Of primary concern is the potential posterior extension of the anterior radial tear, a problem that could lead to dislocation of the nucleus into the vitreous cavity. Three main factors will influence the management of this situation: (1) the density of the lens; (2) the size of the capsulorhexis; and (3) the experience of the surgeon.
Obviously, increasing the lens' density or decreasing the capsulorhexis' size will both make managing the subsequent surgery more difficult. If an inexperienced surgeon is not comfortable with completing phacoemulsification, one option is simply to convert to a “beer can” type of capsulorhexis and then to perform a manual nuclear-expression extracapsular procedure.
Several approaches may be used to complete phacoemulsification. If the lens is not too dense, then the surgeon can sculpt a large central bowl and use the phaco needle to engage and pull the rim of the nucleus into the pupillary space. The nucleus can then be rotated, and the surgeon may repeat this maneuver at multiple locations. As high vacuum brings the individual nuclear quadrants into the center of the work space, it will be possible to fracture the material from the remaining nucleus without putting undue stress on the anterior radial tear.
In denser lenses, one can employ either a divide and conquer or a chopping technique, as long as these maneuvers are performed away from the region of the capsular tear. During the sculpting of a groove, the phaco tip should be directed away from the region of the tear. Once the groove is sufficiently deep, the surgeon should rotate the lens 90º away from the tear in order to complete cracking without adding stress to the region of the tear. A similar approach may be used with a chopping technique.
A single-piece Acrysof lens (Alcon Laboratories, Inc., Fort Worth, TX) is ideal in these situations. The lens can be inserted directly into the capsular bag while its haptics are still folded. The surgeon then orients the lens such that its haptics will expand 90º away from the anterior radial tear. This step will allow completely atraumatic implantation. The capsular bag will seal down and essentially shrinkwrap the IOL, thus providing excellent long-term centration of the lens.
It may also be helpful for less experienced phaco surgeons to realize that large numbers of phaco cases were completed in the 1980s and early 1990s in the presence of multiple radial tears/can-opener capsulotomies.WILLIAM J. FISHKIND, MD, FACS
Radial tears of the anterior capsule commonly occur. In my surgeries, they happen at a rate of approximately 1%. They are most common when the nucleus is hard and the capsulorhexis is relatively small, but the tears may also extend from a notch in the capsulorhexis.
After the identification of a radial tear, it is imperative to prevent it from extending through the equator of the capsular bag and into the posterior capsule. The tear could then become large and be associated with vitreous loss. Thereafter, the anterior capsule might become too unstable to allow the fixation of an IOL in the ciliary sulcus.
For these reasons, I would stop phacoemulsification immediately upon recognizing the radial tear. Before removing the phaco tip, I would fill the anterior chamber with a dispersive ophthalmic viscosurgical device (OVD) in order to prevent the vitreous from moving anteriorly upon the removal of the phaco tip and thus enlarging the tear. Next, I would inject a dispersive viscoelastic above and within the capsular bag, between the nucleus and the bag's equator, in the region of the tear (Figure 1). Because the anterior capsule is not intact, there will be little resistance to the nuclear material moving forward into the anterior chamber.
I would perform phacoemulsification in the anterior chamber and either use a chopping technique or carousel the nucleus without placing pressure on the capsular bag (Figure 2). I would replace the dispersive OVD within the capsular bag as necessary during phacoemulsification to keep the bag full and stable and thus prevent an extension of the tear.
After emulsifying the nucleus, I would perform I/A starting with the subincisional cortex and working toward the area of the anterior capsular tear. I would remove the cortex tangentially but, when approaching the tear, pull toward the tear so as not to extend it. Prior to removing the phaco and I/A tips, I would fill the anterior chamber with an OVD in order to prevent anterior movement of the vitreous.
If the capsule tore posteriorly but no vitreous presented, I would implant the IOL in the sulcus. If the tear extended and vitreous loss occurred, a pars plana, bimanual vitrectomy would be necessary.
Next, I would inject the IOL into the anterior chamber, anterior to the iris. If the posterior capsule is intact, the lens should be placed gently into the OVD-filled bag, perpendicular to the tear in the anterior chamber. If the posterior capsule were torn, the IOL (with a suitably adjusted power) should be placed into the ciliary sulcus, perpendicular to the rent.
The early recognition of tears in the anterior capsule and an attention to detail will allow the successful management of the complication and excellent surgical outcomes.LISA BROTHERS ARBISSER, MD
Upon identifying a tear in the anterior capsule, I would fill the chamber with a dispersive OVD through the sideport incision, withdraw my phaco tip, and inspect the extent of the tear by retracting the iris if necessary. Assuming that the tear does not extend beyond the zonules, I would change my phaco parameters to low flow settings, lower the bottle of BSS, and continue with my usual vertical chop technique but with cautious and minimal rotational force. All the while, I would monitor the tear and keep it in place by maintaining compartmentalization with the OVD over this area. If the tear has extended beyond the zonular insertion, I would use a supracapsular technique.
Great care would be necessary to avoid engaging the edges of the tear during the aspiration of the cortex. If there were any resistance due to poor hydrodissection around the area of the tear, I would use a dry manual technique under a cohesive viscoelastic without irrigation to aspirate the cortex in this area. This approach should provide the most control and prevent forces that might extend the tear.
I would choose a single-piece acrylic IOL, my usual lens, and place it in the bag. Because there is no pent-up energy in this lens as it unfolds, the IOL can be safely implanted in cases such as this one and maneuvered without difficulty before it has unfolded completely so that its haptics are not located in the area of the tear. This lens will stay put and will not cause asymmetric forces in the postoperative period. If only a three-piece lens were available, I would use a bimanual insertion technique and avoid dialing the lens into the bag. I would also make a small radial cut in the anterior capsule, 180º away from the tear, to balance forces and lessen the chance of asymmetric capsular fibrosis, which could lead to decentration of the IOL. Plate haptic lenses would never be appropriate under these circumstances.
I would not remove viscoelastic from the posterior chamber under the IOL in my usual way. Instead, I would constrict the pupil with Miochol-E (Novartis Ophthalmics, Inc., Duluth, GA) after smoothing out the edge of the tear, which the overlying iris would support during aspiration of the OVD from the anterior chamber. Due to the likelihood of residual OVD, I would use an antihypertensive medication to prevent a spike in IOP during the immediate postoperative period. I would expect an uncomplicated postoperative course with an excellent result in this case.MARC MICHELSON, MD
Upon recognizing the tear, my first thought would be, “no big deal.” Not long ago, all phacoemulsification was performed with a can-opener capsulotomy and approximately 15 to 20 radial tears in the anterior capsule. Most of those cases were completed without any tears extending into the posterior capsule.
The advent of the continuous curvilinear capsulorhexis applied a higher technical standard to the cataract operation; in fact, some IOLs require an intact anterior capsulorhexis for insertion. In addition, phaco techniques using high flow and vacuum may place additional stress on an already weakened capsulorhexis, thereby precipitating a potential posterior capsular tear.
In this case, I would attempt to redirect any procedural stressors away from the tear. I routinely use Healon5 (Advanced Medical Optics, Inc., Santa Ana, CA) during phacoemulsification. I would ensure that there was an adequate amount of the OVD in the anterior chamber and add more if necessary in order to apply some increased pressure from the anterior chamber posteriorly against the anterior capsule. This pressure would help stabilize the anterior capsule by prohibiting the development of posterior pressure that could force an extension of the tear. Attempts to hydrodissect with BSS should be abandoned. I would modify fluidics by lowering the aspiration rate to the low 20s, decreasing vacuum to 150mmHg, and proceeding with phacoemulsification at a slower rate. I would also attempt to perform the phacoemulsification at least 1 to 2 clock hours away from the tear and avoid placing the phaco tip near the tear.
If the nucleus does not rotate well within the bag, I would lower the phaco energy and perform an in situ emulsification until the nucleus breaks away freely from the capsular bag. I would not hesitate to remove nucleus from beneath the tear but would do so slowly and cautiously. After nuclear removal, the challenge would be to aspirate the remaining cortex. I usually do not modify my I/A settings, but I would strive to avoid aspirating the torn flap.
If cataract removal could be completed successfully with an intact posterior capsule, I would implant a three-piece silicone or acrylic IOL. I would avoid a single-piece or plate-style lens. My lens of choice is the Alcon Acrysof SN60WF (Alcon Laboratories, Inc.), owing to how little stress it places on the capsule as it gently unfolds. If I were to use a three-piece IOL, I would allow the implant's leading haptic to unfold in the anterior chamber in order to reduce the hazard of a haptic's sweeping across the inside of the bag as the IOL unfolded and expanding the tear. The unfolded lens could then be guided into the bag with little stress to the anterior capsule.
Section Editors Robert J. Cionni, MD; Michael E. Snyder, MD; and Robert H. Osher, MD, are cataract specialists at the Cincinnati Eye Institute in Ohio. They may be reached at (513) 984-5133; firstname.lastname@example.org.
Lisa Brothers Arbisser, MD, is in private practice in Davenport, Iowa, and is immediate past President of the American College of Eye Surgeons. Dr. Arbisser has performed clinical research for and has received travel support and honoraria from Alcon Laboratories, Inc., and Advanced Medical Optics, Inc. She states that she holds no financial interest in the products mentioned herein. Dr. Arbisser may be reached at (563) 323-8888; email@example.com.William J. Fishkind, MD, FACS, is Codirector of Fishkind and Bakewell Eye Care and Surgery Center in Tucson, Arizona, and Clinical Professor of Ophthalmology at the University of Utah in Salt Lake City. He states that he holds no financial interest in the products or companies mentioned herein. Dr. Fishkind may be reached at (520) 293-6740; firstname.lastname@example.org.
Marc Michelson, MD, is Clinical Professor of Ophthalmology at the UAB Medical Center in Birmingham, Alabama. He did not disclose a financial interest in the products or companies mentioned herein. Dr. Michelson may be reached at (205) 930-0930; email@example.com.
Richard Tipperman, MD, is a member of the active teaching staff at Wills Eye Hospital in Philadelphia. He participates on the Speakers Bureau for Alcon Laboratories, Inc., but states that he does not hold a financial interest in the products or other companies mentioned herein. Dr. Tipperman may be reached at (610) 293-0808; firstname.lastname@example.org.