OCT 08, 2008
Cataract/Anterior Segment
Recent refinements in phaco and IOL surgery have led to a myriad of patient benefits including the reduction of pre-existing refractive error, improvement in the quality of vision through the use of aspheric implants and most recently by the introduction of new multifocal and pseudo-accommodating lenses.1 At the heart of these advances, however, is the remarkable reproducibility of the procedure and amazingly low rate of complications.
Nonetheless, on occasion, be it due to "pilot error" or unavoidable ocular characteristics and anatomy, problems will be encountered. Arguably, the single most significant complication still faced by today's phaco surgeon continues to be rupture of the posterior capsule and vitreous loss.2 Fortunately, in the setting of small-incision surgery, if the surgeon adheres to certain fundamental principles and employs proper instrumentation and surgical technique, the vast majority of these complicated eyes will enjoy an outcome that differs little from that of an uncomplicated case.3
The key components to the management of this condition include quick recognition of the problem, avoidance of hypotony, and maintenance of a truly closed-chamber environment. These are predicated on the use of watertight incisions. As such, a much lower rate and volume of infusion may be used, thereby reducing intraocular turbulence. To further enhance control of the intraocular environment and reduce vitreoretinal traction, a separated or bimanual vitrectomy should be used. In this way, the location and vector force of the infusion is displaced from the point where one is attempting to delicately remove vitreous. A reasonable approach is to place both instruments through limbal incisions (Figure 1).