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MONDAY - 9th MAY, 2015; 10.00 AM-11.30 AM, ROOM 211-213 ; SESSION 9 – 202; COURSE ID 3628

TACKLING POSTERIOR CAPSULE RUPTURE AND IOL IMPLANTATION: A VIDEO BASED COURSE

COURSE DESCRIPTION

…THE COURSE WILL HIGHLIGHT THE METHODS OF HANDLING POSTERIOR CAPSULE (PC) RUPTURE, ITS EFFECTIVE MANAGEMENT

AND VARIOUS MODALITIES OF IOL IMPLANTATION.

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BASIC FUNDAMENTALS

Early recognition and management of PC rupture is a key to prevent the sequential complications which can trail and have an adverse effect on the visual output. The following signs should be watched upon for early recognition of a PC rupture. •  Sudden deepening of anterior chamber with

momentary dilation of pupil •  Sudden transitory appearance of red reflex •  Difficulty in rotating a previously mobile

nucleus •  Undue tilting of one pole of nucleus

BASICS

•  Lower down phaco parameters •  Low flow rate •  Moderate vacuum •  Low to moderate phaco burst energy to

promote follow ability

MANAGEMENT PROTOCOL OF PC RUPTURE AND IOL IMPLANTATION

•  In the context of a ruptured posterior capsule, the immediate reflex

action to be deterred on behalf of the surgeon is to withdraw the phacoemulsification probe suddenly from the eye. A dispersive OVD from the side port incision should be used to plug-in the posterior capsule defect and fill and stabilise the anterior chamber followed by withdrawal of the phacoemulsification probe.

•  The posterior capsule rupture when small is converted into a posterior capsulorhexis with stable margin facilitating the implantation of a one piece foldable acrylic IOL in the capsular bag. But if the capsular rupture opening is large, sulcus fixation of an IOL is preferable in cases with adequate anterior capsular margin support. A three piece foldable IOL implant imparts stability when the haptics are placed in the sulcus and the optic is captured into the anterior capsular opening. In cases of inadequate anterior capsular support, various methods of IOL implantation can be implicated like anterior chamber (AC) IOL, Iris claw Retrofixation, Sutured scleral fixation and Glued intrascleral haptic fixation of IOL which imparts a very stable intrascleral fixation.

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LEARNING OBJECTIVES

At the conclusion of this course, attendees will be able to judge, •  How to effectively handle a case of posterior

capsular dehiscence? •  Do’s and Dont’s upon recognition of PC rupture •  Management of vitreous and the importance

and correct method of vitrectomy from anterior segment surgeons perspective

•  Choice of Type and various methods of IOL implantation following PC rupture

TARGET AUDIENCE

The intended audience for this program are comprehensive ophthalmologists with an interest in anterior segment, and allied health personnel

who are performing or assisting with cataract surgery.

COURSE OUTLINE

•  Introduction to the surgical nightmare of intraoperative posterior capsular dehiscence

•  Videos showcasing intraoperative PC rupture and ways to handle it judiciously

•  Videos showcasing IOL implantation in the sulcus along with Optic capture

•  Video showcasing Glued Intrascleral technique of IOL fixation (Glued IOL) and its modifications

•  Videos showcasing IOL Scaffold and Glued IOL scaffold technique

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HANDLING ASSOCIATED COMPLICATIONS OF PC RUPTURE

•  Videos showcasing DMEK with Glued IOL •  Videos showcasing PDEK (Pre-Descemet’s

endothelial keratoplasty) with Glued IOL •  Videos showcasing different modalities of

vitrectomy •  Videos demonstrating how to handle dropped

nucleus and dropped IOLs •  Videos demonstrating pupil re-construction

when associated with a PC Rupture

TYPES OF VITRECTOMY- CONVENTIONAL ROUTE

•  LIMBAL •  PARS PLANA

ç PARS PLICATA VITRECTOMY

PARS PLICATA ANTERIOR VITRECTOMY

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VITREOUS STAINING

•  Triamcinolone acetonide binds to vitreous & facilitates vitreous recognition and removal

•  Reduces post-op inflammation •  Preservative free Triamcinolone is available •  Thorough removal is a must postoperatively

VITRECTOMY END POINT

•  Normal round, regular shape of pupil •  No iris movement during vitreous aspiration •  Deep anterior chamber

ééééé SURGE êêêêê

The inflow volume can be increased by either increasing the bottle height or by enlarging the diameter of the inflow tube. The intraocular pressure increases by 10 mm Hg for every 15 centimeters increase in bottle height above the eye. High steady-state IOPs increase phaco safety by raising the mean IOP level up and away from zero, i.e. by delaying surge related anterior chamber collapse. Air pump increases the amount of fluid inflow thus making the steady-state IOP high. This deepens the anterior chamber, increasing the surgical space available for manoeuvring and thus prevents complications like posterior capsular tears and corneal endothelial damage. The phenomenon of surge is neutralized by rapid inflow of fluid at the time of occlusion break. The recovery to steady-state IOP is so prompt that no surge occurs and this enables the surgeon to remain in foot position 3 through the occlusion break.

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In- The- Bag placement

Sulcus placement Subluxated Bag- IOL Complex with

dislocated endocapsular ring &

segment

IOL IMPLANTATION IN PC RUPTURE - MEETING THE CHALLENGES

The course highlights various intraoperative cataract complications like broken capsule, loss of zonular

integrity, vitreous prolapse and vitreous loss through the incision, retained lens material and provides an update of

techniques for handling complications. …… SURGICAL NIGHTMARE & CHALLENGING VIDEOS WILL

BE SHOWCASED

TACKLING MASSIVE ZONULODIALYSIS & SUBLUXATION

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Lensectomy being done in a case of

traumatic subluxated lens after creation of

scleral flaps for Glued IOL

Thorough vitrectomy Leading haptic of 3-piece foldable IOL

grasped with Glued IOL forceps

GLUED IOL FIXATION – NO ASSISTANT TECHNIQUE (NAT)

Leading haptic lies free & trailing haptic

is flexed into the anterior chamber

Tip of trailing haptic is grasped

Both haptics are externalized

followed by tucking & sealing the flaps with Fibrin glue

IOL SCAFFOLD

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SOEMMERRING RING MANAGEMENT WITH ASSOCIATED PC RUPTURE

Narang P, Agarwal A, Kumar DA et al. Clinical outcomes of intraocular lens scaffold: A one year study. Ophthalmology.

2013; 120 (12): 2442-2448

•  IOL SCAFFOLD is a technique wherein following a PC rupture, the nuclear/cortical remnants are levitated in to the anterior chamber with the help of viscoelastic. A 3- piece foldable IOL is injected below the cortical remnants in a way that the leading haptic lies on the anterior surface of the iris and the trailing haptic lies extruded at the corneal incision. The foldable IOL acts as a scaffold , preventing the nuclear fragments from dropping in to the posterior chamber. The nuclear fragments are then emulsified with the help of phacoemulsification probe. Post-emulsification, the IOL is dialed in to the sulcus and stability is achieved.

•  The IOL Scaffold technique effectively compartmentalizes the anterior and posterior chamber with a foldable IOL following a posterior capsule rupture; there by preventing the drop of any nuclear fragment in to the vitreous cavity.

•  The IOL is placed directly in to the definitive position decreasing the surgical trauma to an already compromised eye. As it is a closed chamber technique; all the advantages of a small incision cataract surgery are retained.

GLUED IOL SCAFFOLD

•  Glued IOL and IOL Scaffold are two independent techniques employed for IOL fixation in cases of posterior capsular rupture with the difference that Glued IOL is done in cases of insufficient capsular support where sulcus fixation is not possible and IOL scaffold is done in cases of intraoperative PCR with large chunk of nucleus still left over for emulsification. In IOL scaffold, the IOL is either placed over the iris or the anterior capsular rim from where it acts as a scaffold compartmentalizing the anterior and posterior chamber; thereby preventing the nuclear fragments from dropping into the vitreous cavity. IOL scaffold cannot be performed in cases of iris deficiency or malformation or in cases of absence of anterior capsular rim. In such a scenario, Glued IOL Scaffold comes into play. It is a technique which amalgamates both the above described techniques and is employed in cases of posterior capsular rupture with insufficient iris/anterior capsular support. Glued IOL is performed initially followed by IOL scaffold; the initial IOL fixation acts as a scaffold followed by emulsification of the nuclear chunks with the phacoemulsification probe.

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DISASTER MANAGEMENT DROPPED NUCLEUS- TECHNIQUES: •  Posterior assisted

levitation •  Phacofragmatome

assisted emulsification of nucleus

•  Phaco-tip assisted levitation of dropped nucleus.

SLEEVELESS PHACOTIP ASSISTED LEVITATION OF

DROPPED NUCLEUS (SPAL)

Clinical outcomes of sleeveless phaco-tip assisted levitation of dropped nucleus.

Br J Ophthalmol. 2014;98:1429–1434. SPAL technique is employed following an incidence of dropped nucleus. In this technique the vacuum is generated when phacotip is close to the dropped nucleus. A moderate amount of vacuum setting is enough to lift the nucleus adequately into the mid- vitreous cavity; followed by initiation of phaco power for adequate embedment. The advantage of holding the nucleus with a sleeveless phacotip enables a firm grip and the nucleus does not tend to fall back in to the vitreous cavity. The firmly embedded nucleus is then easy to levitate in to the anterior chamber. The recommended technique for employing ultrasound energy in the vitreous cavity is to lift the nucleus fragment away from the retinal surface by aspiration in the mid/anterior vitreous cavity, thereby limiting exposure of the posterior pole to ultrasound energy. Followed by successful levitation in to the anterior chamber, the dropped nucleus is then managed with either IOL scaffold or Glued IOL, depending on the status of sulcus support.

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HANDLING CORNEAL DECOMPENSATION

Pseudophakic bullous keratopathy is a known corneal complication following a cataract surgery. various endothelial keratoplasty techniques have been explained in the past including DMEK, DSEK, DMAEK, Ultra thin DSEK ……..

WE INTRODUCE A NEW VARIANT IN TO THE ARENA -

PDEK: PRE-DESCEMET’S ENDOTHELIAL KERATOPLASTY

DROPPED IOL

Agarwal A, Narang P et al. Sleeveless-extrusion cannula for levitation of dislocated intraocular lens. Br J

Ophthalmol. 2014;98:910–914. •  Technical handling of a posteriorly dislocated IOL

requires lot of surgical expertise to avoid the risk of retinal traction and creating an iatrogenic tear. Removal of the silicon sleeve of extrusion cannula gives a wider access of the bore of the cannula to create an effective suction around the IOL. The vacuum created by the sleeveless-extrusion cannula is strong enough to hold the optic of an IOL in the vitreous cavity.

•  This technique is effective for dislocation of any type of IOL including the plate haptic IOLs which are often difficult to grasp with a retinal forceps.

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Single piece IOL lying on the retina being lifted.

Plate haptic IOL on retina.

SUMMARY

•  Anticipate and prepare for complicated cases •  Retro-pupillary removal of cortical matter and

vitreous management allows a more efficient and complete removal of vitreous

•  Do not hesitate to acknowledge your limitations & refer to an expert in case of difficulty

SUGGESTED READING

•  Narang P. No assistant technique- Modified method of haptic externalization of posterior chamber intraocular lens in fibrin glue assisted intrascleral fixation. J Cataract Refract Surg. 2013;39(1): 4-7

•  Narang P, Agarwal A, Kumar DA et al. Clinical outcomes of intraocular lens scaffold: A one year study. Ophthalmology. 2013; 120 (12): 2442-2448.

•  Narang P, Narang S. Glue assisted intrascleral fixation of posterior chamber lens. Indian J Ophthalmol. 2013; 61(4):163-167.

•  Agarwal A, Narang P, Agarwal A et al. Sleeveless extrusion cannula for levitation of dislocated intraocular lens. Br J Ophthalmol. Article in press.

•  Beiko G, Steinert R. Modification of externalized haptic support of glued intraocular lens technique. J Cataract Refract Surg. 2013; 39(3): 323-325

•  Kumar DA, Agarwal A, et al. IOL Scaffold technique for posterior capsular rupture. J Refract Surg. 2012; 28(5):314-5

•  Agarwal A et al. Handshake technique for Glued Intrascleral haptic fixation of a posterior chamber IOL. J Cataract Refract Surg.2013; 39(3): 317-322.

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SUGGESTED READING

•  Agarwal A, Dua H S, Narang P et al. Pre-Descemet’s endothelial keratoplasty (PDEK) Br J Ophthalmol. Article in press.

•  Agarwal A, Narang P, Agarwal A et al. Clinical outcomes of sleevelss phacotip assisted levitation of dropped nucleus. Br J Ophthalmol. Article in press.

•  Agarwal A, Agarwal A, Jacob S, Narang P. Comprehending IOL signs and the significance in Glued IOL Surgery, J Refract Surg. 2013:29(2): 79

•  Agarwal A, Kumar DA et al. Fibrin glue–assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008;34(9):1433–1438

•  Agarwal A et al. Glued IOL scaffolding to create an artificial posterior capsule for nucleus removal in eyes with posterior capsular rent and insufficient iris and sulcus support: a new technique. J Cataract Refract Surg. 2013; 39(3): 326-333

WELCOME