Management of posterior capsule rupture

The approach to management of posterior capsule rupture during cataract surgery differs depending on when the complication occurs, said Peter Barry, MD, during the ESCRS symposium at the 26th APACRS Annual Meeting. The most common timing is during irrigation/aspiration, and in this situation, surgeons can bring the case to completion with IOL implantation after handling the anterior segment via a 2-port trans-limbal vitrectomy. However, if the capsule tears during phacoemulsification and the nucleus or nuclear material drops, calling a retinal colleague is the best course of action, according to Dr. Barry. 'I strongly suggest that dropped nucleus and retained lens fragments in the posterior segment can only be removed safely with a 3-port pars plana vitrectomy. Never use a phaco probe in the vitreous cavity or in the anterior chamber if vitreous is present in the anterior chamber, never infuse the vitreous cavity in order to elevate lens material, and never use a vectis in the vitreous cavity,' he said. Outlining the steps for managing posterior capsule rupture during irrigation/aspiration, Dr. Barry explained that he advocates a 2-port translimbal vitrectomy over a pars plana approach as the latter takes cataract surgeons out of their comfort zone. In performing the vitrectomy, they should dissociate the infusion from the cutter, lower the infusion so there is just enough to preserve anterior chamber depth, and increase the cutting rate to the maximum the machine permits. Vitreous should be removed to a plane behind the torn posterior capsule. 'If vitrectomy is performed with the cutter in the anterior chamber, it will pull the vitreous forward and increase the size of the posterior capsule tear. Having the cutter in the right place pulls the vitreous back to its normal anatomic position to minimize stress on the vitreous base and keeps the flow of infusion pushing the vitreous back toward the cutter,' Dr. Barry explained. 'Above all, take maximum care to preserve the posterior capsule remnants and do not further damage an already compromised capsule, which is a very common mistake. Surgeons have to slow down, not speed up,' he added. To avoid causing a retinal break, Dr. Barry also cautioned that surgeons should never pull the cutter when the vitreous is engaged and never use cellulose sponges to protect the wound for vitrectomy.