Management of a posterior capsule rupture in planned extracapsular cataract extraction and posterior chamber lens implantation

Management of zonular dialysis and posterior capsule rupture during extracapsular cataract extraction is described. The Heslin gravity cannula is advocated to maintain the normal structure of the anterior segment in a closed chamber technique. Lens cortical material is stripped away using the manual technique described by Gills and McIntyre to avoid vitreous loss. It is then possible to proceed with posterior chamber lens implantation. If vitreous loss occurs, an adequate anterior vitrectomy with an automated vitreous cutter is recommended. A posterior chamber lens implant is preferred if there is adequate capsule to support the lens.     

Management of posterior capsule rupture during phacoemulsification using the dry technique

To manage posterior capsule rupture during phacoemulsification, we use a dry technique in which all procedures are performed without an irrigation/aspiration system. The dry technique is characterized by (1) continuous viscoelastic injection instead of fluid irrigation to maintain anterior chamber depth with the posterior capsule and vitreous located posteriorly and (2) static removal of most residual lens material by viscoexpression and/or manual small incision extracapsular cataract extraction without aspiration and dynamic water flow. In 16 cases of posterior capsule rupture managed using the dry technique, the residual nucleus and cortex were readily removed with minimum extension of the ruptured area and new vitreous loss. Although large amounts of viscoelastic material (mean 5.8 mL) were required, rapid and stable visual recovery was comparable to that in patients having uneventful surgery. The dry system is a safe and reliable technique for managing posterior capsule rupture during phacoemulsification.     

Anterior capsule staining using micronized triamcinolone in the absence of red reflex

We describe a technique to stain the anterior lens capsule with micronized triamcinolone to perform a continuous curvilinear capsulorhexis (CCC) during phacoemulsification in the absence of a red reflex due to vitreous hemorrhage. After a self-sealing clear corneal tunnel incision is performed using a 2.75 mm blade, a dispersive ophthalmic viscosurgical device (OVD) is injected to protect the iridocorneal angle. An air bubble as large as possible is injected into the center of the anterior chamber, and a small amount of micronized triamcinolone is then injected as needed to stain the anterior lens capsule. The OVD injection permits the removal of excessive triamcinolone and protects the corneal endothelium from damage during phacoemulsification. A capsulorhexis forceps is used to perform the CCC. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.     

Bimanual microphaco for posterior polar cataracts

We describe a technique in which bimanual microphacoemulsification technique through 2, 1.4 mm incisions is performed for posterior polar cataract extraction. The low-infusion and low-vacuum system provides good anterior chamber stability and followability. The irrigation and aspiration handpieces are interchangeable, enabling removal of the lens fragments without hydrodissection or nucleus rotation. Only 1 (12.5%) of the 8 cases presented here was complicated by posterior capsule rupture. This occurred after epinucleus removal without any vitreous disturbance. The bimanual microphacoemulsification technique appears to minimize the risk for complications, allowing posterior polar cataract extraction to be performed more safely.     

Clinical application of 11-deoxycortisol in visualizing prolapsed vitreous body after posterior capsule rupture in cataract surgery

PURPOSE: To evaluate the clinical usefulness of 11-deoxycortisol, a precursor of cortisol in steroid metabolism, in visualizing the vitreous body in the anterior chamber after posterior capsule rupture during cataract surgery. SETTING: Department of Ophthalmology, Tsukuba University Hospital, Ibaraki, Japan. METHODS: Eight eyes had anterior vitrectomy during cataract surgery using this new technique. A suspension of 11-deoxycortisol was prepared by dilution in balanced salt solution without preservatives or emulsifying agents. After a posterior capsule rupture, the suspension was injected into the anterior chamber. The visual and anatomical outcomes of surgery were evaluated during a follow-up of 7 to 9 months. RESULTS: After the 11-deoxycortisol injection, the vitreous body that had prolapsed through the torn posterior capsule, with white particles entrapped on its surface, became clearly visible. Complete removal of the prolapsed vitreous body was achieved easily and safely using an anterior vitrectomy system. No postoperative complications related to the use of 11-deoxycortisol were observed. CONCLUSION: Injection of 11-deoxycortisol helped visualize the vitreous body in the anterior chamber after posterior capsule rupture. The technique minimized intraoperative and postoperative complications related to posterior capsule rupture and vitreous loss during cataract surgery [corrected]     

Suction posterior capsulorhexis.

A technique for creating a posterior capsulorhexis during phacoemulsification is presented. It can be used in cases with posterior capsule tears or opacities. The free edge of the capsule is grasped with suction using a 2 mL syringe and a 27 gauge Rycroft cannula introduced via the paracentesis. The edge is then manipulated to produce a continuous curvilinear opening in the posterior capsule. The combination of a closed eye plus the use of a viscoelastic agent in the anterior chamber and capsular bag minimizes the possibility of vitreous prolapse during the maneuver. Occlusion of the cannula tip by the posterior capsule reduces the risk of vitreous aspiration. In-the-bag intraocular lens implantation is readily achieved.     

Role of the posterior capsule in the prevention of postoperative bacterial endophthalmitis: experimental primate studies and clinical implications.

The posterior capsule has an important effect on the risk of postoperative bacterial endophthalmitis. In order to investigate whether the posterior capsule inhibited the spread of infection into the vitreous we performed extracapsular cataract extraction in both eyes of 10 primates. In one eye of each primate the posterior capsule was left intact and in the other eye a large posterior capsulectomy was performed. When the anterior chambers were challenged with equivalent inocula of Staphylococcus aureus, one of 10 eyes with an intact posterior capsule developed culture-positive vitreous infection. In contrast, nine of 10 eyes with a large posterior capsulectomy developed culture-positive vitreous infection. In a second experiment we investigated the effect of an intraocular lens on the barrier effect. Ten primates received extracapsular cataract extraction in both eyes and pseudophakic implantation. In one eye of each primate the posterior capsule was left intact and a J-loop monoplanar lens was implanted in the ciliary sulcus. In the other eye of each primate a large posterior capsulectomy was followed by implantation of a monoplanar, non-vaulted pseudophakos into the anterior chamber. None of the 10 eyes with a posterior capsule intact and a posterior chamber lens in place developed positive vitreous cultures or histopathological evidence of vitreous infection. Thus the presence of a posterior chamber lens did not appreciably compromise the barrier effect of the intact posterior capsule. 40% of the eyes with a large posterior capsulectomy and a non-vaulted pseudophakos in the anterior chamber developed culture-positive vitreous infection, and 60% of the eyes showed histopathological evidence of vitreous infection.     

Simplified technique to remove posteriorly dislocated lens implants

Visual loss caused by posterior dislocation of an intraocular lens (IOL) may be managed by placement of a secondary IOL without removal of the dislocated IOL. However, the improved visual acuity may lead to visual disturbances from the mobile, dislocated IOL. Removal of dislocated implants through the pars plana entails risks of a large pars plana incision to include hemorrhage, hypotony, and a greater potential for vitreous traction caused by extraction across the vitreous base. Removal via the corneal limbus lessens these risks but is made more difficult in the presence of a coexisting posterior chamber IOL. The technique reported allows a controlled conversion from posterior to anterior segment surgical techniques that may aid in either the removal or repositioning of posteriorly dislocated lens implants.     

Lens anatomical principles and their technical implications in cataract surgery. Part II: The lens nucleus

Preservation of the intact ("true") capsular bag, with no tears to the periphery, is essential to assure permanent in-the-bag fixation of the intraocular lens. Removal of a large nucleus using the open-system planned extracapsular cataract extraction (ECCE) technique is often associated with tearing of the capsulectomy or serious complications such as zonular rupture, vitreous loss, unintended intracapsular cataract extraction, or posterior lens prolapse. A closed-system planned ECCE technique which allows a safe removal of the lens while maintaining the integrity of the capsular bag is presented. Hydrodissection of the lens nucleus to an epinucleus and a central hard nucleus allows hydroextraction of the small hard core while pushing the posterior capsule backward. The positive pressure in the anterior chamber, provided by the anterior chamber maintainer, keeps the position of the lens steady in its natural location, and minimizes the stress on the zonular apparatus during nucleus delivery. The remaining epinucleus can be either hydroexpressed or aspirated. Fracturing the central core, when possible, enables removal of the lens material through a small limbal incision. Viscoelastic material can be combined with a low-flow, anterior chamber maintainer in a closed-system and provides a useful surgical tool.     

Posterior chamber lens implantation concurrent with vitrectomy for proliferative diabetic retinopathy

Combined operation of cataract removal with posterior chamber intraocular lens implantation and pars plana vitrectomy were performed on 25 eyes in 22 patients with cataract concurrent with diabetic retinopathy. In 21 eyes, extracapsular cataract extraction followed by intraocular lens insertion, aiming at in-the-bag fixation, was performed, and in 4 eyes pars plana lensectomy with anterior capsule left and intraocular lens insertion between the iris and anterior capsule was carried out. Mean postoperative follow-up period was 14 months, ranging from 3 to 32 months. Visual acuity on the last examination was 0.5 or better in 2 eyes (8%), 0.1 or better in 12 eyes (48%), and worse than 0.05 in 9 eyes (36%). Major postoperative complications were fibrin reaction (20 eyes, 80%), pupillary deformation (19 eyes, 76%), pupil capture by intraocular lens (3 eyes, 12%), rhegmatogenous retinal detachment (1 eye, 4%), neovascular glaucoma (2 eyes, 8%), and recurrent vitreous hemorrhage (13 eyes, 52%). Intraocular pressure was well controlled in neovascular glaucoma cases. At the last examination ocular fundus was invisible due to vitreous hemorrhage in two eyes.     

Early morphogenesis of the canine lens capsule,tunica vasculosa lentis posterior,and anterior vitreous body

This study provides transmission electron microscopic observations on the early morphogenesis (from days 25-35 post coitum) of the canine posterior lens capsule, the tunica vasculosa lentis (TVL) posterior and the anterior part of the vitreous body. The presence of an anlage of the posterior lens capsule as early as day 25, recently described histologically, was confirmed by this study. In the period from day 25 to day 35, the polar part of the posterior lens capsule develops 2-29 continuous and parallel lamellae, matching 50 nm and 1.74 microns, respectively. At these early stages, the TVL consists of capillaries that are simple endothelial tubes. From day 28 onward, these can be classified as A-1-alpha capillaries according to the classification of Bennett et al. [3]. In direct proximity to the lens capsule, the vitreous body contains fibrillar material with a morphological appearance similar to that of the lens capsule. This material probably derives from both the capillary endothelial cells' basal lamina and the lens capsule. Only few cellular components were observed in the anterior vitreous body. The development of the described structures is grossly in accordance with that observed in other mammalian species. The observations presented serve as a reference for studies on the pathogenesis of persistent hyperplastic tunica vasculosa lentis/persistent hyperplastic primary vitreous (PHTVL/PHPV), which is an important cause of leucocoria in children and in some dog breeds.     

Chopstick technique for nucleus removal in an impending dropped nucleus

We describe a bimanual chopstick technique for nucleus removal after a posterior capsule tear and an impending dropped nucleus during phacoemulsification. The technique stabilizes the nucleus and nuclear fragments by providing posterior support with a Sinskey hook introduced from the pars plana. Once supported, the nucleus is gripped between 2 instruments, brought out of the capsular bag into the anterior chamber, and then taken out of the enlarged wound. This bimanual removal technique causes minimal disturbance to the vitreous, iris, and cornea.     

A YAG laser technique to facilitate removal of posterior chamber intraocular lenses from the capsular bag

A technique is presented which facilitates repositioning or removal of a decentered capsular bag-fixated posterior chamber intraocular lens. The anterior lens capsule in front of the encapsulated haptic loop is disrupted with the YAG laser. This frees the loop from the capsular bag so a dialing maneuver will not stress the posterior capsule or zonule.     

Late-onset Lens Particle Glaucoma as a Consequence of Posterior Capsule Rupture after Pars Plana Vitrectomy

 Purpose: To report the treatment of late-onset lens particle glaucoma associated with posterior capsule rupture during pars plana vitrectomy. Methods: Case report. Results: A 33-year-old man had severe pain and impaired vision in the left eye after vitrectomy, associated with white fleck-like particles circulating in the anterior chamber. The intraocular pressure (IOP) was 38 mmHg. The anterior lens capsule was intact, however, lens particle glaucoma was diagnosed by the slit-lamp examination, B-mode ultrasonography and ultrasound biomicroscopy (UBM). The lens material was removed by irrigation-aspiration after the patient remained face down for two hours to facilitate precipitation of the lens material from the vitreous into the anterior chamber. IOP after the procedure was 21 mmHg. Conclusion: Posterior lens capsule may be disrupted during vitrectomy. Although the anterior lens capsule is intact, lens particle glaucoma should be considered when IOP increases with particulate matter circulating in the anterior chamber. Surgical removal of this material may be sufficient to control IOP without the need for additional glaucoma surgery.     

Visualizing the vitreous body in the anterior chamber using 11-deoxycortisol after posterior capsule rupture in an animal model

OBJECTIVE: To develop a new technique to visualize vitreous body prolapsed in the anterior chamber using 11-deoxycortisol. STUDY DESIGN: Experimental study. METHODS: An animal model of posterior capsule rupture was developed to investigate the usefulness of 11-deoxycortisol, a precursor of cortisol without steroid activity. After the intentional creation of posterior capsule rupture, the suspension of 11-deoxycortisol was injected into the anterior chamber of rabbit eyes. After gentle irrigation and aspiration, the vitreous body that had prolapsed into the anterior chamber was removed using an anterior vitrectomy cutter. To investigate the safety of 11-deoxycortisol, the biomicroscopic appearance, intraocular pressure (IOP), corneal endothelial count, and microstructure of the corneal endothelium were examined in the rabbits that received injections of 11-deoxycortisol in the anterior chamber. RESULTS: In our posterior capsule rupture model, the vitreous in the anterior chamber became clearly visible, with 11-deoxycortisol showing white particles entrapped on its surface. The injection of 11-deoxycortisol facilitated the complete removal of the vitreous body from the anterior chamber. In intact rabbit eyes, most of the injected 11-deoxycortisol had disappeared from the anterior chamber by 12 hours after injection. The injection of 11-deoxycortisol had no effect on IOP, corneal endothelial density, or the microstructure of the corneal endothelium. CONCLUSIONS: The injection of 11-deoxycortisol in the anterior chamber is useful in visualizing the vitreous body and has no significant side effects. This technique might reduce the intraoperative and postoperative complications of anterior vitrectomy after posterior capsule rupture.     

Management of vitreous loss during cataract surgery under topical anesthesia with transconjunctival vitrectomy system

PURPOSE: A new technique to manage posterior capsular rupture with vitreous prolapse into the anterior chamber during phacoemulsification under topical anesthesia using the sutureless self-sealing 25-gauge transconjuctival vitrectomy system. METHOD: In the event of vitreous prolapse into the anterior chamber, the corneal wound is sutured and cleared of vitreous. A trans conjunctival 25-gauge sclerotomy through the pars plana is made. The high speed 25-guage trans-conjunctival vitrectomy system (TVS-25) under topical anesthesia is introduced and vitrectomy is performed to clear the anterior chamber of vitreous. An anterior vitrectomy is also done. A foldable intraocular lens is subsequently inserted. RESULTS: The vitrectomy is performed in a closed chamber maintaining normal intraocular pressure. The high-speed cutter exerts minimal traction on the vitreous. The accessibility to vitreous improves through the pars plana route ensuring more complete removal of the vitreous and restoration of normal anatomy. Topical anesthesia avoids the risks of globe perforation, retrobulbar hemorrhage, and prolonged postoperative akinesia of the eye. CONCLUSIONS: The 25-gauge pars plana incision is small and self-sealing. This makes the procedure fast, effective, painless and safe.     

后囊膜混浊的先天性白内障术中的连续线形撕后囊术

目的研究后囊膜混浊的先天性白内障摘除术后的后囊膜处理方法。方法在３２只眼后囊膜混浊的先天性白内障中，摘除白内障及植入人工晶体后于后囊膜的旁中心作一穿刺孔，然后向后囊膜与玻璃体前界膜的间隙注入Ｈｅａｌｏｎ，再沿后囊膜穿刺孔边缘线形撕开一个直径约４ｍｍ的圆孔。结果全部术眼后囊膜中央有一透明裂孔，２只眼玻璃体溢出，术后未见人工晶体移位。结论连续线形撕后囊术可使后囊膜混浊的先天性白内障获得视轴透明区，并保持周边囊袋的完整性。     

Cataract Surgery and Transpupillary Silicone Oil Removal Through a Single Scleral Tunnel Incision Under Topical Anesthesia; Sutureless Surgery

The author evaluated the results of combined cataract extraction and transpupillary silicone oil removal through a single scleral tunnel incision, in eyes that had undergone pars plana vitrectomy with silicone oil tamponade. Twenty-four of the 46 eyes were operated on under topical anesthesia with Blumenthal mode mini-nucleus manual extracapsular cataract extraction technique (mini-nuc ECCE), and silicone oil was removed passively through planned posterior capsulorhexis via the scleral tunnel, followed by endocapsular intraocular lens (IOL) implantation. The operation was completed without any suturing. The remaining 22 eyes were similarly operated on with the same cataract extraction technique, but in these cases silicone oil was classically aspirated actively through pars plana sclerotomies. Results were evaluated by visual acuity measurement, duration of operation, and complications. The transpupillary silicone oil removal group had significantly less vitreous hemorrhage (0- 31.8%) and posterior capsule opacification (0-36.4%). Also, the mean duration of the operation was significantly shorter in this group. There was no significant difference between the two groups with regard to postoperative recurrence of retinal detachment (12.5-18.1%) and visual acuity outcome. The combination of mini-nuc ECCE with transpupillary silicone oil removal compares favorably with the combination of silicone oil aspiration through pars plana sclerotomies. This combined technique allows the surgeon to perform the operation under topical anesthesia and no sutures are required. The intervention period is shorter and no posterior capsule opacification or vitreous hemorrhage develops.     

白内障摘出术中后囊破裂时的I期人工晶状体植入

目的 评价在白内障摘出手术中后囊破裂时利和前囊I期后房人工晶状体樾主式的疗效。方法 对10例后囊破裂者利用计划性保留的前囊做为后支撑I期人工晶状体睫状沟植入。结果 术后随访3月，进行视力统计分析。裸眼视力：1.02例、0.84例、0.44例；矫正视力：1.04例、0.84、0.62例。结论 对位于中、下部后囊破裂及少量玻璃体脱出的病人，适当利用保留的前囊做为后支撑，仍可I期植入后房人工晶状体。     

Intercapsular cataract surgery with lens epithelial cell removal. Part I: Without capsulorhexis

Endocapsular phacoemulsification or intercapsular cataract extraction with lens epithelial cell removal using an ultrasound technique was performed on 30 eyes. The anterior capsule was not removed after posterior chamber intraocular lens implantation. After a mean follow-up period of 16.4 +/- 2.8 months, anterior capsule opacification was observed in six eyes, posterior synechias in six eyes, and shrinkage of the anterior capsule below the pupillary area, which resulted from the large opening needed for the intercapsular extraction, in 11 eyes. Other postoperative complications caused by lens epithelial cells such as posterior capsule opacification, intraocular lens dislocation, and fibrinous reaction did not occur. These results suggest it is necessary to remove the lens epithelial cells and the anterior capsule after posterior chamber lens implantation in intercapsular cataract extraction.