has to be separated from the vitrectomy probe
  • A flow rate control has to exist on the vitrectomy machine

What about the understanding of isopressure and iso flow-rate :
As soon as the accident occurs, the infusion bottle has to be lowered. In fact, a too high situated infusion bottle will induce a positive pressure in the anterior chamber which will worsen the capsular rupture and luxate the lens pieces posteriorly.
On the contrary, a too low situated infusion bottle will induce a negative pressure in the anterior chamber which will also worsen the capsular rupture and create a vitreous issue through the cornea.
The understanding of this pressure balance will define the behaviour of the vitreous gel and the iris during the closure of the ocular globe.
Therefore, when the vitrectomy is performed, the flow-rate of the infusion and the flow rate of the aspiration need to be exactly the same.

What about the lens ?

As the vitreo-retinal future is unsettled, a big size lens has to be put in the sulcus, secondarily or immediately if the situation is safe.

Rupture before phako

It can be an anterior rhexis rupture
In this case, it should be converted to a postage stamp procedure. This way, the tensions on the capsular surface can be equalized.

It can be a capsular rupture

  • during hydro dissection
  • following a rhexis rupture
    The clinical symptom will be the deepening of the anterior chamber, then, it has to be immediately converted to a manual extra capsular procedure.
Rupture after phako

It occurs after the nucleus extraction

One should not

  • Break the anterior rhexis
  • Increase the capsular rupture
  • Break the anterior hyaloide ; if it happens, the surgeon should not let any vitreous gel remain in front of the capsular plane

One has to :

  • Work in isopressure
  • Lower the infusion bottle to decrease the positive pressure in the anterior chamber
  • Remove the cortex as completely as possible
  • Perform a rhexis in the posterior capsula if it is possible to avoid the enlargement of the capsular rupture
  • Think about where to place the IOL with no insistence on the capsular bag.
  • It is mandatory to put an IOL with haptics

Nowadays, the achievement of good results and the bad prognosis for complicated cataract surgery help us understand that it is much more convenient to follow up a quiet eye with good visual acuity after two planned surgeries rather than a painful and inflammatory eye with bad vision after only one surgery.
For all these reasons, when the surgery is ended and the situation uncertain, the patient has to be sent to a vitro-retinal surgeon.

ROLE OF THE VITREO-RETINAL SURGEON

  • He has to repair the surgical anatomy to cure the hemato ocular barrier leading to a good visual acuity.
  • The surgical strategy and the immediate and long term complications will be defined by the analysing of the prognosis factors.
The prognosis factors

The cornea

  • The corneal opening needs to be free of vitreous gel and iris, well sutured and watertight.
  • The transparency will be lowered by :
    • an excess of manipulation :
    • the immediate inflammation
    • hypertonia

The luxated lens

Is the lens soft or hard, small or big ? In fact, the inflammation will be more important with soft cortex or intumescent lens pieces. The hardness and the size of the lens will define the surgical technique :

  • either a phako fragmentation by pars-plana
  • or a mechanical fragmentation with the vitrectomy probe and a 28-Gauge needle introduced by pars-plana

The vitreous gel

It is the most important prognosis factor
When present in the anterior chamber, the mechanical irritation of the iris and the adherences occur immediately.
It is obvious to understand, that there immediately is a vicious circle where all the experimental conditions of an uveitis are assembled with :

  • immediate complications :
    • inflammation
    • hypertonia
    • loss of the corneal transparency and the mydriasis
  • long term complications :
    • The Retinal Detachment :
      Statistical studies on retinal detachment show the peculiar seriousness of retinal detachments occurring after a complicated cataract surgery.
    • The Cystoid Macular Edema
      This peculiar edema following complicated cataract surgery is generally resistant to medical therapy, and recurrent. In fact, the permanent hemato-ocular barrier rupture following the capsular rupture is related to the surgical anatomy modifications such as vitreo-capsular adherences, irido-capsular adherences and irido-vitreous adherences. This hemato-ocular barrier rupture explains the inflammatory and painful ciliary syndrome and the lowering of the visual acuity that go with the CME.
Posterior vitrectomy :

Technique :

I regularly use a 2 open-doors vitrectomy helped by the slit lamp and the Kilp lens. The second hand of the surgeon is free, helping him for several manoeuvres during surgery

Goals :

  • One has to clean the anterior chamber from the vitreous gel and to free the strands and adherences
  • One has to clean the cortex and the capsular residues while preserving the anterior rhexis video5.
  • While a complete vitrectomy is being performed, the lens pieces will fall on the posterior fundus as soon as they are free from the vitreous gel video6.
  • Now, they can be picked up with the vitrectomy probe and be brought in the pupilary area.
    Then, phakofagia can be performed helped by a 28 Gauge needle by pars plana. This needle will hold the lens pieces and crash them in the mouth of the vitrectomy probe video8.
  • Occasionally, if the pieces are too hard, the work can be done by phako fragmentation video7.
  • At the end of the surgery, the vitreous cavity needs to be checked carefully.
PFCL

In most cases, there is no posterior vitreous detachment.
Therefore, when PFCL is injected, it will be impossible to take it out completely because of its micro emulsification in the vitreous gel.
Moreover, the corneal transparency and the dilatation of the iris are uncertain. For all of these reasons, I personally do not recommend the use of PFCL during those surgeries.
On the other hand, the interesting thing about this subject is that different surgeons will have different experience and techniques, but at the end, most of them will cure the patients.

CONCLUSION

When the accident occurs, a surgical break needs to be done allowing a check-up to evaluate the situation and define the surgical strategy in order not to worsen the initial situation video4.
The achievement of good results persuades us to prefer two planned surgeries rather than only one with an uncertain result.

  • When this accident occurs, a vitreo-retinal surgery must always be done.
  • When ?
    As soon as possible, because of the inflammatory process.
  • Why ?
    The long term complications belong to the hemato ocular barrier rupture and it never gets better by itself.

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