24.1 Introduction

Posterior capsule rupture (PCR) is an infrequent but a known complication of cataract surgery and it can also be iatrogenically induced during a vitreoretinal surgery. ^{1 , 2 , 3} PCR can lead to significant ocular morbidity and suboptimal outcomes with permanent vision loss if not handled judiciously. Recognition of an intraoperative PCR in early stages is extremely important to limit the extent of complication and prevent it from being detrimental to a greater extent.

Loss of followability of the nuclear fragments, sudden deepening of the anterior chamber (AC) with pupil dilation, or sudden appearance of red glow is one of the early sign of a PCR. At this stage, the surgeon should lower down the machine parameters and try to assess the clinical scenario. Before the phacoemulsification probe is withdrawn from the eye, an ophthalmic viscosurgical device (OVD) is injected onto the AC from the side port incision. This helps to prevent sudden shallowing of the AC and further extension of the PCR. Subsequent to PCR, the initial objective is the safe and thorough removal of vitreous and lens fragments from the AC followed by the next prime objective of the stable placement of an intraocular lens (IOL) selected for best refractive outcomes.

Newer techniques available to anterior and posterior segment surgeons in the setting of PCR allow the surgeons to manage the nuclear fragments with the simultaneous placement of an IOL that acts as scaffold and can be used as a pupillary barrier that blocks the subsequent drop of nuclear fragment into the vitreous cavity during its removal through phacoemulsification (▶Video 24.1, ▶Video 24.2, ▶Video 24.3, ▶Video 24.4, ▶Video 24.5, ▶Video 24.6, ▶Video 24.7, ▶Video 24.8, and ▶Video 24.9).

24.2 Management

The management of PCR depends upon the stage at which the PCR occurred and also upon the extent of posterior capsule (PC) opening. PCR in the initial stages of surgery entails the management of entire nucleus/nuclear fragments along with the vitreous and PC opening management, whereas in the later stages, it involves managing the cortical matter and the vitreous prolapse (▶Fig. 24.1). Often with big PC opening, nucleus drop also may occur that involves the management from a vitreoretinal surgeon.

24.3 Vitrectomy and Its Importance

Disruption of the anterior vitreoretinal barrier can enhance the rate of postoperative complications like endophthalmitis, retinal detachment, and cystoid macular edema (CME). ^{4 , 5} Along with this, complete removal of the vitreous from the AC is equally essential as it can lead to traction and also it can be detrimental to the corneal endothelium along with the rise of IOP. Staining of the transparent vitreous can help a lot in optimizing the visual outcomes as the stained vitreous strands can be easily visualized and managed by the surgeon. ^{6 , 7 , 8}

Triamcinolone staining (▶Fig. 24.2) is the most common method employed for enhancing the visualization of the prolapsed vitreous. ^{9 , 10} Triamcinolone acetonide aids in the visualization of transparent ocular structures by attachment to the collagen matrix of vitreous. ^{11 , 12} Before starting anterior vitrectomy, triamcinolone acetonide can be instilled into the AC. This enhances the visibility of vitreous and ensures adequate vitreous cutting with the vitrector along with appropriate judgment of the endpoint of vitrectomy.

Introduction of infusion into the eye is essential (▶Fig. 24.3 and ▶Fig. 24.4) before performing vitrectomy. The basic principle of vitreous cutting should be adopted: “Cutting should be more than suction.” In other words, the vitrectomy cutter rate should be set higher, whereas the suction should be at moderate levels as if we do not follow this rule and have a suction rate more than the cutting rate, a lot of vitreous gets aspirated even before the vitreous strands have been completely cut. This can lead to vitreous traction and all its sequential complications.

24.4 Posterior Assisted Levitation

Packard and Kinnear described the technique of levitating the sinking nucleus with a spatula ¹³ that was later named as posterior assisted levitation (PAL) by Kelman. ^{14 , 15} Chang et al ¹⁶ described Viscoat-assisted PAL where a Viscoat-filled cannula is introduced through the pars plana site and the Viscoat is injected beneath the nucleus so that it helps to cushion the nuclear fragments that are then lifted with the cannula of the Viscoat-filled syringe into the AC.

Following a PCR, the corneal tunnel incision is sutured, as it is essential to secure the wound. The sclerotomy incision for PAL can be made with a microvitreoretinal (MVR) blade or with a trocar at a distance of 3 to 3.5 mm away from the limbus in the region of pars plana. Trocars have an advantage of creating a self-sealing incision without the need of conjunctival peritomy.

A rod is passed through the trocar and the nuclear fragments are manipulated and are lifted with the rod into the AC (▶Fig. 24.5a, b). While doing PAL, another rod can also be passed from the side port incision so as to support the fragments when they are present in the AC and prevent them from falling back into the vitreous cavity (▶Fig. 24.5c, d). Once the fragments are in the AC, they are made to rest on the anterior surface of the iris tissue.