STORY Tips on managing this complication during cataract surgery

ADVANCE PL ANNING When a nucleus has dislocated deep into the vitreous cavity, surgeons should perform a thorough anterior vitrectomy and then implant an IOL. If the capsulorhexis is intact and smaller than the optic, it is highly desirable to place a multipiece IOL in the ciliary sulcus and capture the lens’ optic in the capsulorhexis because of the stable fixation that this approach provides. The IOL’s power should not be adjusted, as it should when placed in the sulcus without capture of the optic, because the effective lens position will essentially be the same as if the lens were entirely within the capsular bag. If the capsulorhexis is too large for an IOL with a 6-mm optic, surgeons may wish to implant an IOL with a 6.5-mm optic (eg, MA50 or MN50 series [Alcon Laboratories, Inc., Fort Worth, TX]). If the capsulorhexis is not intact but capsular support seems to be adequate, placing a PCIOL within the sulcus is appropriate. When inserting the IOL, it may be wise to tie a suture to the trailing haptic until the lens is safely located at the desired position. The suture can then be cut as it passes beneath the iris sphincter. Of course, should capsular support be inadequate for PCIOL insertion, the surgeon may either suture the PCIOL or place an ACIOL. PREVENTION At the first sign of an open posterior capsule, I recommend injecting an ophthalmic viscosurgical device (OVD) behind any remaining nucleus. Doing so can be difficult, depending on the location of the lenticular material, if the OVD cannula is inserted through the limbus. The injection, however, is entirely straightforward if the pars plana route is employed as follows. I attach a sharp, disposable 30-gauge needle to the syringe containing the OVD; I strongly prefer Viscoat (Alcon Laboratories, Inc.), because its dispersive nature causes it to resist aspiration during the remainder of the procedure. Next, I insert the needle through the pars plana at a distance of 3.5 mm posterior to the limbus. I inject a generous amount of the OVD immediately posterior to the nucleus, and it may be necessary to simultaneously release fluid from the anterior chamber to avoid overinflation of the globe. I then inject an OVD through the limbus and anterior to the nucleus. Phacoemulsification can then be continued under relatively low flow and vacuum settings to complete nuclear removal.