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Cataract Complications, Part 1
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The 2013 Cataract Spotlight Session presented a full range of challenging cases, from surprising instrument snafus to torn capsules with vitreous loss.


This past November, the 12th annual Spotlight on Cataract Surgery Symposium at the Academy’s Annual Meeting was entitled “M&M Rounds: Learning From My Mistakes.” Cochaired by William Fishkind, MD, and myself, this four-hour case-based video symposium was focused on cataract surgical complications.

Every cataract surgeon makes mistakes and suffers complications, but it is how and what we learn from them that makes us better ophthalmologists. During the symposium, 18 cataract experts each presented a video case in which something went wrong, and a complication occurred that taught them valuable lessons. At critical decision points during the case, the video was paused and the attendees were then asked to make clinical decisions using electronic audience response pads. Next, two discussants (who had not viewed the case) were asked to make their own management recommendation and to comment on the audience responses before the video of the outcome was shown. The audience also voted on the best teaching cases and selected those surgeons who demonstrated the most courage—both in the OR and on the podium.

The 18 video case presentations covered the full spectrum of surgical complications, from the common to the rare—and from the spectacular save to the demoralizing outcome. The complications included anterior capsular tears (both with and without the femtosecond laser); instrument snafus (jammed forceps and projectile cannulas); entanglement with capsule retractors, capsular tension rings (CTRs), and Malyugin rings; suprachoroidal effusion; descending nuclei and intraocular lenses (IOLs); IOL exchange complications; and capsules or zonules ruptured at virtually every stage of surgery. Even those attendees who thought that they had “seen it all” were shaking their heads at some of these cases. The entire symposium with videos can be seen if you purchase AAO Meetings on Demand (go to www.aao.org/2013 and click “AAO Meetings on Demand”).

Samuel Masket, MD, concluded the symposium by delivering the ninth annual AAO Charles Kelman Lecture. Dr. Masket’s presentation, “25 Years of the JCRS Consultation Section,” highlighted surgical solutions to complicated cataract or IOL cases that had been featured in his long-running column in the Journal of Cataract and Refractive Surgery.

This EyeNet article reports the results of the audience response questions, along with written commentary from presenters and panelists. Because of the anonymous nature of this polling method, the audience opinions are always interesting and were discussed in real time during the symposium by our panelists. Finally, I want to especially thank our 18 audacious video presenters. It is much easier to present your best cases instead of your complications in front of several thousand attendees. We all appreciate their humility, courage, and generosity in sharing these cases with us so that we might all improve our surgical judgment and skills.

—David F. Chang, MD 
Cataract Spotlight Program Cochairman 


Case 1: From Champagne to Lemonade

A Miotic Pupil With an Anterior Capsular Tear


Roger Steinert’s patient had a small pupil, and a fibrotic pigmented membrane was peeled from the pupil edge. After a pupil expansion ring was implanted, a defect was noted in the anterior capsule. The defect might have been caused by the pupil instrumentation.

Q  At this point, with an anterior capsular tear/defect and a moderately firm nucleus, what would be your strategy?

No change; continue with slow intracapsular phaco


Add relaxing continuous curvilinear capsulorrhexis (CCC) cuts and then continue intracapsular phaco


Convert to can-opener capsulotomy, then continue intracapsular phaco


Prolapse the nucleus for supracapsular phaco


Convert to manual extracapsular cataract extraction (ECCE)


Roger Steinert This case began with an unexpected problem in the anterior capsule, disclosed by the gape seen when staining with trypan blue revealed a midperipheral anterior capsular defect. Interestingly, the video does not give any clue when or how this defect occurred. What became clear, however, is that the defect could not be included in the capsulorrhexis. Given the advanced state of the cataract, perhaps the positive pressure inside the lens was the reason the defect extended far enough to the periphery that it could not be included in the circular tear capsulotomy (a mini-“Argentinean flag” sign). Now confronted with a single defect in the capsulorrhexis, the surgeon had to decide how to minimize the potential for an extension wraparound tear. Gentle and low-force techniques would certainly be appropriate.

My personal choice was to add three more defects in the capsulorrhexis, at 3, 6, and 9 o’clock relative to the incision. In doing so, I referenced a lesson learned from can-opener capsulotomy in ECCE—in these cases, we never saw wraparound tears when we expressed the intact large nucleus through the capsulotomy. (That is, multiple weak areas will allow an enlargement that does not extend beyond the lens equator.) In this case, by adding three more defects in the capsulorrhexis, I was able to relieve all of the stress from the single defect and reduce the pressures on that area that might extend into a wraparound tear.

Audrey Talley Rostov An anterior capsular tear always presents a management challenge. Care must be taken to minimize adverse sequelae, including further extension of the tear and vitreous loss. The majority of the respondents voted to continue with slow, careful intracapsular phaco. This is a reasonable option if one takes great care to avoid excessive manipulation of the bag and uses an ophthalmic viscosurgical device (OVD) generously to avoid catching the edge of the capsule in the phaco tip, thereby increasing the likelihood of the extension of the capsular tear.

The audience’s second choice—prolapsing the nucleus for supracapsular phaco—would be my preferred approach for this situation. After injecting cohesive OVD beneath the nucleus and dispersive OVD above the nucleus to protect the corneal endothelium, the surgeon can then perform phaco carefully in a “soft shell” fashion, thus avoiding the capsular tear and iris while protecting the corneal endothelium. Consideration can also be given to utilizing trypan blue to stain the capsule and provide some capsular stiffening while also creating better visualization so that one can avoid catching it in the phaco or irrigation and aspiration (I&A) tip.

The audience’s third choice (and the method used here), the creation of relaxing incisions in the capsulorrhexis, provides a great surgical pearl for releasing stress on the capsule and allowing a safe phacoemulsification to continue.


Case 2: Conundrum

A Wraparound Tear in a Multifocal IOL Patient

Stephen Lane’s patient had a femtosecond laser capsulotomy. Following cortical cleanup, a wraparound posterior capsular tear, presumably from a femtosecond tag, was noted. A multifocal IOL had been planned.

How would you proceed with this wraparound posterior capsular tear?

No vitrectomy, but implant a posterior chamber IOL (PCIOL) in the sulcus


Perform limbal vitrectomy prior to sulcus PCIOL implantation


Perform pars plana anterior vitrectomy prior to sulcus PCIOL implantation


Perform a manual posterior capsulorrhexis (with or without a vitrectomy)


Perform a femtosecond laser posterior capsulorrhexis (with or without a vitrectomy)


Following a partial posterior curvilinear capsulotomy with a radial anterior/posterior capsular tear, I’d implant a:

One-piece monofocal IOL in the bag


One-piece multifocal IOL in the bag


Three-piece monofocal IOL in the sulcus


Three-piece multifocal IOL in the sulcus (unsutured)


Three-piece multifocal IOL in the sulcus (sutured)


Stephen Lane A wraparound capsular tear is most commonly a result of an anterior capsular rim discontinuity that tears out to the zonules or beyond to the posterior capsule. Frequently, this discontinuity is so small that the surgeon is not aware that it exists.

The unique feature of this case is that the anterior capsulorrhexis created by the femtosecond laser appeared completely intact at the conclusion of nuclear and cortical removal. However, the positive pressure created upon decompression of the anterior chamber with removal of the irrigation cannula at the conclusion of I&A was enough to cause a wraparound tear. The lesson to be learned is to never allow decompression of the anterior chamber if there is any concern about an anterior capsular discontinuity. Instead, instill OVD before removing the irrigation cannula to maintain an adequate intraocular pressure (IOP) to keep the anterior segment inflated.

In this case, there was never any evidence of vitreous loss, so a vitrectomy was not necessary. After instilling OVD to tamponade the vitreous face, I converted the posterior capsular tear to a posterior rhexis with a “keyhole” in the anterior capsule. This was done in order to prevent further extension of the capsular opening posteriorly. With this reassurance, a single-piece multifocal IOL was placed in the capsular bag. I took care with the orientation of the haptics, positioning them 90 degrees away from the keyhole in the anterior capsule. Although a multipiece multifocal IOL could have been placed in the sulcus (with or without optic capture), the stability of the IOL in the capsule was felt to be superior, given the circumstances discussed above. Indeed, the IOL has remained stable with a good visual result with one year of follow-up.

Robert Cionni Although a radial anterior capsular tear might seem nonthreatening, it really needs to be treated as a significant potential threat! Even in skilled hands, 40 percent of anterior capsular tears will wrap around to involve the posterior capsule, and 20 percent will develop vitreous prolapse, requiring a vitrectomy.1 Therefore, all anterior capsular extensions should be managed as carefully as posterior capsular tears.

I agree with the majority of the polled audience that proceeding with gentle removal of the nucleus and cortex is the correct approach. The key to preventing a wraparound tear to the posterior capsule and ensuing vitreous prolapse is to avoid anterior chamber collapse while limiting forces at the anterior capsular edge as well as avoiding overexpansion of the capsular bag. A single-piece acrylic PCIOL, carefully placed into the capsular bag with the haptics oriented away from the area of the anterior capsular extension, should result in a stable/centered IOL in the long term.

If a posterior capsular tear occurs following a radial anterior capsular extension and a posterior CCC is achieved, either a single-piece IOL in the bag or a three-piece IOL in the sulcus is appropriate for long-term stability, unless the posterior CCC is too large to ensure in-the-bag stability. In the latter instance, sulcus placement of a three-piece IOL is indicated. In either case, there is no need to avoid placement of a multifocal IOL.


1 Marques F et al. J Cataract Refract Surg. 2006:32(10);1638-1642.


Case 3: Killing Me Softly

A Soft Nucleus With Posterior Capsular Rupture

Brock Bakewell’s case involved a soft nucleus that did not rotate. As phaco proceeded, a tear in the posterior capsule occurred, and vitreous prolapse ensued.      

Soft nucleus won’t rotate. Now what?

Continue cautious phaco


Stop; hydrodissect again


Stop; viscodissect


Use an OVD and mechanically maneuver (e.g., spatula)


Switch to I&A


Brock Bakewell Even though the patient ended up with a sulcus-fixated IOL captured by the anterior capsulorrhexis and a 20/20 outcome without any retinal tears, the case could have been handled differently. The complication could have been prevented if a more thorough hydrodissection had been performed from the outset. As a rule of thumb, a surgeon should never proceed with phacoemulsification until it is possible to freely rotate the nucleus, no matter how soft it is. Injecting balanced salt solution (BSS) through a Binkhorst cannula works well to free up the nucleus subincisionally.

In this case, once the posterior capsular tear happened, a dispersive OVD should have been injected into the rent prior to removal of the phaco needle. Even though vitreous did not present immediately, a dispersive OVD can sometimes prevent vitreous prolapse during I&A of the residual paranuclear material and cortex. When the vitreous did present, triamcinolone could have been used to identify it, making bimanual vitrectomy through paracentesis incisions easier and potentially less traumatic.

Ehud Assia This case illustrates the importance of effective hydrodissection in eyes with a soft nucleus. In these eyes, mechanical separation of lens material using a spatula or other instrument may be even more difficult than it is in eyes with harder nuclei, as the instrument may penetrate through the lens material during mechanical manipulation rather than separate it from the lens capsule. If lens material does not rotate during surgery, hydrodissection or viscodissection should be performed again.

Most of the audience favored viscodissection; however, this maneuver should be done very cautiously. Fluid will always find its way out. In contrast, if the flow of a viscoelastic substance is blocked, it may accumulate and eventually explode the posterior capsule. Studies have shown that OVD is more efficient in maintaining a space between the lens material and the capsule after it was first separated by fluid.

Another significant point is the adjustment of the phaco parameters to the hardness of the cataract. Many surgeons have a favored setting that they use in most of their cases; however, there is no “one program fits all.” Soft lenses do not require burst mode, and the aspiration rate should be lowered to prevent a fast and uncontrolled aspiration of the epinucleus and cortical fibers along with the posterior capsule. Although switching to I&A may work well, hydrodissection should be done prior to lens aspiration. In any case, failure to rotate the lens material should not be ignored, and any attempt to separate the lens material from the capsule should be done prior to its removal.


Case 1 to 3

The “CPR Award” voted for the surgeon whose case demonstrated the best save (successful rescue from impending disaster):

Roger Steinert: Miotic pupil


Stephen Lane: Femtosecond laser/multifocal IOL


Brock Bakewell: Soft nucleus



Case 4: The Donnenfeld Snap Technique

Enlarging a Small Capsulorrhexis

Eric Donnenfeld presented a case in which he manually enlarged a contracted capsulorrhexis in the setting of unexpected zonular weakness. 

An anterior capsule flap overlying the IOL optic is noted. What would you do next?

Stop—you’ve done enough


Leave it, but inject Miochol-E


Trim the capsule flap with intraocular microscissors


Excise the capsule flap with bimanual vitrectomy instrumentation


Manually complete the tear (“snap” maneuver)


Eric Donnenfeld This patient had intractable dysphotopsia following cataract surgery and was quite miserable with her quality of vision. The anterior capsule—the presumed cause of her dysphotopsia—was overriding the IOL in one quadrant. Treatment options included implanting a plano piggyback IOL, vaulting the IOL in front of the anterior capsule, and trimming the quadrant of capsule.

The surgeon attempted to manually tear the anterior capsule, which resulted in vitreous loss. During the bimanual vitrectomy, the surgeon was able to trim the aberrant capsule with I&A vitrectomy mode.

This resulted in resolution of the patient’s symptoms, which confirmed that the anterior capsule override was the cause of her dysphotopsia.

In retrospect, removing the capsule was the right decision, and using a manual tear was the wrong technique. Using the vitrector to trim the capsule or employing microscissors would have been less traumatic and equally effective.

Skip Nichamin The audience’s leading response was to stop and do nothing. In cases of weakened zonules with a tenuous capsular bag/IOL complex, this can, at times, be an acceptable option. The cause of the zonular weakness—for example, a progressive degenerative condition versus a nonprogressive traumatic etiology—along with the particular anatomy of the case will help the surgeon determine the best strategy.

I personally would lean toward a bimanual technique, using intraocular microscissors to enlarge the opening, along with using microforceps in the opposite hand to stabilize structures and provide countertraction to the force of the cutting scissors. Both instruments would be placed through watertight paracentesis incisions. Generous use of a cohesive OVD to maintain space and a dispersive agent to tamponade the area of exposed hyaloid would also be key considerations.


Case 5: Open or Closed?

A Posterior Polar Cataract

Sonia Yoo presented a posterior polar cataract patient. Because of a capsular defect, the posterior capsule tore when the anterior chamber suddenly shallowed after the I&A tip was withdrawn.

For a posterior polar cataract, I would:

Hydrodissect and hydrodelineate


Viscodissect and hydrodelineate


Hydrodelineate only


Skip all hydrosteps


Refer these cases


Q  In this case with posterior capsular rupture successfully managed, I would:

Immediately inform the patient of the complication


Wait until later to discuss the complication


Not discuss any complication unless other problems arose


Tell the patient, “Good news; we’ve avoided the inconvenience of a later Nd:YAG capsulotomy”


Bonnie Henderson Management of posterior polar cataracts can be tricky. The polar cataract is a discoid opaque area of the posterior lens composed of malformed lens fibers. The polar cataract can be adherent to the posterior capsule—and, in turn, the central capsular area can be weak. Not all cases will result in a capsular tear; therefore, it can take a surgeon by surprise if she is not prepared.

The first question refers to the single most important change that a surgeon can make when operating on a posterior polar cataract. Hydrodissection should be avoided to prevent additional pressure in the weakened posterior capsular area. Even gentle hydrodissection or viscodissection between the capsule and lens can cause a cleavage of the posterior capsule. Therefore, it is often considered a safer approach to hydrodelineate the nucleus to separate the inner harder core from the softer epinucleus. The inner core can then be removed while leaving the epinucleus as a protective shell. The epinucleus is subsequently removed cautiously to evaluate for any opening of the posterior capsule.

If there is a hole in the capsule, as in this case, it is paramount to stabilize the anterior chamber with viscoelastic solution before removing any instruments. The capsular defect should be managed like any other posterior capsular defect by minimizing chamber fluctuations, lowering fluidics, and cutting vitreous strands that migrate anteriorly.

When a complication occurs, even if it is managed appropriately and without incident, I believe that it is best to inform the patient. Every surgeon has and will have complications. This is the nature of surgery. Therefore, the patient should be informed of significant problems that occur. Additionally, when this is the case, it is essential to make the patient aware of any signs and symptoms of potential postoperative complications. This discussion is best held on either the day of or the day after surgery.


Case 6: Complex Cases Gone Wild

A Dense Traumatic Cataract

Ike Ahmed’s case was a dense traumatic cataract. After a CTR was placed, phaco was complicated by a posterior capsular tear. This posed the question of whether to attempt a posterior capsulorrhexis—or to simply place an IOL in the ciliary sulcus.

A posterior capsular tear is noted with a CTR already inserted into the capsular bag. What now?

Posterior capsulorrhexis and implant a nontoric single-piece acrylic IOL


Posterior capsulorrhexis and implant a toric IOL


Implant a three-piece IOL in the ciliary sulcus


Implant a three-piece IOL in the sulcus and capsulorrhexis capture


Implant a three-piece IOL in the sulcus and suture fixation


Ike Ahmed This was a complex case with 180 degrees of zonular dialysis present. Plans were made to use a sutured capsular tension segment (CTS) and a CTR to provide adequate capsular bag centration and support. These were placed early in the case, but the presence of a posterior capsular rent—which occurred during the removal of the last nuclear fragment—increased the risk of peripheral extension. As soon as the tear was noted, prevention of anterior chamber shallowing was critical to prevent extension. Thus, the anterior chamber was filled with OVD prior to removal of the phaco handpiece.

At this point, one has to consider where IOL fixation will be attempted and plan accordingly. The plurality of the audience voted to place a three-piece PCIOL in the sulcus with optic capture. However, the presence of the CTS, with its central eyelet around the capsulorrhexis, would cause excessive optic tilt; thus, I believe that this strategy is not advisable. (If only the CTR was in the bag, then optic capture would be quite reasonable.) Almost a quarter of the audience elected to place a three-piece PCIOL in the sulcus; without adequate zonular support, this would increase the risk of IOL decentration. (If both the CTR and CTS could be retained and sutured, then this would be a viable option.) As one can see, the presence of the large zonular dialysis and CTS/CTR in the bag creates additional issues in the presence of a posterior chamber rent.

At this point, I elected to attempt a posterior CCC to prevent the tear from extending further into the periphery during cortical removal and IOL insertion—which is a major risk with the CTR in place—as well as to retain the advantages of in-the-bag placement of the capsular tension devices and the PCIOL. A pars plana incision was made at this point to manage vitreous prolapse and decompress behind the posterior chamber to prevent further extension. This was a critical decision that I believe made performing the rhexis more manageable.

Dispersive OVD was injected posterior to the tear, and microscissors were used to cut and create a flap in the posterior chamber just beyond the central tear. Microforceps were used to continue the tear in a circular fashion. Tips for performing a posterior CCC include 1) balancing pressure anterior and posterior to the posterior chamber (OVD should be injected behind and in front to sandwich the posterior chamber, but not to the point of overfilling); and 2) grasping and regrasping often, using both standard shearing as well as stretching techniques for continuing the tear. Careful focusing and managing vector forces are important during the creation of the rhexis. In this case, a 4-mm posterior CCC was performed. It is important to keep the rhexis from being too large.

Once the posterior CCC was created, cortical removal was performed, and 7-0 Gore-Tex suture was used to suture the CTS to the sclera in the area of dialysis. A single-piece toric PCIOL was then placed in the bag and positioned carefully. The presence of a pars plana incision aided in removal of the OVD behind the toric IOL with the use of the vitrector.

Alan Crandall This case is very interesting as well as complex. The original plan was to place a single-piece toric IOL within the bag. Due to zonular weakness, a CTS and CTR were implanted. However, the posterior capsule was torn later during surgery.

It is critical to understand the problems that the tear created. In a case such as this one, the first step is to not come out of the eye until an OVD is placed to prevent vitreous from coming forward. (A dispersive OVD can be used to hold the vitreous face back.) Once the chamber is stabilized, then one can decide how to approach the situation. A CTR will place centrifugal force symmetrically on the bag—and because the tear did not extend, it would make sense to attempt a posterior rhexis. However, it is important to avoid overfilling the bag, as that could lead to an extension of the tear and make the rhexis attempt difficult. A single-piece IOL cannot be placed into the sulcus, as it will likely cause pigment dispersion and secondary glaucoma, but it can be placed if the posterior rhexis is completed.

The audience response seems to indicate that most surgeons are not comfortable with a posterior rhexis in this setting. If one is not comfortable with a posterior rhexis, then this would not be a good case in which to attempt it, and the fourth answer would make good sense. Rotation of a toric lens into the correct position would have to be carefully performed in this case given the zonular issue; a bimanual rotation with minimal force on the complex could be used. Removal of the OVD must also be done carefully to make sure that the lens does not rotate and no further forces destabilize the IOL/bag complex.

Overall, this was beautiful surgery; it shows that it’s critical to have multiple game plans with well-thought-out approaches.


Case 4 to 6

The “Grand Rounds” Award voted for the surgeon who presented the best teaching case:

Ike Ahmed: Dense traumatic cataract


Sonia Yoo: Posterior polar cataract


Eric Donnenfeld: An errant anterior capsular tear



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