Mgmtpcr

1. DR.POONAM SHRESTHA

2. INTRODUCTION
 Any breach in the continuity of posterior capsule
 Posterior capsule tears (PCT) can be preexisting (congenital or
traumatic), spontaneous, or intrasurgical
 Incidence of intrasurgical PCT : 1- 4%
 Depends upon equipment, setup, and surgeon’s experience and
skill

3. PREDISPOSING FACTORS
1. Equipment related
(a) Operating microscope
(b) Phacomachine
2. Extraocular – Ergonomics
(a) Prominent eyebrows
(b) Deep set eyes
(c) Narrow palpebral fissure
(d) Disorders of spine
3. Ocular
(a) Corneal causes
(b) Anterior chamber depth
(c) Iris and pupillary factors
(d) Capsule, lens and zonules
4. Surgeon’s factor

4. PCR with / without vitreous
disturbances ??
 PCR without accompanying vitreous disturbance increases
risk of CME,vitreous prolapse into the anterior chamber and
pseudophakic retinal detachment
 Once vitreous is lost, the postoperative course is
complicated in 30% of patients with an increased incidence
of hyphaema, retained cortex, corneal edema, blurred vision
and long term retinal problems including chronic CME,
macular holes ,retinal detachment and choroidal
detachment.

5. MECHANISM OF PCR
1. Wound construction: leaky wounds are the most
important factor for unstable AC
2. Anterior continuous curvilinear capsulorhexis (CCC):
 It can withstand turbulence, pressure and mechanical
stress created by the fluid, nucleus, chopper, IOL, etc.,
during phacoemulsification
 Rhexis margin tear (RMT) can extend posterioly to cause
posterior capsular tear.

6. Mechanism of PCR contd…
4. During Hydrodissection:
 Block to outflow: The outflow may be blocked due to
increased resistance offered by viscoelastic in the chamber or a
small CCC/small pupil
 Injection of too much fluid
 Inherent weakness

7. Mechanism of PCR contd…
5.During Nuclear management
• posterior extension of the anterior capsular opening
• direct damage to the edge of the rhexis by ultrasound
tip
• zonular disinsertion through traction linked to the
manipulations performed on the nucleus
• insufficient phaco power used to emulsify a very hard
cataract
• mechanical trauma to the capsule during various
nuclear maneuvers

8. 6. During irrigation-aspiration
• especially in the sub-incisional area due to poor
access and decreased visibility
• use of excessive vacuum
• Aspiration done with port close to the posterior
capsule
• Aspiration done in the presence of a shallow chamber

9. Mechanism of PCR contd…
7.During capsular polishing: During
polishing, a well-focused PC in
retro-illumination view under high
magnification and a bag filled with
visco-elastic substances is a must
to prevent posterior capsular tear.
8.During IOL implantation: IOL
implantation should be done under
a well pressurized globe.

10. When does posterior capsule tear ?
 The highest incidence of posterior capsular tear
during phacoemulsification occurs
1) toward the end of emulsification when the last
pieces of nucleus are to be emulsified
2) during polishing of the posterior capsule
3) during I/A

11. Early recognition of posterior capsular rupture
 Sudden deepening of the anterior chamber with
momentary dilatation of the pupil
 Sudden transitory appearance of a clear red reflex
peripherally
 Inability to rotate a previously mobile nucleus
 Excessive lateral mobility or displacement of the
nucleus and loss of nucleus followability
 Excessive tipping of one pole of the nucleus
 Partial descent of the nucleus into the anterior
vitreous space

12. CONFIRMATION OF HYALOID FACE RUPTURE
Signs of HFR
• Torn edge
– Shiny/golden
– Rolled up
• Anterior chamber
– Irregular depth
• Nucleus: Restricted
movements of the
fragments
• Irregular pupil
TESTS:
• Sponge test
• Stain test
• Endoillumination
cannula

13. GOALS OF MANAGEMENT OF PCR
 To avoid posterior dislocation of nucleus, nuclear fragments,
epinucleus or cortical matter into the vitreous cavity.
 Prevent any damage to the corneal endothelial surface.
 Prevent enlargement of tear
 Prevent damage to capsulorhexis
 Minimize size of vitrectomy, avoiding traction
 Removal of left over cortex
 Maintain the wound size
 Proper positioning of the IOL

14. MANAGEMENT STRATEGIES
 Extent of PCT
 Intactness of hyaloid face
 Location of the nucleus – whether dislodged into the
vitreous cavity
 Availability of equipment – vitreous cutter, vitrectomy
machine
 Availability of alternative IOLs
 Knowledge about anterior vitrectomy
 Availability of VR surgeon

15. Early response to PCR
 Sudden unplugging of the incision will result in
emptying and collapse of the anterior chamber.
 Instead, the anterior chamber should be filled with
viscoelastic through the side port incision to block
vitreous prolapse and stabilize any remaining lens
material prior to removal of the phaco or I/A hand
piece.
 The surgeon should stay in foot pedal position 1, and
as the viscoelastic is injected he should change to foot
position (0) and the handpiece can then be safely
removed after the anterior chamber is filled.

16. To Phaco or convert to ECCE?
 Situation with posterior capsular defect and retained
nuclear material without vitreous prolapse
 Depends on the bulk of the residual nucleus material,
the degree of nuclear sclerosis, the size of the rent,size
of pupil and surgeons experience
 If the nucleus is soft, and if only a small residual
amount remains, continuing with phacoemulsification
may be a reasonable option

17.  Surgeon should use the second instrument to move
the remaining nucleus away from the tear to complete
the emulsification
 Procedure should be slowed down by reducing the
aspiration flow rate, decreasing the vacuum and by
lowering the infusion bottle
 Sheets glide can be introduced between the nucleus
and the capsular tear by enlarging the phaco incision
by 0.5 mm

18.  Once the nucleus has been emulsified, the phaco
handpiece should be removed only after the anterior
chamber has been stabilized
 Residual cortex and epinucleus can be removed safely
by employing low vacuum, low flow, bimanual I/A
through clear corneal incisions

19. Conversion to ECCE
 PCR is suspected during hydrodissection or early
phacoemulsification and if there is a significant
amount of residual nucleus
 Sclerocorneal tunnel incision is constructed
temporally or superiorly
 While expelling the nucleus the vectis should
apply pressure against the posterior lip of the
wound, rather than lifting and dragging the
nucleus against the cornea.

20. Posterior Capsule Tear with Hyaloid Face
Intact and Nuclear Material Present
 Dispersive viscoelastic agent should be injected to plug
the posterior capsule tear
 Nuclear material is moved into the anterior chamber with a
spatula and emulsified with short bursts
 Low bottle height (20–40 cm above the patient’s head),
low flow rate (10–15 cc/min), high vacuum (120–200 mm
Hg) and low ultrasound (20–40%)

21. PCT with hyaloid face ruptured without
luxation of nuclear matter into vitreous
 If the residual nuclear material is small in volume, dry
anterior vitrectomy is performed and the residual
nucleus is emulsified after it has been cleaned of the
vitreous
 Phacoemulsification is performed using high vacuum
(150–200 mm Hg), low flow (10–15 cc/min) and low
ultrasound (30–50%)

22. PCT WITH PARTIALLY DESCENDED NUCLEUS
Posterior assisted leviation (PAL):
Viscoat cannula inserted through a parsplana stab
incision located 3.5 mm behind the limbus
Injecting Viscoat and maneuvering the cannula tip
itself, the nucleus can be elevated through the
capsulorhexis and pupil and into the anterior
chamber.

23. PCT with hyaloid face ruptured &luxation of
nuclear matter into vitreous
 Attempts at retrieval of dislocated nucleus carry high
risk of creating peripheral tears
 Removal of the remaining cortical material should be
attempted with preservation of the anterior and
posterior capsule
 Anterior vitrectomy should be performed so as to
allow closure of the wound without vitreous
incarceration
 Secondary removal of dislocated nucleus through
three port pars plana vitrectomy

24. VITRECTOMY
• Microsurgical (20G) advanced vitrectomy cutter
with high performance proportional linear suction
control is a necessity for anterior vitrectomy
• Use of the maximum possible cutting rate, lowest
vacuum and flow rates reduces traction on the
retina
• The vitrectomy cutter should be advanced or held
stationary during anterior vitrectomy and never
pulled away while cutting

25. Bimanual technique with separate infusion line
 The coaxial sleeve around the vitrector is removed
and replaced by a separate infusion line so the
vitrector tip becomes less bulky
 The vitrectomy tip is inserted through the opening
in the posterior capsule and placed a mm or two
behind the posterior capsule
 The aspiration port is directed upwards towards
the cornea

26. TECHNIQUE OF PERFORMING ANTERIOR VITRECTOMY.
Place the cutter through the PC Rent with the cutting port facing upwards. The
strategy is to pull the vitreous from the anterior chamber down to the cutter

27.  It is advisable to begin the vitrectomy dry and
then infuse BSS gently, if the chamber tends to
collapse, through the side port.
 More vitreous will prolapse if the pressure in the
anterior chamber is low when the aspiration
continues.
 The vitrectomy tip should not be placed through
the primary phaco incision because the incision is
the wrong size for it.

28. DRY VITRECTOMY
 Useful technique in performing a small vitrectomy
 If the eye softens the pressure in the eye can be
equalized by putting more viscoelastic in to the
anterior chamber
 Advantage of pushing vitreous towards the back of
the eye and reducing the amount of vitrectomy
that has to be performed.

29. The best strategy when performing a vitrectomy is to
avoid violating more vitreous than is actually needed,
without disturbing the rest of the vitreous especially
that which overlies the vitreous base.

30. IOL Placement
 Be sure pupil is round
 Be certain incisions are sealable
 Evaluate the intactness of CCC
 Evaluate the extent of posterior capsular
tear and residual sulcus support

31. IOL placement contd…
 When the posterior capsular rent is small (<6mm)
with well defined borders the tear can be converted
into a posterior continuous curvilinear
capsulorhexis and IOL placed in the bag
 If the tear is large (>6mm) with peripheral
extensions and poorly defined borders posterior
capsulorhexis is not possible and the IOL should be
implanted in the ciliary sulcus
 IOL should be positioned 90° away from the axis of
the tear

32. IOL placement contd…
 If the IOL shows signs of poor fixation it can be
repositioned from the capsular bag into the
ciliary sulcus, sutured into the ciliary sulcus or
exchanged for an anterior chamber IOL

33. Placement of ACIOL
1. Choose the correct powered ACIOL
2. Anterior vitrectomy is performed to take care of any
remaining vitreous
3. Constrict pupil and perform iridectomy
4. Enlarging the incision
5. Inserting the IOL: While advancing the leading loop of
the ACIOL towards the opposite angle so that it does
not touch the iris

34. Wrong placement of an ACIOL : If
an ACIOL is inserted with a
downward direction, its haptic will
get stuck in the iris which can lead
to an irregular pupil.
Correct placement of an ACIOL: An
ACIOL should be inserted with an
upward direction, so that the haptic
does not interfere with the iris,and on
reaching just before the angle the
direction of the IOL is changed.
6. Wound closure: Suturing of the wound is essential, as a shallow AC
in presence of an ACIOL can lead to damage to the cornea.

35. CONCLUSION
 Identify the presence of predisposing factors
and appropriate modification of the surgical
plan
 Early recognition and treatment of capsular
tear and vitreous loss prevents serious
complications and improves postoperative
outcomes

36. REFERENCES
1. Robert H Osher, Robert J Cionni. Intra Operative Complications of
PhacoemulsificatioNSurgery: Chapter 39; Part Seven Roger Steinert, et
al..editor, in CATARACT SURGERY : Techniques, Complications and
Management, Second Edition; Elseiver Science; (USA); 2004: Page 469-486.
2. Marc A. Michelson.Torn Posterior Capsule : Chapter 18 William J Fishkind.
Editor; In Complications in Phacoemulsification: Avoidance, Recognition and
Management; Thieme Medical publishers (New York); 2002; Page 123-132.
3. Lucio Buratto, Richard Packard.Complications : Chapter 22 Lucio Buratto,
Robert H Osher, Samuel Masket. Editors In Cataract Surgery in Complicated
Cases; Slack Incorporated (USA) 2000; page 291-350
4. William J Fishkind. Posterior Capsular Tear: Avoidance, Recognition and
Management; Chapter 31 Rasik B Vajpayee, editors;in 1Phacoemulsification
Surgery;Jaypee Brothers Medical Publishers (India) 2005; Page 237-249
5. Louis D Nichamin. Management of a Broken Posterior Capsule and Advanced
Vitrectomy Technique. In Ophthalmic Hyperguide.
6. David F Chang. Recognizing and Managing Posterior Capsule Rupture. In
Ophthalmic Hyperguide.