December 2018

CATARACT

Cataract editor’s corner of the world
Recovering from a posterior capsule hole


by Rich Daly EyeWorld Contributing Writer


OVD is injected into the posterior capsular to block the hole during surgery.

To minimize damage to the hole, the lens haptics are placed 90 degrees away from it.
Source: Uday Devgan, MD

 

In this “Cataract editor’s corner of the world,” we delve once again into a challenging complicated cataract case. We have the privilege of hearing from Uday Devgan, MD, on how to manage a posterior capsular tear/rupture. He eloquently walks us through recognition and responses should such a case occur.
As surgeons, we would ultimately like to have a complication-free record. However, the reality is that if you operate, complications are going to occur either due to the nature of the case/eye, the patient, or just because stuff happens. I had a great mentor once tell me when I was a senior resident, “It’s not how you mess up, it’s how you clean up.” This holds true to this day. I tell my residents this all the time, and to try and learn from them, too. Dr. Devgan is bold enough to review his complications with us, and I am hoping we can all learn from them and take away useful pearls.

Rosa Braga-Mele, MD,
Cataract editor

Surgeon explains the challenges of and recovery from a posterior capsular hole during cataract surgery

Posterior capsule holes happen. But watching for them and quickly responding can keep a bad situation from becoming worse.
Uday Devgan, MD, clinical professor of ophthalmology, Jules Stein Eye Institute, University of California Los Angeles (UCLA), chief of ophthalmology, Olive View-UCLA Medical Center, and private practice, Devgan Eye Surgery, had a routine cataract case where the challenge arose.
Such ruptures stem from inadvertent contact with a very thin—usually about 4 μm—posterior capsule during the course of cataract surgery. They can arise with any cataract patient.
“The problem was not the patient, it was me, the surgeon,” Dr. Devgan said about the case. “When I was removing the cataract, the phaco tip inadvertently made contact with the capsule and made that rupture occur.”
When the capsule breaks and a surgeon doesn’t notice it, the problem can quickly worsen if the vitreous prolapses and the cataract falls back toward the retina.
But because the complication is a round hole in the capsule, early recognition allows taking steps to avoid any further issue. In this case, Dr. Devgan’s vigilance avoided any prolapse, avoided the need for a vitrectomy, and prevented the cataract from falling back. He was even able to use the original lens implant chosen to go into the capsular bag.
“That’s all because we recognized the error when it happened and immediately took the steps to counter it,” Dr. Devgan said.

Watchful eye

Cataract surgeons should be routinely looking for posterior capsule holes during procedures.
“Maybe I’m too extreme, but I don’t even play music in the operating room,” Dr. Devgan said. “I want to focus intently on this 5–8 minute surgery, and I’m looking at everything, even the slightest change. It’s like when you are driving—are you paying attention or are you doing it passively? I want to be active and present, notice what I’m doing and see what my hands are doing. If I detect anything that is not normal, I act on it.”
There are no tricks to detecting such holes beyond visual indicators.
In this case, the phaco tip went through the nuclear piece to puncture a hole in the posterior capsule. One hint that Dr. Devgan got of a violation of the posterior capsule was a briefly visible hole through a hemi-nucleus.
“That’s another warning sign—there shouldn’t be a through and through hole in a nuclear piece,” Dr. Devgan said.
But attitude may be the most important part of finding such breaks.
“The best thing to do is avoid the common instinct of denial,” Dr. Devgan said. “That’s what most surgeons—myself included—tend to do. The best way is to go in with the expectation that things will occasionally happen.”

How to respond

When a capsular break is found, Dr. Devgan has a standard approach. First, don’t pull the phaco probe out of the eye, and then, try to close the hole. This is accomplished by injecting dispersive viscoelastic through the posterior capsule and preventing the anterior chamber from collapsing. That also can prevent any cataract pieces from going backward.
“That keeps the vitreous back and keeps the cataract in the anterior segment,” Dr. Devgan said. “When I have a hole, the barrier is broken, so the first step is to close that hole. You must temporarily plug the hole.”
Second, keep the hole from enlarging. That includes avoiding any aspiration in the hole and reducing the aggressiveness of your irrigation/aspiration settings.
Once the cortex is all removed, prevent anterior chamber collapse by instilling more viscoelastic to tamponade the hole, and to fill the anterior chamber and capsular bag.
“The defect didn’t open up more and the posterior capsule stayed in place,” Dr. Devgan said. “Normally, if there’s a large posterior capsule break, you can’t put the lens in a bag so you have to fixate it in some other way. But here, the break ended up being so small that it did not extend so we could still put our lens right in the capsular bag, and that even helped cover the hole more.”
Dr. Devgan also oriented the lens haptics 90 degrees away from the posterior capsular hole to ensure that they would not intersect it.
Another change in such cases is that the hydration of the corneal incision should be done before removal of the viscoelastic to prevent collapse of the anterior chamber. Then, use low pressure and lower bottle height during irrigation/aspiration to remove the viscoelastic. Small shallowing can be quickly addressed by increased hydration.

When a hole is manageable

Dr. Devgan’s delineation between when a hole is manageable and when it’s unmanageable is if the defect is one-third the size of the optic diameter. Any hole that size or smaller still allows lens placement in the capsular bag.
“If I have a huge hole, I can’t put the lens in,” Dr. Devgan said. “But when the lens is 6 mm in diameter and the hole is 2 or 3 mm in diameter, I can certainly put that lens in the capsular bag.”
At the end of the case it’s important not to let the anterior hyaloid face collapse and allow vitreous to come through.
In the postop period, the surgeon needs to look to ensure there’s no vitreous prolapse, as he or she would as part of any routine postop care.
“I fumbled the ball, but I recovered and everything was fine,” Dr. Devgan said. “The capsular defect had no effect on the patient’s visual outcome because it was caught quickly. When you catch a complication like this early, you can still have problems but you can recover the ball. “
The case illustrates that every surgeon will face a complication sooner or later, and the key is
knowing how to minimize and recover from it. The full case including video can be seen at www.CataractCoach.com.

Editors’ note: Dr. Devgan has no financial interests related to his comments.

Contact information

Devgan: devgan@gmail.com

Recovering from a posterior capsule hole Recovering from a posterior capsule hole
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