Vitreous loss is inevitable. Given the volume of cataract surgery and the variety of pathology presented by the human eye, even in the best of hands there will be some rate of complications involving loss of the integrity of the capsular or zonular structure. Our obligation to our patients is to prevent vitreous loss where predictable, and minimize the impact of the consequences where possible.
Complications can be placed into three categories: a broken capsule or loss of zonular integrity with an intact vitreous face; vitreous prolapse (defined as vitreous within the confines of the anterior chamber); and vitreous loss through the incision. The likelihood of post-operative sequelae increases significantly with each of these categories, and motivates the surgeon to recognize and control damage at the earliest stage. The more vitreous traction we permit or cause, and the more we fail to prevent inflammation, the lower chance of an ideal outcome we offer our patient.
In the heat of the battle, we are least likely to be logical and analytical. It behooves us to prepare a flow chart of maneuvers and a sequence of decisions before entering a patient’s eye. This paper will provide a framework to achieve an optimal result.
Prevention
“An ounce of prevention is worth a pound of cure”. We heard it from our mothers as youngsters, and the adage remains valuable today in every endeavor. Each step of cataract surgery is built on the solid foundation of the prior maneuver. If we have misjudged the patient’s ability to tolerate the choice of anesthesia (or the lack thereof), or our ability to communicate and work on a moving target, we have set the stage for disaster. I advocate always having a ‘plan B’, i.e., standby intravenous anesthesia or the wherewithal to initiate subtenons injection intraoperatively.
Wound construction is central to the maintenance of the chamber. Minimal leak through the main incision as well as the paracentesis results in a deep chamber and minimization of surge. An understanding of the fluidics and dynamics of the phacoemulsification machine employed is critical to be able to anticipate trouble and optimize the intraocular environment.
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