Dr LaHood Surgery

Be very suspicious…

It is my advice to be very suspicious of a unilateral whait cataract in a patient with a history of intravitreal injections.


Because a posterior capsule rupture could be waiting for you!

I recently came across such a case (see the video of the procedure here) and I can demonstrate and talk through a few key points to management for those that are interested.

  1. Always stain the capsule with the vision blue to see the rhexis!
  2. Use a heavy viscoelastic to flatten the anterior capsule which may be under tension from a swollen lens.
  3. Use a needle to decompress the swollen lens before an Argentinian flag can form.
  4. Frequently refill the anterior chamber with visco to stay in control of the rhexis and avoid tear outs.
  5. Don’t hydrodissect as it can cause a blow out of a posterior capsule defect, losing the whole lens backwards. Hydrodelineation can be a great idea but in this cataract the dense nucleus takes up all the space.
  6. I have chosen to divide and conquer to avoid putting a chopper into vitreous but always keep your second instrument behind each segment to keep them elevated.
  7. Low bottle height to keep things slow and stable, not forcing anterior contents posteriorly.
  8. Triamcinolone stains and identifies vitreous which can be vitrectomised. Visco keeps vitreous walled off posteriorly.
  9. A three-piece IOL should be placed in the sulcus. You can see I was optimistic and had a one-piece toric IOL planned with my digital marking but it wasn’t to be. Instead, astigmatism can be treated with corneal laser later.
  10. Any time vitreous may be on the loose, suture your main incision and use miochol to highlight any vitreous to incisions that would cause a peaked pupil.

It’s amazing how a thin and fragile capsule separates us from so much trouble in standard cases.

But these eyes can still have great outcomes if you are prepared and suspicious!

See the video and post here.

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