What Is The Frequency Capsular Tear After Lens Repair

• Journal List
• Indian J Ophthalmol
• v.65(12); 2022 Dec
• PMC5742964

Indian J Ophthalmol. 2022 December; 65(12): 1359–1369.

Posterior capsular hire: Prevention and management

Arup Chakrabarti

Chief, Cataract and Glaucoma Services, Chakrabarti Eye Intendance Middle, Kochulloor, Trivandrum, Kerala, Republic of india

Nazneen Nazm

^oneAssistant Professor, Ophthalmology ESI-PGIMSR, ESIC Medical College and ESIC Hospital, The W Bengal Academy of Wellness Sciences, Kolkata, West Bengal, India

Received 2022 Nov 7; Accepted 2022 Nov ix.

Abstract

This review article deals with a potentially sight threatening complication – rupture of the posterior capsule – during cataract surgery. Cataract surgery is the most commonly performed surgical process in ophthalmology and despite tremendous technical and technological advancements, posterior capsular rent (PCR) nonetheless occurs. PCR occurs both in the hands of experienced senior surgeons and the neophyte surgeons, although with a higher frequency in the latter group. Additionally, sure types of cataracts are decumbent to this development. If managed properly in a timely mode the eventual outcome may be no dissimilar from that of an elementary case. All the same, improper direction may lead to serious complications with a higher incidence of permanent visual disability. The article covers the management of posterior capsular hire from two perspectives: 1. Identifying patients at higher risk and measures to manage such patients past surgical discipline, and 2. Intraoperative management of posterior capsular hire and various example scenarios to minimize long-term complications. This review is written for experienced and not-then-experienced center surgeons akin to empathise and manage PCR.

Keywords: Cataract, cataract surgery, complications, posterior capsule, posterior capsule rent

The outcome of unproblematic phacoemulsification in the present scenario is excellent. Yet, despite the advances in the field of cataract surgery, surgical complications nevertheless occur. Posterior capsular hire (PCR) is the about common potentially sight-threatening intraoperative complication during cataract surgery. PCR may call for additional surgical procedures, increased postoperative follow-up visits, and a higher incidence of postoperative complications which may impair final visual outcome. Even so, today, the command rendered through airtight chamber modern surgical techniques may let for a last visual result similar to an unproblematic case. Information technology is desirable to be better prepared for this complication to prevent it or manage it well. An improperly managed PCR, with or without a vitreous loss (VL), can adversely impact the excellent effect associated with routine cataract surgery. Although each patient with PCR is unique several basic surgical principles utilise universally, and every cataract surgeon should acquire these primal principles to avoid and manage the long-term sequelae. With this thought, this review focuses on prevention and management of PCR.

Incidence of Posterior Capsular Rent

The overall incidence of PCR reported in the literature varies from 0.2% to xiv%.[ane,2,3,4,5,6] The rate of VL is institute to be between 1% and 5%.[5,6,7,8,ix,10,11,12,thirteen,14,15,16] In the recent years, advanced techniques, instrumentation, and engineering science have reduced PCR rate to 0.45%–5.2%.[1,17] The incidence of PCR in surgeries performed by experienced surgeons is placed at 0.45%–three.six%.[ane] For surgeons converting from extra capsular cataract extraction (ECCE) to phacoemulsification, the PCR incidence is effectually four.8%–11%.[1,xv,xvi]

Mutual Predisposing Factors for Posterior Capsular Hire

Certain take a chance factors predispose to PCR.[xv,17] These hazard factors should be looked for in every patient planned for cataract surgery. Identification of loftier-risk factors tin potentially improve on the informed consent process for patients and for surgeons to institute appropriate safety measures to postpone or reduce the occurrence of this much dreaded complication.

The predisposing factors may be broadly classified as patient-related, surgeon-related, intraoperative factors, and those related to devices/machines [Table one].

Tabular array 1

Mutual predisposing factors for posterior capsular hire

Full general Factors

Information technology has been the experience of the author and others that elderly, anxious, demented, and disoriented patients are at higher risk for PCR. This could be due to inadvertent head movements during surgery or associated comorbidities. Narendran et al. confirmed a steady rise in complication rate with increasing patient age.[15] Berler noted a variation in complexity rate with historic period, with an increase in rates of PCR, VL, and retained nuclear fragments over the age of 88 years.[eighteen]

Extraocular Factors

Extraocular hazard factors are commonly associated with hard access to surgical field due to concrete limitations and/or express visibility of operative field. This includes deep set up eyes with prominent brow, exaggerated Bell'southward miracle and corneal opacities (pterygium, extensive arcus senilis, scar, and band keratopathy). Dumbo asteroid hyalosis may render the posterior capsule PC less visible during phacoemulsification. The surgeon is brash to stay away from PC during phacoemulsification in these eyes.

Reduced Work Space

Small-scale Pupil: Intraoperative miosis is an of import risk factor.[15,19,20] Attempt should exist made to amplify the student pharmacologically. A student dilating device may exist employed. Intraoperative floppy iris syndrome (IFIS) is an important crusade of small educatee and may be associated with a loftier incidence of intraoperative complications including PCR with or without VL.[21,22]

Shallow Anterior Bedchamber

In high hypermetropia, the anterior sleeping accommodation (Air conditioning) is crowded and shallow. The PC is closer to phaco needle and thus at increased hazard of PCR. Iris prolapse is likewise more common since infusion from the phaco tip may flow behind the iris root ballooning it and forcing information technology out of the incision. Hence, early use of pulsed phaco fluidics is of paramount importance. A slightly more inductive incision with careful attention to incision size and minimal use of second instrument in Air conditioning during phacoemulsification is desirable.[23]

Excessive Anterior Chamber Depth

In high myopia and previously vitrectomized eyes, AC is deeper with more trampolining of PC. Excessive AC deepening occurs due to a pressure slope resulting in reverse pupillary block (lens-iris-diaphragm retropulsion syndrome [LIDRS]). Vitreous is more likely to be liquefied and degenerated. At that place is thus an increased chance for loss of nucleus fragments into deep vitreous in example of PCR. Several strategies can help deal with LIDRS-lowering the infusion bottle and auto vacuum and menstruation settings. Some other method is to neutralize the pressure level gradient between anterior and posterior chambers by using the second instrument to manually drag iris from anterior lens surface. A unmarried iris hook also may serve the desired function.[24]

Cataract Type

Certain types of cataract are at a higher adventure for developing PCR. They are: (ane) Posterior polar cataract PPC[25,26] and cataract associated with posterior lenticonus or lentiglobus.[27,28] (2) Postvitrectomy cataract [Fig. one] (three) White cataract (4) Brunescent/black cataract,[15,29] and (5) Traumatic cataract. Preoperative counselling in such patients should include thorough discussion on potential for PCR and its sequelae.

Posterior capsular hire in a postvitrectomy silicone-oil filled eye. Note the appearance of silicone oil globule

Pseudoexfoliation

Pseudoexfoliation (PXF) syndrome is known to be associated with weak zonules, poor pupillary dilation, and hard cataract predisposing the middle to an increased incidence of PCR or zonular dehiscence. In their study, Drolsum et al. found that eyes with PXF syndrome undergoing cataract surgery had a two.half dozen-fold increase in capsular/zonular complications compared to optics without PXF.[30]

Surgeon-Related Factors

Surgeon inexperience is considered high-risk factor for PCR. PCR rate for phacoemulsification performed past experienced surgeons is 0.45%–3.6%[1] while for surgeons converting from ECCE to phacoemulsification, it is around 4.eight%–xi%.[1,15,31] The current incidence of PCR in surgeries performed by residents is effectually 0.8%–8.9%.[31,32,33,34] The incidence of PCR is lower in loftier-volume surgeons.

Intraoperative Factors

Frequent preoperative instillation of topical anesthetic agents and povidone-iodine (an important component of infection prophylaxis) on cornea may result in corneal epithelial brume. This may exist aggravated past surface exposure due to infrequent blinking. Suboptimal visibility may increment the risk of PCR. Hence, it is prudent to exist judicious in the employ of topical coldhearted agents in the preoperative period. Instructing the patient to go on the middle airtight during the immediate preoperative waiting period and frequent intraoperative lubrication may minimize this trouble.

A pocket-sized diameter continuous curvilinear capsulorhexis (CCC) may predispose the middle to develop capsulorhexis block during cortical cleaving hydrodissection. Connected hydrodissection without capsular bag decompression raises hydrostatic pressure level thus causing a blowout of PC. At that place is likewise a constant risk of trauma to the modest capsulorhexis margin with the oscillating phaco needle or chopping instrument. Enlarging the modest capsulorhexis before hydrodissection is a good strategy to prevent hydrodissection-related complications including PCR.

An incomplete or escaped CCC is another of import risk factor. In the presence of an incomplete capsulorhexis or a sharp angular notch in the capsulorhexis margin, the rapid buildup of intracapsular force per unit area or vigorous endocapsular manipulations may issue in a peripheral extension of the capsulorhexis margin leading to a capsular tear. Hence, cortical cleaving hydrodissection, if performed, should be done very gently. Furthermore, aggressive in-the-handbag nuclear maneuvers (rotation, cracking, or chopping) should exist avoided. Some surgeons adopt using a nonrotational phaco technique employing gentle chopping maneuvers in the capsular pocketbook or even in a more inductive aeroplane while protecting cornea with the dispersive ophthalmic viscosurgical device (OVD).

The most severe tears occur during attempted emulsification of nucleus. An intact capsulorrhexis and utilise of low vacuum, low aspiration phacoemulsification reduce the incidence of PCR by minimizing surge. Depression power phacoemulsification adds to the safety by reducing the take a chance of piercing through the nucleus and rupturing the PC. However, with the bachelor current new-generation phacomachines, phacoemulsification can be performed safely with high vacuum parameters. During phacoemulsification, the second instrument of an appropriate design may be placed behind the remaining nucleus to hold the PC back and physically prevent it from contacting the phaco needle. Recently, a silicone irrigation aspiration (I/A) tip has get available, which may provide superior capsular protection.

A thorough noesis of phacoemulsification motorcar parameters is mandatory to prevent the occurrence of surge, maintenance of Ac depth, also equally incidence of PCR. Sudden intraoperative equipment malfunction, suboptimal illumination or alignment of the microscope, the inadequacy of the infusion period ("bottle-over" situation!) besides equally kinked infusion or aspiration tubings may predispose to PCR. A thorough assessment before starting surgery volition prevent these mishaps.

Prevention of Posterior Capsular Rent

An ounce of prevention is better than a pound of cure. An all-out try should be made to avert PCR during phacoemulsification.

Having an intact capsulorhexis margin is of paramount importance to preclude PCR. Cortical cleaving hydrodissection should be avoided in cataracts with a compromised PC. Posterior capsular blow out and "pupillary snap" is a common sequelae when cortical cleaving hydrodissection is attempted in these circumstances. Pupillary snap may also complicate a brisk hydrodissection in small capsulorhexis situations especially in elderly females with hard cataracts.

The pupillary snap sign was first described past Ronald Yeoh who reported sudden hasty pupillary constriction during hydrodissection and backward tilting of nucleus when phacoemulsification was continued.[35] He explained the phenomenon occurring when nerveless fluid backside the nucleus burst through the PC with posterior deportation of lens-iris diaphragm.

Knowledge of the phase of phacoemulsification when PC alienation is more likely to occur is of import. PCR is virtually common toward the finish of phacoemulsification (a) at the fourth dimension of emulsification of final nuclear piece (b) during IA and (c) during PC polishing; followed by early on/mid phaco when the phaco needle may be inadvertently passed through the nucleus resulting in tear of PC or capsular equator.

Early on Recognition of Zonular Rupture or Posterior Capsular Rent

If a PCR is not recognized in fourth dimension, connected intraocular maneuvres required for phacoemulsification (viz., nuclear rotation, sculpting, nifty, and chopping) and fluctuations in Air-conditioning depth will quickly enlarge the tear. Early recognition of PCR [Fig. 2] and prompt prophylactic measures will forestall expansion of the tear size, nucleus driblet, and vitreous prolapse.

Large irregular posterior capsular rent

Signs of early on PCR or zonular dehiscence are:

• Sudden deepening of Air conditioning with momentary pupil dilation

• Sudden transitory appearance of a clear carmine reflex peripherally

• Apparent disability to rotate a previously mobile nucleus

• Reduced efficiency of nucleus sculpting and a tendency for the nucleus to brandish a vibratory/tremulous movement

• Sudden difficulty in burial the phaco needle into nucleus

• Excessive tipping of one pole of the nucleus

• The partial descent of the nucleus into anterior vitreous space.

Some of these signs are transient. However, if the surgeon is alert, an early on diagnosis of PCR may be suspected fifty-fifty though the PCR may not be visualized due to the overlying nucleus. If posterior capsule or zonular rupture is suspected the surgeon should make up one's mind whether to continue with phacoemulsification or convert to a safer nonphaco technique. This decision is based on the corporeality of nucleus remaining, the density of nucleus, other accompanying risk factors (e.yard., small pupil, loose zonules, suboptimal endothelial status, etc.) and the individual surgeon's level of conviction and experience.

Most PC tears are small-scale, to begin with. The surgeon should try to continue them from enlarging or extending peripherally preserving as much of PC as possible.

Posterior Sheathing Hire-Avoiding (or Delaying) Extension of the Hire and Vitreous Loss

Equally soon equally a problem is sensed, a knee joint-wiggle reflex to suddenly withdraw the phaco or I/A tip from the eye should exist avoided because this causes sudden AC collapse, rapid enlargement of PCR and vitreous prolapse. Rather the surgeon should stay put with irrigation running. AC should be filled with OVD through the side port incision to block vitreous prolapse and stabilize any remaining lens cloth before the removal of the phaco or I/A handpiece [Fig. 3]. The surgeon should stay in human foot pedal position 1 with the irrigation running, and as the OVD is injected, he should change to foot position 0. The handpiece tin can then be safely removed. A low viscosity, less cohesive, and highly dispersive OVD is ideal as this helps to plug the PCR and tamponade the anterior hyaloid face up better. Nevertheless, if not available at hand, any other OVD can be used. Capsular pathoanatomy should be carefully assessed based on which the subsequent surgical strategy should be planned.

Posterior capsular rent; injection of ophthalmic viscosurgical device substance into anterior chamber with Irrigation in-place

Posterior Capsular Rent and Retained Nuclear Material without Vitreous Prolapse

In such situation, the surgeon should decide whether to continue with phacoemulsification or convert to a safe nonphaco technique (manual small incision cataract surgery, i.e. M-SICS or standard ECCE). If the nucleus is soft, and particularly if just a small residual amount remains, standing with phacoemulsification may be a reasonable option. A Visco Shield strategy is employed in which the area of PCR is plugged with a generous dollop of dispersive OVD (Viscoat, Alcon). The remaining nucleus is moved away from the tear with the second musical instrument such as Sinskey hook to complete the emulsification. The nucleus should non be rotated using the phaco tip. The nuclear emulsification should be slowed downwards by reducing the aspiration flow rate, decreasing the vacuum (thereby reducing post occlusion surge) and by lowering the infusion bottle (to foreclose pressurizing the inductive segment and driving the nucleus into the vitreous cavity). Short bursts of low energy ultrasound with low aspiration, effective vacuum, and reduced irrigation will decrease the risk of nuclear loss, chamber shallowing, and vitreous prolapse.

Intraocular lens (IOL) Scaffold [Fig. 4] is some other technique which has been described wherein a multipiece hydrophobic acrylic IOL is placed at a airplane inductive to the PCR and the nucleus is emulsified in Ac in front of the IOL.

Intraocular lens scaffold technique (Movie courtesy Dr. Priya Narang). In this technique, a multi-slice hydrophobic acrylic intraocular lens is placed at a plane anterior to the posterior capsular hire and the nucleus is emulsified in inductive sleeping accommodation in front of the intraocular lens

Removal of residual cortex and epinucleus tin be safely achieved without extending PCR by following several surgical principles. The bimanual technique offers safer and amend access to the sub-incisional surface area and allows the aspirating port to be positioned peripherally aimed abroad from the rent or dehiscence. Lowering I/A flow and vacuum settings will reduce speed and postocclusion surge, respectively. The cortex remote from the tear should be removed initially and should be stripped toward the rent. Any forcefulness generated away from it volition cause its extension. Heroic efforts to remove all cortex should be avoided since such attempts might extend the tear and further compromise capsular purse integrity. An alternative method of cortical removal is manual aspiration using both a bent cannula and a J-shaped cannula under the protection of an OVD. This transmission technique of "dry" aspiration of cortex decreases the risk of tear extension and VL.

Conversion to a Safer NonPhaco Technique (Manual Pocket-size Incision Cataract Surgery/Extra Capsular Cataract Extraction)

If a PCR is suspected or discovered at an early stage and if there is a significant corporeality of residual nucleus (especially brunescent), or if other coexisting chance factors are present, it is advisable to convert to either M-SICS or ECCE. The first step is to prevent the loss of nuclear fragment(s) into vitreous. Afterwards stabilizing the nucleus past injecting a dispersive OVD underneath information technology, a Sinskey hook passed through a fresh paracentesis opposite the incision may be used to loosen and manipulate nuclear textile into the Air conditioning. It may exist necessary to employ a relaxing incision to the capsulorhexis margin for nuclear manipulation. A bimanual technique using the 2nd hook from an additional paracentesis site may help in some situations.

If a temporal clear corneal incision was constructed, it may be sutured, and a fresh superior or temporal sclerocorneal tunnel incision should exist synthetic. If a sclerocorneal incision had been utilized to start with it, information technology tin can be extended. Incision size depends on the size of the remainder nuclear fragment. Side by side, an irrigating vectis and/or secondary lens manipulator is used to excerpt nucleus nether cover of OVD. While expelling the nucleus the vectis should apply gentle pressure confronting the posterior lip of the wound. Lifting and dragging of nucleus against the cornea and bimanual pressure-counter pressure technique should not be employed. Once the lens nucleus has been removed, inductive segment surgery should continue as per the guidelines suggested in the succeeding sections. The wound is sutured with interrupted or running 10-0 nylon suture.

A canvass'due south guide-assisted nucleus fragment removal is some other option but is not used commonly nowadays.

Posterior Capsular Rent with Balance Nucleus and Vitreous Prolapse

The goal in this situation is to remove the remaining lens matter (nucleus, epinucleus, and as much cortex equally possible) without causing vitreoretinal traction and without extending the PCR while at the same fourth dimension minimizing vitreous loss (VL). The following strategies help the surgeon in arriving at this goal: (1) rescuing or managing a partially descended nucleus, (2) an advisable anterior vitrectomy technique and (3) removal of the residual lens matter.

Rescuing a Partially Descended Nucleus

Early recognition of PCR is crucial to avoid a dropped nucleus. If the surgeon fails to detect a PCR early enough, he may go on with standard phaco maneuvers and the forces will aggrandize the pocket-sized defect into a bigger hiatus thus causing nucleus drop. Sinking of the nuclear fragment into posterior segment depends on factors such as brunescence of the nucleus, the status of the vitreous, and size of the PCR. A brunescent nucleus may chop-chop sink into the posterior segment through a liquefied vitreous even without ancestor vitreous loss. However, in the presence of formed vitreous, the nucleus may descend only partially allowing for rescue maneuvers.

In the face of a descending or partially descended nucleus below PC, no endeavor should be made to chase the nucleus with the phaco tip. An ideal strategy is to lift the nucleus into a more inductive plane in the bag, pupillary plane or AC for subsequent direction either by extraction via a nonphaco technique or by careful phacoemulsification. This tin can be accomplished through pars plana or through inductive segment.

The nucleus may be successfully maneuvered past injecting dispersive OVD behind the nucleus (viscolevitation) and/or guiding information technology with a hook via limbal approach. This strategy may fail in presence of a small-scale and intact capsulorhexis, small-scale pupil, vitreous prolapse effectually the nucleus and lateral or posterior location of the descended nucleus.

Posterior-Assisted Levitation Technique

Charles Kelman described this technique in 1996 and coined the term posterior assisted levitation (PAL).[36,37] All the same, in 1991, Richard Packard described a similar technique.[38] He later modified his technique past using a dispersive viscoelastic through the pars plana to elevate nuclear pieces, which was presented at the American Lodge of Cataract and Refractive Surgeons Meeting in 1999.

In the classic PAL technique,[38,39] a pars plana sclerotomy is performed at the 11 o' clock meridian, 3.5 mm behind the limbus using a 20 G microvitreoretinal (MVR) blade. A spatula passed through the sclerotomy is placed behind the nucleus which is so elevated forwards into the Ac and afterward managed past phacoemulsification or manual removal. Residual vitreous is removed past performing bimanual anterior vitrectomy through pars plana sclerotomy and the limbal paracentesis.

The PAL technique has been discouraged by vitreoretinal surgeons as a complication-decumbent procedure with the potential of inducing unwarranted vitreous base of operations traction leading to retinal holes and subsequent retinal detachment.

Managing Residue Nucleus with Vitreous Loss

If the rescued nucleus has been levitated largely intact into the Ac, it may be desirable to convert to manual SICS or ECCE (as described previously). Smaller fragments may be removed past phacoemulsification employing "Visco Shield" strategy. "Lens Scaffold" technique may exist utilized.[40,41] Surgical removal of vitreous in AC and endothelial protection with generous amounts of a dispersive OVD are 2 prerequisites earlier attempting phacoemulsification through this strategy.

If there is minimal vitreous in AC and if it can be accomplished safely, an effort may exist made to remove cortex and epinucleus past employing bimanual I/A or "dry technique" before vitrectomy. This maneuver may decrease the hazard of lens matter loss into the vitreous, as the supporting vitreous is surgically removed. Withal, once vitreous gets ensnared in the phaco tip or aspiration port, it should be suitably addressed (described in the subsequent section).

Vitrectomy for Inductive Segment Surgeons

Every anterior segment microsurgeon should accept vitrectomy techniques and equipment at his or her fingertips and should be aware of

1. Vitrectomy instrumentation

2. Infusion options

3. Basic principles and technique of inductive vitrectomy.

Vitrectomy Instrumentation

Microsurgical advanced vitrectomy cutter with high performance proportional linear suction control is a necessity for anterior segment surgery. Although 20-estimate (20G) vitrectomy cutter tin can exist used, nowadays 23G and 25G cutters have become more than popular. Phacoemulsification handpiece should never be used to remove the vitreous as the phaco probe liquefies hyaluronic acrid lone only does non cut the collagen fibers.

Settings for Anterior Vitrectomy

Use of the maximum possible cutting rate, lowest vacuum and flow rates reduces traction on the retina. The vitrectomy cutter should exist advanced or held stationary during inductive vitrectomy and never pulled away while cutting.

Testing for Vitreous in Anterior Sleeping room

Detection of vitreous in Ac at an early stage is crucial to prevent farther vitreous disturbance and contain collateral damage.

Vitreous gel is invisible under the microscope. Hence, triamcinolone acetonide (TA) has been used by retinal surgeons to optimize visibility of vitreous body [Fig. 5] during pars plana vitrectomy.[42,43] Burk et al. and Yamakiri et al. have reported the intracameral apply of TA to enhance the visibility of vitreous in the Ac after PCR during cataract surgery.[44,45] TA particles get entrapped and impregnated in the vitreous rendering it visible nether microscope.

Triamcinolone acetate injection in anterior chamber to stain the vitreous prior to anterior vitrectomy in case of posterior capsular rent

Preservative-free triamcinolone (Aurocort, 4%, Aurolab, India) is preferred. Vitreous in AC should ideally exist confirmed past triamcinolone injection as before long as a PCR is suspected. It is as well used after IOL implantation. If vitreous strands are detected, a final vitrectomy is done.

Infusion Options

1) Coaxial Infusion Cannula for vitrectomy by slipping the infusion sleeve over the vitrectomy tip is no longer used since there are several disadvantages and dangers of using a coaxial organisation such equally: (a) Enlargement of the PCR (b) Hydration of the vitreous and (c) Flushing more vitreous into Ac.

Bimanual Technique with Dissever Infusion Line

This is the preferred technique and can be achieved through either bimanual limbal or pars plana anterior vitrectomy.

Bimanual limbal anterior vitrectomy

The infusion line is connected to an AC maintainer or the irrigation handpiece of the bimanual I/A organization. The infusion cannula should be kept parallel to the iris uttermost from the location of PCR and hence the infusion is directed toward AC and the vitrectomy cutter tin can remove the fluid earlier it escapes into the body of the vitreous [Fig. six]. The vitrector tip is passed through a paracentesis wound of matching size. A fresh paracentesis may be fashioned if not already present. This facilitates vitrectomy in a airtight chamber away from the main phaco wound. The vitrectomy tip is inserted through the opening in the PCR and placed 1–2 mm behind the posterior capsule. The aspiration port is directed up toward cornea.

Bimanual limbal anterior vitrectomy

The strategy is to pull the vitreous in AC downward to the vitrectomy tip until Air conditioning is clear of vitreous. Vitreous should exist removed to the level of and only below the PC leaving the remaining vitreous intact. Vitreous removal is facilitated by staining with triamcinolone. An effective strategy is to initiate dry vitrectomy and then gently initiate balanced saline solution infusion when the chamber tends to collapse. A closed bedroom environment with a deep AC is mandatory to optimize the outcomes.

The pars plana approach for anterior vitrectomy

Vitreoretinal traction can exist reduced significantly by performing the vitrectomy through a pars plana incision. This allows the surgeon to "pull down" or "bring home" the prolapsed vitreous from the Ac, thus markedly reducing the amount of vitreous that is removed from the eye. When working from the limbus and bringing vitreous upward, it is more difficult to detect an endpoint, hence unintentionally a considerable portion of the vitreous body is removed and the eye becomes hypotonic.[46]

Another advantage is the enhanced access to rest lens affair. The surgeon tin can remove fifty-fifty dense nuclear textile with the vitrector by gradually increasing vacuum and reducing the cutting rate. For performing an anterior vitrectomy, the recommended parameters are highest cutting charge per unit with lowest possible vacuum that volition permit vitreous aspiration.[47] In this style, a more consummate anterior vitrectomy can be accomplished thereby reducing secondary complications: increased intraocular force per unit area (IOP), inflammation, and cystoid macular edema. To assess completeness of vitrectomy and for better visualization, staining of the vitreous with preservative-free TA is advised.[48]

Infusion may be placed through a limbal paracentesis incision or a second pars plana incision. The surgeon should select the clock 60 minutes of vitrectomy incision to best access remaining lenticular material. The 3, 6, nine, and 12 o'clock scleral incisions should be avoided to avoid injury to ciliary vessels and nerves. A caliper should be used to mensurate iii.5 mm posterior to the limbus in the quadrant most convenient to the dominant hand, avoiding perforating vessels.[49]

Depending on surgeon's preference, a 23 or 25-gauge vitrectomy can be performed.[50] These let sutureless surgery. A dedicated dispensable valved trocar cannula should exist used to create an appropriately sized watertight biplanar incision. The trocar organization is a hollow tubed cannula that encases a sharp MVR bract. Once the incision is completed the bract is withdrawn leaving the tube as a conduit for the vitrectomy cutter. A trocar cannula system offers another reward: it protrudes into the vitreous cavity, and hence, the vitrectomy probe never gets close to the retinal surface, as information technology does when inserted through a bare sclerotomy. This design provides a margin of safety for entry and exit and decreases the take a chance of retinal tears.

A soft eye can develop choroidal detachment or hemorrhage due to incomplete penetration with this procedure.

It is important to preserve equally much of the capsule every bit possible, particularly the anterior capsular rim, to facilitate IOL implantation. The infusion should be minimal—just enough to maintain an acceptable IOP. Generous use of appropriate OVD will aid in maintaining volume, further decreasing the need for infusion. A dispersive OVD works best to tamponade the hyaloid face, while a more cohesive OVD maintains infinite.

Vitrectomy without Irrigation (Dry Vitrectomy)

This is a useful technique in performing a pocket-size vitrectomy. This technique has the added advantage of pushing vitreous backwards thus reducing the amount of vitrectomy required.

Intraocular Lens Direction in the Presence of a Posterior Capsular Rent

The primary requirement for a well-centered in the pocketbook IOL later on phacoemulsification surgery is a stable capsule-zonular support. In a PCR situation, the sheathing-purse complex is compromised. In this state of affairs, the surgeon is confronted with the effect of when and how to correct the aphakic condition for optimal visual rehabilitation.[51] The residual capsule-zonular support and the exact anatomy of the PCR should be clearly understood before making a decision.

Gentle retraction of the iris nether OVD protection at multiple locations may provide an idea every bit to the about desirable location and orientation of posterior sleeping room IOL (PCIOL), its design and optimal implantation technique. The various methods of IOL fixation in the absence of an adequate sheathing-zonular support are summarized in Tabular array ii.

Table 2

The various methods of fixation of an intraocular lens in the presence of an inadequate sheathing-zonular support

If PCR is pocket-size with well-divers borders and is central in the location the irregular rent tin can be converted into a posterior continuous curvilinear capsulorhexis (PCCC). This renders the tear stiff and resistant to a peripheral extension even if the capsular purse happens to be stretched during IOL implantation. The surgeon may then employ whatsoever in the bag PCIOL of his choice. IOL implantation using a dialing technique is likely to exert more force than a abaft haptic compression maneuver or a slowly unfolding IOL in the capsular bag.

However, if at that place is a meaning loss of the posterior capsule a standard endocapsular PCIOL is ruled out. A iii-piece hydrophobic acrylic PCIOL (with a minimum optic diameter of 6 mm and haptic diameter of 13 mm) placed in the ciliary sulcus is a expert selection. If the capsulorhexis is intact and smaller than the optic, the PCIOL optic should be posteriorly captured/buttonholed [Figs. ​ 7, ​ eight]. This strategy locks the IOL in identify guarding confronting future decentration. IOL power adjustment is not required since the IOL optic is located within the capsular pocketbook. If successful optic capture has non been achieved the PCIOL is fixed in the ciliary sulcus. Since the IOL position is more than anterior the power is adjusted in accordance with an online nomogram available at http://doctor-hill.com/iol-main/pocketbook-sulcus.htm.[52] This roughly corresponds to a 5% reduction from the predicted capsular bag IOL power. A single-piece hydrophobic acrylic IOL should never be implanted in the ciliary sulcus. If the overall capsular support is institute inadequate for PCIOL implantation, a power-adjusted ACIOL or iris-fixated IOL is an selection. Some surgeons prefer to leave the patient aphakic and consider a secondary IOL implantation with the hope that progressive capsular fibrosis may offering stability for a sulcus-fixated PCIOL. Scleral fixated (sutured/unsutured) IOL is another option. With recent advances in VR surgical techniques, some surgeons adopt implanting an IOL in the primary sitting with the dropped lens matter removal by pars plana vitrectomy by a VR surgeon planned as a secondary procedure.

Posterior bedroom intraocular lens posterior chamber intraocular lens implantation in case of posterior capsular rent; optic of the intraocular lens being captured through the posterior capsular hire

Round pupil and well-centered posterior bedroom intraocular lens (placed in the capsular purse with optic capture) in a example of posterior capsular rent

Postoperative Management in Posterior Capsular Rent

Endophthalmitis prophylaxis with intracameral moxifloxacin bachelor every bit Vigamox (off-label) and postoperative apply of one oral dose of moxifloxacin (400 mg P. O.) should be considered since it crosses the blood–retinal barrier to achieve an appropriate minimum inhibitory concentration (MIC) in the vitreous.[53]

Patients with a ruptured hyaloid confront need an aggressive anti-inflammatory regimen which should offset in the firsthand postoperative menses.[54]

It is necessary to warn all patients who have undergone anterior vitrectomy to expect floaters postoperatively and to report if they experience pain or decreasing vision at whatever time. Postoperative IOP spikes should be treated aggressively and followed up closely, particularly over the first 48 h. Retinal test with scleral indentation to visualize the retinal periphery is done in all patients i–two weeks after surgery. The patients should be closely monitored for cystoid macular edema CME with an Amsler grid at home looking for decreased dissimilarity and metamorphopsia. Optical coherence tomography is indicated during follow-up. A longer taper of topical steroids and continuing topical nonsteroidal anti-inflammatory drugs for a longer period than routine cases (off-label) to prevent CME is indicated. Ocular hypertension prophylaxis is wise for eyes with residual OVD or lens fragments. In case of retained lens material, a timely referral to a retinal specialist for definitive handling is needed. Information technology is critical to inform these patients of their increased risk of developing a retinal tear or detachment in futurity, in addition to the increased run a risk of glaucoma and CME.[54,55]

Complications Associated with Posterior Capsular Rent

PCR carries the risk of precipitating additional bug which may require vitrectomy, loss of lens textile into the vitreous crenel (0.05%–i.2%), a higher incidence of postoperative complications such as chronic intraocular inflammation, CME (41%), IOL dislocation, retinal disengagement (0.2%–8.3%), and endophthalmitis.[1,2,3]

Complications associated with PCR can be classified into those involving the anterior segment and posterior segment of the eye.

Anterior segment complications of PCR tin can be divided into:[4,five]

• Early postoperative inductive segment complications: Striate keratopathy, corneal edema, glaucoma, uveitis, and fibrinous reaction

• Late postoperative anterior segment complications: Pseudophakic bullous keratopathy, glaucoma, and epithelial downgrowth into AC.

Early on Postoperative Anterior Segment Complications

Striate keratopathy and corneal edema[5,6] may be caused by (a) corneal endothelial damage and inadequate endothelial pump function due to surgical trauma, (b) excessive intraocular manipulation during vitrectomy and removal of the nuclear fragments from Air-conditioning (c) increased IOP after surgery (d) uveitis due to excessive intraoperative iris damage and (e) presence of vitreous in the Air conditioning, if not cleared adequately, volition cause persistent vitreo-corneal bear on and endothelial damage in the long run.

Glaucoma: Both open up-bending and closed-angle mechanisms may contribute to elevated IOP in the early on equally well as late postoperative catamenia. Open-angle glaucoma may result from blockage of outflow channels past retained OVD, vitreous, retained nuclear/cortical fragments, inflammatory cells, paint dispersion from excessive intraocular manipulation, and exacerbation of preexisting glaucoma or steroid-induced glaucoma. Employ of TA may also cause an IOP spike in the postoperative period if a thorough inductive vitrectomy is not performed.

OVD molecules block the trabecular meshwork and cause open up-angle glaucoma within the first 4–eight h postoperatively, and resolves within 24–72 h.[6,7,viii] Close monitoring of IOP is required in the early postoperative menstruum. IOP spikes can be managed with topical and systemic anti-glaucoma drugs.

Presence of vitreous in Ac may cause aqueous outflow obstruction in the early and late postoperative period. It may or may not be associated with pregnant inflammation.

Dislocation of lens fragments into vitreous cavity is associated with elevated IOP in up to fifty% of the cases.[9] Vitrectomy within the commencement 2 weeks postoperatively is recommended to reduce the incidence of glaucoma. IOP should be medically controlled till corneal edema resolves before planning vitrectomy. Residual cortical thing in the anterior segment is common after a PC tear and may cause lens-particle glaucoma necessitating topical steroids and anti-glaucoma drugs.

Inflammatory glaucoma may be due to trabeculitis, endotheliitis or cellular debris blocking the trabecular meshwork. Topical beta-blockers, topical and systemic carbonic anhydrase inhibitors and hyperosmotic agents (mannitol xx%) are the preferred agents. Miotics and prostaglandin analogs are avoided because they may induce more inflammation.

Uveitis and fibrinous reaction:[v,10,xi] Iritis and uveitis occur postoperatively due to excessive intraoperative handling of uveal tissue, retained cortical textile or OVD, and residual vitreous in the Air conditioning. Intraoperative factors such as prolonged surgical fourth dimension and vitrectomy may contribute to increased inflammation.

Late postoperative anterior segment complications

Pseudophakic bullous keratopathy[5,10,xi] presents as long-standing corneal edema, unresponsive to medical management. It is due to corneal decompensation every bit a result of the inadequate endothelial function. In patients with an intraoperative VL the risk of corneal decompensation is increased.

Epithelial downgrowth into Air-conditioning-vitreous incarceration in surgical wound prevents proper wound closure and may allow surface epithelium to enter Ac. This may result in a canvass of epithelial downgrowth over the iris or corneal endothelium and may further contribute to bullous keratopathy and intractable glaucoma.

Posterior segment complications of posterior capsular hire

Confused lens fragment

The reported incidence of nuclear fragments in vitreous cavity following a PCR is 0.3% (ii-3operations/1000/year)[12,xiii] to ane.1%[fourteen] and is reported to be inversely proportional to the surgeons' experience and surgical volume. PCRs in phacoemulsification are more central than in ECCE and are hence more conducive to the posterior migration of the nuclear fragment.

The complications of a dropped nucleus include elevated IOP, uveitis, corneal edema, CME, and retinal detachment. Hence, proper management of VL and retained lens fragments is the most crucial factor influencing the chances of an excellent visual outcome.

Dislocated posterior sleeping accommodation intraocular lens

Early postoperative dislocation is caused by placing part or all of the IOL through the PCR into the anterior vitreous. When dislocation occurs more than a few days or weeks afterward surgery, it is attributed to spontaneous IOL haptic rotation away from the meridian of posterior capsular remnants. A dislocated IOL tin produce complications such as corneal edema, recurrent intraocular inflammation, retinal detachment, CME, and glaucoma all of which class relative indications for vitreous surgery.

Pseudophakic cystoid macular edema

The incidence of pseudophakic cystoid macular edema (PCME) in eyes with PCR and VL has been reported equally 21%–46%.[xv] Presence of PCR, iris trauma, VL, retained lens fragments, and prolonged operating time are all predispositions which result in multiple insults to the vascular permeability and retinal homeostatic mechanisms, resulting in an increased risk of developing PCME.[15] Selection of IOL as well plays a role in PCME development. Iris-fixated IOLs have the highest reported charge per unit of PCME, and AC IOLs (ACIOLs) have a college rate than PC IOLs.[15]

Retinal disengagement afterward cataract surgery with posterior capsular rent

Pseudophakic retinal disengagement (RD) constitutes forty%.[xvi,17,18] of patients referred to vitreoretinal surgeons for retinal reattachment surgery. The incidence of RD after cataract surgery ranges from 0.vi% to 1.vii% during the first postoperative year. The estimated risk for developing RD was 5.five times higher in patients who had undergone cataract surgery than in those who did not. The average i% incidence of RD later on uncomplicated cataract surgery increases to 8.6% afterward the occurrence of intraoperative PCR and VL, and 14.5% when lens fragments are retained.

Postoperative endophthalmitis

The incidence of endophthalmitis post-obit cataract surgery in estimates from 8 large studies range from 0.05% to 0.thirty%.[19,20,21,22,23,24]

Taban et al. in a meta-analysis of the literature identified 215 studies reporting rates of postoperative endophthalmitis subsequently cataract surgery, collectively amid 3,140,650 patients. The endophthalmitis charge per unit was 0.128%.[23] One of the nigh important risk factors associated with endophthalmitis following cataract surgery is the occurrence of intraoperative PCR and demand for anterior vitrectomy.

The risk of developing this complication is increased in the presence of intraoperative (such equally PCR, VL, etc.) and postoperative complications such as vitreous incarceration at the section, vitreous wick, wound dehiscence, suture abscess, or wound site infection.

Conclusion

The incidence of PCR can be decreased significantly by identifying the presence of predisposing factors and appropriate modification of the surgical plan. Early on recognition of posterior capsular tear along with prompt management of capsular tear and vitreous prolapse is primal to the expert postoperative event.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/take given his/her/their consent for his/her/their images and other clinical data to exist reported in the periodical. The patients understand that their names and initials will not be published and due efforts volition be made to conceal their identity, but anonymity cannot exist guaranteed.

Fiscal back up and sponsorship

Nada.

Conflicts of interest

There are no conflicts of interest.

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What Is The Frequency Capsular Tear After Lens Repair,

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5742964/

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