15 Posterior Capsular Rupture and Intraocular Lens Implantation

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, and sudden appearance of red glow are some of the early signs 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 Before the phacoemulsification probe is withdrawn from the eye, ophthalmic viscosurgical device (OVD) is injected into the AC from the side port incision. This helps 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.

15.2 Management

The management of PCR depends on the stage at which the PCR occurred and also on the extent of posterior capsule 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 the managing the cortical matter and the vitreous prolapse ( Fig. 15.1). Often, with big posterior capsule opening, nucleus drop also may occur that involves the management from a vitreoretinal surgeon.

15.3 Vitrectomy and Its Importance

Disruption of the anterior vitreoretinal barrier can enhance the rate of postoperative complications such as endophthalmitis, retinal detachment, and cystoid macular edema.^4,5 Along with this, complete removal of the vitreous from the AC is equally essential as it can lead to traction and it can also be detrimental to the corneal endothelium along with the raise of intraocular pressure (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

Fig. 15.1 Posterior capsule rupture with residual cortical matter.

Fig. 15.2 Triamcinolone staining for detection of the vitreous strands in anterior chamber.

Fig. 15.3 Fluid infusion is introduced into the eye to perform vitrectomy.

Fig. 15.4 Vitrectomy being performed after pupil dilation with iris hooks.

Triamcinolone staining ( Fig. 15.2) 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. 15.3, Fig. 15.4) 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 because if we do not follow this rule and have suction rate more than the cutting rate, then 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.

15.4 Posterior Assisted Levitation

Packard and Kinnear described the technique of levitating the sinking nucleus with a spatula¹³ that was later named as posterior assisted levitation (PAL) by Kelman.^14,15 Chang and Packard¹⁶ described Viscoat-assisted PAL where through the pars plana site a Viscoat filled cannula is introduced and the Viscoat is injected beneath the nucleus so that it helps 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 micro-vitreoretinal 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.

Fig. 15.5 Posterior assisted levitation. (a) Nuclear fragment seen lying in the pupillary zone. (b) Standard pars plana incision made with trocar. A rod is inserted through the trocar to lift the nucleus. (c) The rod is placed beneath the nuclear fragment and the nuclear pieces are pushed forward and placed into the anterior chamber (AC). Another rod inserted from the side port incision can be used to support the nuclear pieces that are being levitated into the AC. (d) All the nuclear pieces are resting into the AC.

Fig. 15.6 An intraocular lens scaffold procedure where the nucleus is levitated into anterior chamber.

A rod is passed through the trocar and the nuclear fragments are manipulated and lifted with the rod into the AC ( Fig. 15.5a, 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. 15.5c, d). Once the fragments are in the AC, they are made to rest on the anterior surface of the iris tissue.

15.5 Intraocular Lens Scaffold

The word scaffold is derived from Medieval Latin word “scaffuldus” of Old French origin, which means “a temporary platform.” As the name suggests, an IOL is used as a scaffold to compartmentalize the eye into anterior and posterior segments with the placement of an IOL that seals the posterior capsular opening.^17,18

As soon as the PCR is recognized, the surgery is halted and OVD is injected from the side port incision to stabilize the AC. The phaco probe is then withdrawn and all the nuclear fragments are levitated into the AC ( Fig. 15.6). A trocar or an AC maintainer (ACM) is introduced into the eye and fluid is switched ON with care being taken that the flow of fluid does not push the nuclear pieces into the vitreous cavity. A limited vitrectomy is done at moderate settings and a three-piece foldable IOL is injected beneath the nuclear fragments. The haptics are made to rest either on the anterior surface of the iris tissue or in the sulcus above the margin of capsulorhexis. Phacoemulsification probe is then introduced and the remaining nuclear fragments are emulsified with phaco machine set at low parameters ( Fig. 15.7).

Once the nuclear fragments are emulsified ( Fig. 15.8), the IOL is dialed into the sulcus if placed previously on the iris tissue. With the pre-placement of an IOL, a barrier is created between the AC and the posterior chamber. The IOL also prevents the nucleus drop and also facilitates emulsification procedure by acting as a scaffold. IOL scaffold allows the management of PCR without enlargement of the corneal incision, thereby passing all the advantages of a closed chamber incision surgery.

Fig. 15.7 A three-piece foldable intraocular lens is injected beneath the nuclear fragments and is placed above the iris tissue. The nucleus is emulsified with a phaco probe.

Fig. 15.8 All the nuclear fragments are emulsified and the intraocular lens (IOL) is seen resting on the anterior surface of the iris tissue. This IOL is then dialed into the sulcus.

Fig. 15.9 A three-piece foldable intraocular lens is being placed into the sulcus.

Once the nuclear fragments are emulsified, optic capture as a procedure can be performed to stabilize the IOL placement in cases with adequate sulcus support and good continuous curvilinear capsulorhexis (CCC). The essentials for performing an optic capture are a capsulorhexis that is at least 1 to 2 mm smaller than the diameter of the IOL so that the CCC opening gets plugged by the IOL optic, thereby preventing the vitreous from bulging into the AC. Gimbel and DeBroff19 have described six different types of optic capture that can be employed by the surgeons for stable IOL placement in cases with PCR. The different variations are as follows:

1. Both haptics in the sulcus and IOL optic capture through anterior CCC ( Fig. 15.9, Fig. 15.10, Fig. 15.11).

2. Both haptics in the sulcus and IOL optic capture through an anterior capsule opening and a posterior CCC (PCCC).

Fig. 15.10 The intraocular lens is dialed into the sulcus with the optic capture into the margins of anterior capsulorhexis.

Fig. 15.11 A well-tucked intraocular lens into the sulcus with optic capture. Corneal incisions are sutured with 10–0 nylon.

Glued intrascleral haptic fixation (glued IOL) is an established technique for secondary IOL fixation.20,21,22,23 Two partial-thickness scleral flaps approximately 2 × 2 mm are made 180 degrees opposite to each other. Sclerotomy is done with a 22-gauge needle about 1 mm from the limbus beneath the scleral flaps. After the introduction of infusion in the eye, thorough vitrectomy is done to clear the vitreous in the pupillary space and the AC. An ACM or a trocar-ACM²⁴ can be employed for fluid infusion into the AC or trocar can also be placed at pars plana site depending on the surgeon’s preference. A 23-gauge vitrectomy probe is introduced and a thorough vitrectomy is done. Triamcinolone can be used to stain the vitreous for easy visualization. Corneal tunnel is fashioned with a 2.8-mm keratome and a side port incision is framed midway between the left sclerotomy site and the corneal tunnel.

A three-piece foldable IOL is loaded and is injected into the eye. While doing so, the injector is withdrawn a bit in a way that the trailing haptic lies at the corneal incision. Glued IOL forceps are introduced from the left sclerotomy incision and the tip of the haptic is grasped followed by its externalization after the entire IOL has unfolded. The trailing haptic is flexed inside the eye and the “handshake technique”^21,22 is performed till the trailing haptic is externalized. Scleral pockets are made with a 26-gauge needle and the haptics are tucked. Vitrectomy is done at the sclerotomy site to cut down all the vitreous strands. Infusion is stopped, the scleral bed is dried, and glue is applied to seal the flaps. Fibrin glue can also be used to seal all the conjunctival peritomy sites and corneal incisions.

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