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Similar to PCR management presentation of pcrPPT.pptx
PCR management presentation of pcrPPT.pptx
- 2. Any breachin the continuity of posterior capsule Posterior capsule tears (PCT) can be pre-existing (congenital or traumatic), spontaneous, or intra- surgical Incidence of intra-surgical PCT : 1%- 4% Depends upon equipment, setup, and surgeon’s experience and skill
- 3. PCR withouta vitreous disturbance -increases risk of CME, vitreous prolapse into the anterior chamber and pseudophakic retinal detachment Once vitreous is lost-postoperative course is complicated in 30% of patients with an increased incidence of hyphaema, retained cortex, corneal edema, blurred vision and long term retinal problems including chronic CME, macular holes, retinal detachment and choroidal detachment.
- 4. General factors: Elderly Anxious Obese Demented Disoriented patients
- 5. Deep seteyes Prominent brow Exaggerated bells phenomenon Narrow palpebral fissure Disorders of spine
- 6. Corneal causes-opacity,thick arcus, pterygium, band keratopathy Anterior chamber depth-shallow , deep Iris and pupillary factors-small pupil Capsule, lens and zonules – posterior polar, zonular weakness
- 8. Wound construction: leaky woundsare the most important factor for unstable AC Continous curvilinear capsulorrhexis: CCC can withstand turbulence, pressure and mechanical stress created by the fluid, nucleus, chopper, IOL, etc Rhexis margin tear (RMT) could be primary, occurring at the stage of performing anterior CCC or secondary, i.e., happening at any other stage of the surgery
- 9. Situations where thereis more chance of having rhexis margin tear are: Intumescent or hypermarure cataract Pediatric cataract Hard cataract Fibrosed capsule
- 10. 1. Block tooutflow 2. Injection of too much fluid 3. Inherent weakness
- 11. Posterior extensionof the anterior capsular opening Direct damage to the edge of the rhexis by ultrasound tip Zonular disinsertion through traction linked to the manipulations performed on the nucleus Insufficient phaco power used to emulsify a very hard cataract Mechanical trauma to the capsule during various nuclear maneuvers
- 12. Especially inthe sub-incisional area due to poor access and decreased visibility Use of excessive vacuum Aspiration done with port close to the posterior capsule Aspiration done in the presence of a shallow chamber
- 13. IOL implantation shouldbe done under a well pressurized globe
- 15. Sudden deepeningof the anterior chamber with momentary dilatation of the pupil Sudden transitory appearance of a clear red reflex peripherally Inability to rotate a previously mobile nucleus Excessive lateral mobility or displacement of the nucleus and loss of nucleus followability Excessive tipping of one pole of the nucleus Partial descent of the nucleus into the anterior vitreous space
- 16. Once PCT isnoted, or one is in doubt about the status of the posterior capsule, surgeons needs to be calm
- 17. Next step isto confirm PCR but more than that it is important to recognize hyaloid face rupture and vitreous prolapse
- 18. Signs of HFR Torn edge – Shiny/golden – Rolled up Anterior chamber – Irregular depth Nucleus- Restricted movements of the fragments Irregular pupil Tests: Sponge test Sweep test Halo test
- 20. Extent ofPCT Intactness of hyaloid face Location of the nucleus – whether dislodged into the vitreous cavity Availability of equipment – vitreous cutter, vitrectomy machine ,alternative IOLs, VR surgeon Knowledge about anterior vitrectomy
- 21. Sudden unpluggingof the incision avoided-emptying and collapse of the anterior chamber. filled with viscoelastic to block vitreous prolapse and stabilize any remaining lens material To Phaco or convert to ECCE?
- 22. If the PCRis small(not more than 3mm) and central with intact hyaloid face – PCR can be converted to CCC.
- 23. Situation with posteriorcapsular defect and retained nuclear material without vitreous prolapse Depends on the bulk of the residual nucleus material, the degree of nuclear sclerosis, the size of the rent, size of pupil and surgeons experience If the nucleus is soft, and if only a small residual amount remains, continuing with phacoemulsification may be a reasonable option
- 24. Second instrumentto move the remaining nucleus away from the tear to complete the emulsification Procedure slowed down by reducing the aspiration flow rate, decreasing the vacuum and by lowering the infusion bottle Sheets glide introduced between the nucleus and the capsular tear by enlarging the phaco- incision by 0.5 mm
- 25. Soft nuclearfragments are crushed between two instruments, such as chopper, Sinskey hook or a repositor Viscoelastic passed beneath fragments Injected with pressure at the posterior lip of wound Causing viscoelasic to flow along with nuclear fragments
- 26. Automated vitreous cutter verygood option for soft cataracts and epi-nuclear plate Phacoemulsification without scaffold Small PCT and if vitreous face not disturbed Phacoemulsification with scaffold HEMA boat Lens glide IOL scaffold
- 27. If theresidual nuclear material is small in volume, dry anterior vitrectomy is performed and the residual nucleus is emulsified after it has been cleaned of the vitreous Phacoemulsification is performed using high vacuum (150–200 mm Hg), low flow (10–15 cc/min) and low ultrasound (30–50%)
- 28. Posterior assisted leviation(PAL) Viscoat cannula inserted through a pars plana stab incision Injecting Viscoat and maneuvering the cannula tip Nucleus elevated through the capsulorhexis and pupil and into the anterior chamber
- 29. Attempts atretrieval of dislocated nucleus -high risk of creating peripheral tears Removal of the remaining cortical material Anterior vitrectomy -allow closure of the wound without vitreous incarceration Secondary removal of dislocated nucleus-three port PPV
- 30. Microsurgical (20G)advanced vitrectomy cutter with high performance proportional linear suction control Maximum possible cutting rate, lowest vacuum and flow rates reduces traction on the retina Cutter-advanced or held stationary during anterior vitrectomy and never pulled away while cutting
- 32. Coaxial sleeve-removed and replaced by a separate infusion line –less bulky Tip is inserted through the opening in the posterior capsule and placed a mm or two behind the PC Aspiration port directed upwards towards the cornea
- 33. The best strategywhen performing a vitrectomy is to avoid violating more vitreous than is actually needed, without disturbing the rest of the vitreous especially that which overlies the vitreous base
- 34. Be surepupil is round Evaluate the intactness of CCC Evaluate the extent of posterior capsular tear and residual sulcus support
- 35. PCR small(<3mm) with well defined borders the tear- converted into a posterior CCC and IOL -bag large (>6mm) with peripheral extensions and poorly defined borders -IOL in the ciliary sulcus IOL positioned 90° away from the axis of the tear
- 37. 1. Choose thecorrect powered ACIOL 2. Anterior vitrectomy 3. Constrict pupil and iridectomy 4. Enlarging the incision 5. Inserting the IOL While advancing the leading loop of the ACIOL towards the opposite angle so that it does not touch the iris
- 41. Cystoid macularedema Retinal break and detachment Uveitis Increased IOP Corneal edema
- 42. Managed by vitreo-retinalsurgeon either in same setting or later on Needs PPV
- 43. The management ofposteriorly dislocated lens matter by the vitreo-retinal surgeon entails 1. Pars plana vitrectomy 2. Removal of retained lens matter 3. Intraocular lens management 4. Management of associated complications e.g. Dropped IOL, Retinal detachment.
- 44. Immediate/Early Single procedurefor patient Possible reduced risk of glaucoma (<3 weeks) Uveitis less severe Macular edema less severe Late Better fundus visualization PVD more likely Lens material softer: possible lower risk of retinal complications
- 45. Micro-incision vitrectomy Ensure a well-sealed cataract wound and a stable anterior chamber Anterior vitrectomy-to cut band of vitreous connecting to posterior chamber Core vitrectomy-remove central vitreous PVD induction
- 46. 1. Removal ofsoft or small lens fragments With cutter (800 cuts/ min) Light pipe to crush pieces and feed them into cutter Aspiration mode for cortex
- 47. 2. Removal oflarge or hard fragments or entire nucleus Phacofragmentome used Softer epinuclear aspirated to uncover the hard centre Aspiration engage the r fragments lift them from the posterior vitreous cavity. Once into the mid vitreous cavity- ultrasound power on to emulsify
- 48. Settings for ultrasound Power: 20-50% depending on hardness of nucleus Vaccum: 150–200 mm Hg. Bottle height increased before starting phaco- fragmentation to prevent hypotony Pulse mode used
- 49. Advantages Protects maculafrom contusion injuries by the lens pieces that fall during fragmentation. Causes the lens pieces to float on its surface, reducing risk of retinal damage during manipulating these pieces off the retinal surface. Forms a protective layer over the posterior pole and - reduce damage from the ultrasonic energy of the fragmatome
- 50. Where difficultfragmentation and fundus view obscured due to hazy cornea-nucleus brought to AC-delivered via limbal incision After core vitrectomy and PVD induction, PFCL injected upto the level of sclerotomies (two vials would be needed for this) - nucleus is pushed up to the level of the pupil.
- 52. IOL tackledafter removal of the dropped lens matter -either repositioned or explanted Lifted with a retinal pick forceps - brought into the anterior chamber.
- 54. After removalof nucleus PFCL injected to flatten retina Endolaser performed PFCL air exchange done with gas or silicone oil
Editor's Notes
- #5 inadvertent head movements during surgery or associated comorbiditie in those in elderly, anxious patients