So I'm Jill Bixler, one of the Comprehensive ophthalmologists at the Kellogg Eye Center at the University of Michigan, and today we're going to talk about management of capsular complications. The most important part of capsular complications is trying to avoid them. And so you need to anticipate problems that might be causing trouble with the capsule during your cataract surgery. Things such as trauma or pseudoexfoliation, or syndromes such as Marfan's disease can cause weakness of the zonules, and may cause you to lose capsular support during surgery. Things such as a small pupil or possibly floppy iris syndrome in Flomax users are something that are also important to note. A large body mass index can cause increased posterior pressure, which can cause your posterior capsule to come forward during surgery. And, people with very short eyes, like your high, hyperops may also not have much room between their anterior chamber and their posterior capsule. Then there are also things such as a posterior polar cataract, of which this is an example. And if you anticipate these problems you may not always be able to, avoid a capsular complication, but you will be able to, deal with it, very efficiently. At the anatomy of the capsule, the anterior capsule is thicker than the posterior capsule and is a little more sturdy, and you'll be able to see that during surgery. But the important thing to remember is that, both portions of the capsule, anterior and posterior are very delicate. And so you need to treat it with the utmost respect during surgery. We can divide the capsular complications into, the anterior and posterior capsule. And they have very different complications, and considerations during surgery and after surgery. Anterior capsules, you can get a radialization, or peripheral extension of your capsulorrhexis, or you can also mis-size your capsulorrhexis. When you get a peripheral extension of your capsulorrhexis, the first thing to do is to recognize that that's happening. When you notice that your capsulorrhexis is starting to straighten out and move posteriorly, you can inject some more of the viscoelastic and that will help flatten your anterior lens, so that it will let you reposition your flap and try to bring the extension,into the center. You can either use either cystotome or Utrata forceps to redirect capsulorrhexis. Sometimes though its too far into the periphery and so, you are unable to rescue it. In that case you can use scissors, to start a capsulorrhexis flap in the other direction. And you may be able to actually us it to meet up with the other tear. And sometimes, that can even result in a continuous curvilinear capsulorrhexis. Other times, that would just completes the capsulorrhexis so that you are able to continue with your surgery. And you can also use a can opener technique to finish your capsulorrhexis. So true or false? Once an anterior capsule radialization has occurred, an anterior chamber lens must be used, and that's false. If the radialization stays anterior, then you may still be able to put the intraocular lens in the capsular bag. Even if it does extend posteriorly, still may be able to put a focus lens in the posterior chamber. And how do you orient the haptics if you are putting a lens in a capsular bag that has had a radialization? And you want to put it away from the radial tear, and when you think about the, the design of the intraocular lenses it's important to remember, that you're haptics extend far posteriorly, and so you want to put those away from, the area of radicalization, so they don't get into the anterior vitreous in that area. If you have an anterior radialization, again, the most important thing to try to do is to confine it to the anterior capsule. And to do this, you want to minimize stress on the capsule. So you want to lower your bottle height. You want to do a very good hydrodelineation so that you're able to move the nucleus of the lens. Without putting stress on the most portion of the cataract if we'll pull on the capsule. You're going to need high phaco power so that you're not moving the cataract around as you're phacoing it. And when you do, your irrigation aspirations for cortical removal, you want to do that aspiration in the direction of the radialization so you don't unzip it further. And then, again, when you put the lens implant in, either in the bag or if it has extended posteriorly. In the focus, you want to put your haptics away from the radialization. If you do your capsulorrhexis size too large, the crystalline lens tends to be unstable during surgery, and the posterior capsule also tends to be much more unstable. It often comes forward, and so you want to be careful, with your phaco and especially when you're removing the last few pieces of the cataract, just want to be careful with your irrigation aspiration handpiece. And the silicone handpieces are great, but they still can break the capsule, and you always want to make sure that you inspect your irrigation aspiration handpiece under the microscope before you put it in the eye, because often, there are cracks in the silicone where the silicone and metal meet. And your surgical technician's often not able to see that without the aid of a microscope, so you should always inspect every instrument before you put it inside the eye. You also might want to consider putting Miochol or Miostat in the eye after your lens is implanted, to ensure its stability and so that you don't find that you have iris capture the next morning in clinic. If your capsulorrhexis is too small, you want to avoid an aggressive hydrodissection, because if you prolapse the lens forward into the anterior chamber, and your capsulorrhexis is too small, you may end up causing a radialization. Everything about the case is going to be harder with a small capsulorrhexis. It's harder to construct a proper groove. Harder to get the quadrants up, especially in a very mature lens. Harder to get the subincisional cortex with the end of the case. You also risk capsular contraction syndrome, or phimosis. And, you will not be doing your retinal colleagues a favor, because as your capsule will fibrose in the months and years after the surgery, it's very hard to get a peripheral view of the retina, to be small capsulorhexis. Once you interact your lenses in the bag and stable, you can sometimes enlarge your capsulorrhexis and you may want to consider that depending on how large it is and what other conditions the patient have, has that may make peripheral retinal examination important. Now, the posterior capsule rent, of course, this is the thing that people worry most about. And the most important part of this is to recognize that something has happened. Everyone has a moment of denial and they think that, you know, what they just thought they saw didn't actually happen. But complications happen to everyone and so it's important to know that even if you have complication, you need to be able to deal with it quickly, and efficiently so that you can get the best outcome for your patient. And part of doing that is not denying that it's happened. So if you notice that there's a sudden chamber deepening or it's all of a sudden hard to manipulate the lens fragments in the eye compared to earlier in the case, these can be signs that you do have a posterior capsular rend. This is also called followability. Lens fragments tend to go more peripheral than expected when you're trying to rotate them, or if your red reflex all of a sudden gets very bright. These are all things that should concern you and at least cause you to pause for a moment, and inspect the capsule as best you can before you go on with your case. When you recognize that a rent has occurred, what should you do? You should continue to phaco so that you don't lose the nucleus in to the vitreous cavity. You should remove all your instruments from the eye right away. You should keep irrigating while you inject viscoelastic into the rent. Or you should stop irrigating but keep your instruments in the eye? And you want to keep irrigating while you inject viscoelastic into the rent. When you have a rent it is essential decision time on lots of things and how this case will go from this point forward. You'd need to decide if you're going to convert to an extracapsular cataract surgery or continue to phaco, and this partly depends on the amount of lens that you have left and the grade of the lens that you have left. If you're doing this case under topical anesthesia, you may consider doing a subtenon's anesthetic injection, and this also depends on at what point in the case the rent occurred. You also may consider a posterior capsulotomy. The key for managing a posterior capsular rent is you want to keep a closed system. The vitreous will move toward the areas of the low pressure, and that's why when you recognize a rent has occurred you keep irrigating as you're injecting viscoelastic. The viscoelastic will help tampen all the vitreous back and slowly increase the pressure inside the eye, while your irrigation is doing the same initially. Once you have enough viscoelastic in the eye, then you will stop irrigating and then gently remove it from the eye. You want to suture your main incision, again, to minimize the possibility of low pressure anteriorly. And then you want to create appropriate sized paracenteses for your vitrectomy handpiece. When you're inserting your intraocular lens, you're almost always going to be suturing these incisions afterwards. So you want to make sure that your incision if large enough that you're not putting a lot of pressure on th eyes, you're getting the lens inside the eye. because pushing on your incision in a very vigorous manner, can bring more vitreous jelly forward. Anterior vitrectomy we do it these days mostly with a bimanual irrigation and vitractor, you want to irrigate high and cut low. And that's the same principle, you want to keep the irrigation that's creating the pressure, high so that there's high pressure anteriorly that the vitreous will not move forward, and then you cut underneath it. You want a low bottle height and that's partially so that you don't extend the rent beyond the size that it already is. You want to use a low vacuum, if you do a vitrectomy with a high vacuum you can keep pulling vitreous towards you [LAUGH] for a very long period of time. So low vacuum. You want to clean up what's there. But you don't want to pull all the vitreous forward into your vitrector. And you also want to use a very high cut rate. And you may consider staining the vitreous with triamcinolone. Although you do need to be cautious especially in your patients with glaucoma. Because a high percentage of patients will have a steroid responsive glaucoma, that can cause you more trouble in the long term. Sometimes you will continue use your phaco emulsification handpiece even with a posterior capsular rent. And in this case what you want to do is you want to create a sandwich of dispersive viscoelastic around your remaining cataract pieces. The dispersive viscoelastic underneath your, cataract piece will keep the vitreous back and keep your cataract fragment forward. And then you want to quilt dispersive viscoelastic over your fragment, to help protect your endothelium. If you know at this point that you are going to have to use an anterior chamber interocular lens you may be considering enlarging your incision at this time and using a sheets glide tampen all the vitreous back and keep your lens forward. Often, I also move these pieces of cataract over the iris, or over a portion of the capsule that is still intact, so that it will give some extra support. You also want to keep the phaco tip as occluded as possible, so you want to do this for a large lenticular pieces and once you start almost finding it to include emulsifying until the piece is gone. Small pieces tend to go back more easily, and so you really want to get rid of the cataract fragments as quickly as possible. And you should not chase pieces of the cataract into the vitreous. Once they're, once they're gone into the vitreous cavity, they're gone. And at that point, we will turn to our retina colleagues, if needed, to retrieve them from the eye. Another thing that you can sometimes do is actually just prolapse the remaining pieces of the cataract out of the incision, with dispersive viscoelastic. When it's time to remove your epinucleus and cortex, you might want to consider doing this in a dry system. This means that you're not putting active irrigation inside the eye. And it's a very controlled method of removing cortex and epinucleus. So you again reform the chamber with viscoelastic and use it to hold back any vitreous coming forward, and then you can use either a Simcoe cannula or a J-cannula to remove your cortex or epinucleus in a very controlled fashion. You can also do this in a non-dry setting by using the anterior vitrectomy setup, and for this you want to go to the I/A cut setting on the vitrector. This is why a good foot pedal control is so important and why you should not necessarily use continuous irrigation for your early phaco cases, because you need to be able to go from position one, which is irrigation, to position two, which is aspiration, without going to position three, which is cutting. That way, you can go to position two and aspirate in any remaining epinucleus or cortex, while not cutting and going to position three. So that you can hopefully maintain your anterior capsule and still put in sulcus lens in at the end of the case. The intraocular lens implantation, will come next after you have removed whatever you can of the lens inside the eye, and cleaned up the vitreous as best you can. You may do a three piece lens in the sulcus, and this is if you have an intact interior capsule. And you may want to consider capturing your optic behind the capsule. And this is, again, if you have a continuous curvilinear capsulorrhexis that is slightly smaller than the size of the optic. Once you put the lens in the haptics in the sulcus, that you can then capture the optic behind the anterior capsule. This will tamponade vitreous behind the optic, and also keep your lens centered and in good position. You may have to do an anterior chamber lens and if you do that you need to remember to a peripheral iridotomy, so you don't get pupilliary blockage in the future. And you want to constrict the pupil either with Miochol or Miostat, to avoid iris capture of the haptics and feet of the anterior chamber intraocular lens. The Miochol or Miostat will actually serve functions, and I use them in all cases even if I'm not putting in an anterior chamber lens. It will help you identify a peaked pupil which is a, hint that you still have vitreous in the anterior chamber. It also helps seal your intraocular lens in place and can stretch [INAUDIBLE] open and may help mitigate pressure spikes after surgery. Pressure spikes after surgery when you do a vitrectomy are very common because you often leave some viscoelastic inside the eye. Signs of vitreous can be an uncentered intraocular lens, a peaked capsulorrhexis or a peaked pupil. And if you see any of these things, you need to investigate further. It's much easier to deal with vitreous in the anterior chamber while you're in the operating room, as opposed to in the clinic the next day. So step by step. The first thing to remember is in the operating room, you are the captain of the ship. You know, the operating room works as a team, and every member is very important, and you need to treat everyone with respect. But at the same time it's not a democracy. You are the one who's in charge, and you set the tone for the entire room, and the entire case. So if you don't panic and if you stay calm, then you will allow the rest of your team to stay calm, and help you as efficiently as possible. So you want to put the phaco tip in the eye, and then put in some viscoelastic via the paracentesis incision. At that point you will remove your phaco tip and then you'll do a weck cell vitrectomy. To clean up any vitreous that might be coming out of your incisions. After you've done a vitrectomy thoroughly you want to do some viscoelastic to push back the vitreous though your incisions. You'll suture your main wound and then create a second paracentesis and enlarge your first for the protector hand pieces. And you'll do your anterior vitrectomy. And if there are any lens fragments, remove those, again, either with a victractor or viscoelastic. Add a little more viscoelastic and enlarge the wound. And then place your victractor lens. And again, that, where you place the lens depends on how much capsular support that you have. You want to gently remove your anterior viscoelastic. Put in some Miochol and suture the wound at the end of the case. Post-operative management, these patients have a longer post-operative course and you need to be honest with them after surgery about what happened. At the same time you can be overall very optimistic for their visual outcome, but you often need to use some extra medications for a longer period of time to help you get there. I often will use acetazolamide after surgery, because I almost always leave viscoelastic inside the eye. Because if you do too vigorous of an viscoelastic removal you can also bring vitreous forward. So I'll often give them the acetazolamide in the post-op area the night after surgery and the morning after surgery. I often use an inside eye drop because the risk of macular edema after these cases is much higher. And I use this typically for a 12 week course, and also, often the corneal endothelium by these longer cases and so you'll need increased topical steroids and also for a longer period of time. It is also important to be honest with your patients so there are slightly increased risks with complicated surgeries. There's an increase of a retinal detachment. Increased risk of endophthaltmitis and again an increased risk of cystoid macular edema. So you need to make sure that, in addition to discussing, the happenings of the case with your patient, you also let them know the warning signs that should bring them into see you right away. So that if, they do develop any complications post-operatively they can be dealt with as early as possible.