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.
- Always stain the capsule with the vision blue to see the rhexis!
- Use a heavy viscoelastic to flatten the anterior capsule which may be under tension from a swollen lens.
- Use a needle to decompress the swollen lens before an Argentinian flag can form.
- Frequently refill the anterior chamber with visco to stay in control of the rhexis and avoid tear outs.
- 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.
- 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.
- Low bottle height to keep things slow and stable, not forcing anterior contents posteriorly.
- Triamcinolone stains and identifies vitreous which can be vitrectomised. Visco keeps vitreous walled off posteriorly.
- 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.
- 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!