Anterior capsular tear during horizontal chop in cataract surgery


Hi, it’s Dr. Devgan doing a video review for
EyeGuru. Here’s our paracentesis being made and it
looks pretty good. Main incision with a groove there at the gray
line. Looks like a multiplanar incision being made. We want an appropriate tunnel length and we’re
hitting Descement’s right about there. I like the change of the angle to ensure the appropriate
tunnel length. That looks great. Cystotome used to start the capsulorrhexis. That looks pretty good so far. I do like how the eyelashes are draped out
of the way and the lid margins are not visible. That’s perfect. Now Utrata’s being used. It looks like this is the end of the capsulorhexis. Completing that here, that looks good. Here we’re hitting the right side of the incision
a little bit. Need to float that incision a little bit better. But so far so good. Hydrodissection being done. And it looks like we’ll tap down the nucleus. Here’s a chop being attempted. Now the problem already is the probe is too
far in the center of the nucleus and not towards the periphery. And so the probe should be more subincisional. So that’s why it didn’t propogate an appropriate
chop. In addition, we’re using this awkward chopper
that has this ball tip which is really not my favorite. Now here, that red reflex is bad. I mean that’s pulling on the capsule. There’s no cortex there. That’s probably where the anterior capsular
rim broke. So we’ll remove the rest of this cataract. This is obviously sped up at lightning speed
here. Cataract comes out. Epinuclear shell comes out. And there we can see there’s the broken anterior
capsular rim. Now what’s the key here? The key is to avoid having this rip backwards
to the posterior capsule. That’s the most important issue now. You’ll still have a beautiful outcome here. You’ll get the lens in the bag and have a nice result. But the key here is to be very careful removing
the cortex. So do that area where it’s ripped last. And they’re doing that here. So do the rest of the cortex removal. And you’ll notice there are actually two pieces
of cataract material in the anterior vitreous. Well how’d they get there? Around this area, when the chop went in there,
you saw that really bright red reflex. That allowed pieces of cataract material to
extend back through this barrier into the anterior vitreous. So here we’re doing a nice slow motion to
remove the cortex at that one area, being very careful not to grab the capsular rim. You don’t want to grab the capsule, just the
cortex. You could also use the 27 gauge cannula and
do it manually. But I like this technique so far. And here, boom it’s done. Now leave it well enough alone. Don’t do any more. The lens is going in, that’s appropriate. Now we need to rotate it so that the haptics
open away from that area. And you see that one piece of chunk that’s
still in the vitreous. It’s probably not going to be too much of
a big deal. The patient is going to have some prolonged
inflammation. Watch them carefully. But I don’t think you need to do, at this
point at least, a referral for pars plana lensectomy So taking out the rest of the viscoelastic. Being very careful with stability here. Because if you push on that lens, you can
cause that rip in the capsule to extend posteriorly. So they hydrate the incisions appropriately. And it looks pretty good. Again, watch the patient carefully in the postoperative period. Those two little pieces are going to cause
some postoperative inflammation. So let’s look at the discussion below and
we’ll talk more.

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