VITREOUS PROLAPSE

MANAGEMENT
 INCIDENCE
Posterior capsule rent (PCR)- Vitreous prolapse (VP)
• Reported to occur in 0.5% to 7.5% cataract surgery
• The 1997 to 1998 United Kingdom National Cataract Survey: 4.3%
• Emory University Georgia: a significant reduction in vitreous loss rates after the
first 80 resident cases (5.1% vs 1.9%; P = .03)
• In Mexico (2007): Posterior capsular rupture (PCR) : 52% , zonular dialysis: 18%. In
the PCR and zonular dialysis groups, 60% and 58% of the cases required anterior
vitrectomy respectively, while 3.6% required pars plana posterior vitrectomy
• Moorfield london 2014: posterior capsule rupture: 24% with a rate of nuclear lens
material drop in the posterior segment of 5%
• The UK Cataract National Database (2009) of cataract surgery performed
by all grades of surgeons reported a posterior capsular rupture rate of
1.92%
Risk factors:
• Junior surgeons performing the surgery (AOR: 3.73 for Senior house officers)
• Dense cataracts (AOR: 2.99)
• Pseudoexfoliation/phacodonesis (AOR: 2.92)
• Presence of vitreous opacities (AOR: 2.46)
• Age [AOR]: 2.37 for those older than 90 years
• Diabetic retinopathy (AOR: 1.63)
• Use of the systemic medication doxazosin (alpha agonist) (AOR: 1.51)
• Axial lengths of greater than 26.0 mm (AOR: 1.47)
• Small pupil size (AOR: 1.45)
• Presence of glaucoma (AOR: 1.3)
• Male gender (AOR: 1.28)
• Inability to lie flat (AOR: 1.27)

Improper management PCR can have an adverse impact on the outcome of

cataract surgery
Vitreous loss appears  most crucial factor determining the eventual visual
outcome
 PCR, with or without vitreous
disturbanceincreased incidence of:
– Hyphema
– Persistent post operative inflammation
– Retained cortex
– Corneal edema
– Post operative endophthalmitis
– Cystoid macular edema (if chronic leading to
macular pseudoholes)
– Tractional retinal detachment in long standing
case or vitreous wick syndrome
 Predisposing factors
• Posterior polar cataract (with a pre-existing posterior
capsular dehiscence)
• Traumatic cataract
• Mature cataract
• Hypermature cataract
• Post-vitrectomy cataract
• Eyes with long axial length (with weak bag and weak
zonules)
• Eyes with short axial length (with crowded anterior
chamber)
• Pseudoexfoliation cases (with weak bag, weak zonules and
poorly dilating pupil)
 Intraoperative factors

• Poor visibility due to deep set eyes with prominent brow

• Fluid pooling
• Dense arcus
• Corneal scars
• Small pupil (as in diabetic patients, post-uveitic posterior
synechiae
 Intraoperative factors
• Pseudoexfoliation
• Traumatic cataracts
• Senile pupillary rigidity
• Extension of radial tears of the anterior CCC
• Small pupil
– Intacameral adrenaline
– multiple sphincterotomies
– Stretch pupilloplasty
– Iris hooks
 Intraoperative factors
Vigorous hydrodissection specially in incomplete
rhexis in cases
• Posterior polar cataract
• Traumatic cataract
• Pseudoexfoliation
• Mature and hypermature cataract
 Intraoperative factors
Factors for posterior capsular tear during the
hydroprocedures:
1. Block to outflow: The outflow may be blocked due to
increased resistance offered by visco-elastic in the chamber
or a small CCC/ small pupil. Also injecting from the side
port, when the main wound is well sealed can lead to a PCT.
2. Injection of too much fluid: Injection of too much fluid with
too much pres-sure
3. Inherent weakness: Weak capsule may be seen in case of
posterior polar cataract, high myopes, post-vitrectomy,
traumatic cataracts, pseudo-exfoliative syndro-mes and
some cases of posterior subcapsular cataract
 Intraoperative factors
• High vacuum and high power settings
• One handed technique-chasing the fragments
• Sculpting too deep/too peripheral
• Direct hit by phacoemulsification probe, chopper
or dialer (poor control dominant-non dominant
hand)
• Occurs during removal of last fragment of nucleus
following a transient post-occlusion surge in
phacoemulsification
 Intraoperative factors
• Manipulation in the bag without adequately
pressurizing the anterior chamber  anterior
chamber collapsing ↑posterior capsule
coming up and getting caught
• Intraocular lens placement and IOL rotating
• Irrigation aspiration of cortex tags of
anterior/posterior capsule can be caught into
the probe
• During polishing of the posterior capsule
 Early recognition
Signs of a posterior capsule rent/vitreous prolapse:
• Sudden deepening of the anterior chamber
• Momentary dilatation of the pupil (snap sign)
• Pupil distortion
• Sudden brightening of the fundal glow
• Visible vitreous in AC
• Nucleus paradoxically moves away on aspiration,sways sideways or
falters posteriorly away from the nucleus
• Tiiting of one pole of the nucleus.
• Nuclear fragments which were previously mobile, lose their
mobility
• Whole of the nucleus or a part of it may suddenly sink or disappear
posteriorly into the vitreous cavity
1 What should we do
• Phaco probe should not be withdrawn instantly in
a haste
• Inject the viscoelastic with the non dominant
hand through the sideport to inflate the bag
properly and then withdrawn the phaco probe
• This precaution will prevent
– Anterior chamber from collapsing  leading to
enlargement of the rent disruption of the anterior
hyaloid face  prolapse of the vitreous into the
anterior chamber
Prime importance to prevent further complications
2
Confirm the presence of vitreous prolapsed into the anterior chamber
• SWAB TEST : Sweep a sponge or swab stick along the site of
incisionVitreous if present can be seen as strands along the
section
• SWEEP TEST: Sweep the spatula from the anterior chamber angle
under the incision towards the rent  vitreous if present will be
seen getting dragged as it has a tendency to come towards the
wound
• HALO TEST: Put viscoelastic in the bag, to flatten it or keep it slightly
convex but not concave to elicit the halo test look for the ring
reflex. Intact PC: halo (+). Ring reflex will broken at the site of PCT
• STAIN TEST: Stain with triamcinolone acetonide just adjacent to the
margin of the rent  milky white stained.
Halo test
3
• Decide about the management of the nucleus
that depend on
– Extent of the rent and size
– Nucleus position
– Nucleus hardness
• PCR is small and a soft nucleus is left
– Moved away nucleus from the site of rent and
phacoemulsification can be continued
– Aspiration flow rate should be low
– Vacuum should also be low to prevent post-
occlusion surge
– Use of lens glide has been advocated by some to
facilitate this step (IOL scaffold technique)
• Large brunescent nucleus
– convert to a large incision sugery
– Enlarge the wound
– Another wound and stitch the previous wound to
have better AC stability
• Residual cortex and epinucleus should be
removed using low flow, low vacuum
• Bimanual irrigation aspiration technique
• Manual IA using simcoe
• Cortex remote from the rent should be stripped
towards the rent site and not vice-versa
• “dry aspiration”
• Epinuclear sheet can also be taken out through
viscoexpression
• If the nucleus has descended partially into
vitreous
– Its prudent not to go chasing behind it
– Posterior assisted levitation technique can be used
to bring the nucleus into the pupillary plane and
anterior chamber through the pars plana route for
further management
– Retrieval of nucleus from deep vitreous is not
recommended and should be dealt with after a
suitable interval by a vitreoretinal surgeon
• Anterior vitrectomy must be carried out
meticulously to prevent a myriad of post
operative complications like
– vitreous wick syndrome
– vitreous touch syndrome
– Endophthalmitis
– cystoids macular edema
– Glaucoma
– Tractional retinal detachment.
• Sponge vitrectomy is now obsolete because of
the intense vitroretinal traction it used to
exert
• Automated vitrectomy should be done
– Vitrectomy probe should never be inserted
through the main wound  Instead a separate
1mm incision should be made started at the
section and then proceed inwards
– Maximum possible cutting rates (upto 800 or
more) with low vacuum and flow rate should be
used
• Bimanual technique for infusion during vitrectomy is a
better option than coaxial cannulas  Coaxial infusion
canulas have a tendency to enlarge the rent as well as
it hydrates the vitreous to a greater extent
• Vitrectomy tip should go at least 1-2 mm behind the
posterior capsule. The aspiration port is directed
upwards towards the cornea.
• Alternatively, few advocate 23gauge or 25 gauge pars
planavitrectomy as it does not pull the vitreous
anteriorly and transects the vitreous at its base which
lessens the chance of post-operative vitreoretinal
tractional components to a greater extent
• For confirming the completion of vitrectomy,
following simple maneuvers can be used
• Inject air bubble and look for its fragmentation.
• Inject pilocarpine and look for peaking of pupil.
• Inject triamcinolone acetonide which will stain
the vitreous.
• In cases where posterior capsule rent has
occurred but anterior vitreous phase is intact, a
prophylactic peripheral iridectomy must be done.
• Next step is the placement of intraocular lens.
It again depends on the site and extent of
rent. It is better to place a 3-piece lens in
sulcus. If the rent is small lens can also be
placed into the bag without much dialing.
Whether in bag or in sulcus the haptics should
be oriented 90 degrees away from the rent.
After placing the lens check for its stability and
centration. If required, we have to opt for iris-
fixation or scleral fixation of the lens
 PCR Management Steps... TIPS!!!
1. STAY CALM

2. FREEZE movements, reduce bottle height

3. Inject visco from side port

4. Stop irrigation

5. Press reflux

6. Withdraw phaco tip from AC

7. Assess damage-site , extent of rent.

 PCR Management Steps... TIPS!!!

8. Mechanized bimanual vitrectomy

9. Removal of residual nuclear fragments

10. Dry cortex aspiration

11. Re-assess capsular support and insert

IOL …PC / AC

12. Secure wound closure

13. Post op care-antibiotics, steroids,

NSAIDs