POSTERIORLY DISLOCATED
RETAINED LENS MATERIAL
DR.ZEINA AL_JUNAIDI
INTRODUCTION
Posteriorly dislocated lens fragments, also known as retained lens material (RLM), are a
complication of cataract extraction, particularly phacoemulsification
These patients are at high risk of significant intraocular inflammation, increased intraocular
pressure (IOP), corneal decompensation, cystoid macular edema (CME), and
rhegmatogenous retinal detachment (RRD)
INDICATIONS
Postcataract extraction:
• Nuclear fragments in the vitreous
• Substantial cortical fragments in the vitreous or capsular bag.
Particularly with:
• Persistent intraocular inflammation
• Poorly controlled IOP
• Vitreous hemorrhage and/or concern for retinal tear or retinal
detachment
• Unacceptably symptomatic vitreous opacities
• Need for urgent visual rehabilitation.
INDICATIONS
Primary lens removal:
• Visually significant crystalline lens subluxation or dislocation
(e.g. trauma or Marfan’s syndrome)
• Known or suspected prior posterior capsule violation
• Persistent fetal vasculature (some cases)
• In combination with posterior segment procedures to aid in
visualization or access.
CONTRAINDICATIONS
Small cortical lens fragments that can be managed medically
Corneal edema that significantly impairs visualization for PPV
Presence of moderate-to-large-sized choroidal detachments.
MECHANISM OF ACTION
PPL is the physical disassembly and aspiration of lens material.
Elimination of RLM reduces the stimulus for inflammation that causes elevated IOP and
CME.
ANTERIOR VITRECTOMY
An anterior vitrectomy can be defined as the removal of vitreous from the anterior
chamber, or the anterior third of the vitreous cavity.
The approach can be anterior via the clear cornea, or sclerocorneal limbus,
or posterior via the pars plana
ANTERIOR VITRECTOMY
Most common indications for an anterior vitrectomy are capsular rupture during cataract
surgery or in cases of surgery for anterior segment trauma
removal of vitreal fibers bound to the iris or to the surgical wound, as a measure of
avoiding complications related to vitreous adhesions such as cystoid macular edema or
vitreocorneal touch syndrome, which could provoke corneal edema.
ANTERIOR VITRECTOMY
the most important step in management is to recognize that capsular rupture has
occurred.
Early recognition of a capsular tear may :
1.limit the size of the rupture
2. limit the amount of vitreous prolapse.
Posterior capsular tears occur at the highest rate toward the end of phacoemulsification,
when few pieces of nucleus
during irrigation and aspiration (I&A) of cortical
material;
during capsular polishing.
VITRECTOMY FOLLOWING VITREOUS LOSS
Vitreous is lost when the posterior capsule is torn during surgery.
signs that indicate capsular rupture such
1. deepening of the anterior chamber
2. difficult displacement of crystalline lens material.
3. sudden pupillary dilation
4. nucleus or remaining nuclear fragments may also move posteriorly through the capsular
tear
5. nuclear fragments may not flow as readily toward the phaco tip
hydrostatic pressures between the anterior and posterior chambers are abruptly equalized
fluid currents no longer circulate through an enclosed bag and when vitreous clogs the aspiration port
Often rupture occurs beneath the nucleus and passes undetected by the surgeon
PANIC STEPS
Stop phaco tip aspiration
Keep all instruments in the eye; do not remove them
Maintain irrigation; pedal at position 1
Withdraw the paracentesis instrument
Generously fill the anterior chamber with viscoelastic
Once the anterior chamber has been filled with viscoelastic, the phaco tip can be
removed and the situation assessed
PANIC STEPS
Often the buttonhole widens as the pressure in the anterior chamber falls because of flow
cessation without having adequately filled the anterior chamber with viscoelastic
It is important to stop aspiration since the entire vitreous sac could be suctioned.
The viscoelastic maintains the IOP and keeps the vitreous in a posterior position.
ANTERIOR VITRECTOMY
The goals of anterior vitrectomy are
1.to remove the vitreous from the anterior chamber,
2.to clear any vitreous from the entry incisions
3.to allow an IOL to be placed
ANTERIOR VITRECTOMY
COAXIAL IRRIGATION
Traditionally vitrectomy was performed using the vitrectome with coaxial irrigation, which
was inserted through the phaco incision lowering the height of the infusion bottle.
this method has the consequence of enlarging the capsular tear and hydrating the vitreous
provoking its escape toward the anterior chamber and incisions.
The use of the vitrectome with coaxial infusion is therefore not recommended
ANTERIOR VITRECTOMY
ANTERIOR VITRECTOMY
BIMANUAL APPROACH
an additional side port incision should be made to accommodate the vitrector.
Use of the preexisting phaco wound, which is too large for the sleeveless vitrector, results
in a less-stable anterior chamber as fluid, and possibly more vitreous, leak through the
wound.
The additional side port incision also allows greater access to the whole anterior chamber,
as the irrigation cannula and the vitrector can be placed through either port
ANTERIOR VITRECTOMY
BIMANUAL APPROACH
The bottle height should be greatly lowered, to 15 to 20 centimeters above the eye, before
placing the infusion into the anterior chamber.
After the vitrector is placed through the second side port incision, a closed system is
established and the vitrectomy can begin
ANTERIOR VITRECTOMY
BIMANUAL APPROACH
Handling nucleus and cortex:
relatively small piece:
piece is still in the anterior chamber
1.lower the bottle height significantly
2.use viscoelastic to bring the piece up
3.enlarge the wound to 3 or 4 mm,
4. express it through the incision
ANTERIOR VITRECTOMY
BIMANUAL APPROACH
larger piece
You can perform either ECCE or PHACO
ECCE If vitreous prolapse or vitreous loss has already occurred, this will usually be the strategy of choice
PHACO no vitreous prolapse,
the nucleus is still well supported within the capsular bag,
the capsular defect is small and localized,
the nucleus is soft,
small amount of residual nucleus remains
1.bury the phaco tip in it
2. bring it up
3. using a second instrument, or something like a Sheets Glide or a Bobbit Glide to act as a pseudo-
ANTERIOR VITRECTOMY
BIMANUAL APPROACH
cortical material
The most common time for vitreous is while removing the last bit of nuclear material or
during cortical removal. The main emphasis during this phase is to remove any residual
cortical material following vitrectomy.
After the vitreous has been removed from the anterior chamber, you can go after cortex.
irrigated a small amount of triam into the anterior chamber and then BSS irrigation,
confirming the absence of prolapsed vitreous
You can then place a nice layer of dispersive viscoelastic over the rent, and keep the bag
open with a cohesive OVD
You now have three choices for cortex removal: 1. The safest choice is to do it dry
2.switch your vitrectomy settings to I/A cut
3. most efficient, choice, is bimanual I/A
ANTERIOR VITRECTOMY
BIMANUAL APPROACH
cortical material
Dry method
cannula on a 3- or 5-mm syringe, target a little cortex and then strip it away in a cohesive-
OVD-filled environment. This is safest because there’s no turbulence created. However, you
have to keep filling the eye with OVD to keep it normotensive. Therefore, it’s not very
efficient if you have lots of cortex.
ANTERIOR VITRECTOMY
BIMANUAL APPROACH
cortical material
Bimanual method
This keeps the pressure superior so as not to encourage more vitreous to come forward.
You can then target the cortex, keeping in mind that you can’t allow the chamber to
collapse, so you have to fill it with OVD before you come out
ANTERIOR VITRECTOMY
BIMANUAL APPROACH
Closing
place a stitch even if the wound appears stable and sealed
If the wound doesn’t seal easily, however, don’t just place a suture. It may have vitreous
incarcerated in it, so you’ll need to instill Triessence to visualize any strands
Instillation of acetylcholine can also help identify any remaining vitreous in the anterior
chamber by revealing irregular eddy currents around vitreous strands and by showing
peaking of the miotic pupil (indicating vitreous remaining in an incision)
CLINICAL FEATURES
The degree of intraocular inflammation may depend upon the
1.size of the retained lens fragment,
2.and probably is greater if it is nuclear as opposed to cortical
3.in nature, the time since cataract surgery,
4.the individual’s inflammatory response, a
5.the extent of other intraocular manipulations
Retinal detachment coexisting with retained lens material occurs in up to 5% of the
cases,but may be diminishing as less aggressive management techniques are endorsed by
the cataract surgeon ,The ultimate prognosis is worse when retinal tear or retinal
detachment coexists in an eye with retained lens material.
INDICATION AND TIMING OF SURGICAL
INTERVENTION
The minimum fragment size at which vitrectomy surgical intervention is recommended has
not been definitely established
Recommendations have generally drifted towards recommending surgical intervention if
any nuclear material or if sizable amounts of cortical material are encountered.
The timing of surgical intervention has been long debated Ideally, a several days to 1 week
deferral of vitrectomy surgical intervention is recommendable by the vitreoretinal surgeon
to allow for abatement of corneal endothelium edema which could allow a better view for
vitrectomy, as well as a better understanding of the magnitude of other factors such as
pressure and inflammation control.
SURGICAL TECHNIQUE
Visualization can be challenging in RLM cases due to corneal opacity
and poor pupillary dilation.
Wide-field, non-contact viewing systems are especially helpful in these
cases.
Maneuvers to deturgesce the cornea (rolling or scraping) or stretch the
pupil may be necessary to improve visualization.
Standard three-port PPV involves placement of an infusion line and
two other sclerotomies for bimanual surgery
SURGICAL TECHNIQUE
Following completion of a core
vitrectomy, a posterior vitreous
detachment (if not already present)
should be induced
This step may be challenging if
substantial RLM is acting as a
counterforce.
A peripheral dissection with the aid of
scleral depression helps to remove
small lens fragments hiding in the
vitreous base, most often inferiorly
SURGICAL TECHNIQUE
The clinical scenario dictates the choice of instrumentation
In settings where the vitrectomy handpiece is used for lens removal, momentary
vitrectomy mode with a continuous low cut rate can help avoid clogging.
Handpiece Indication Mechanism
25-gauge vitrector Limited cortical material Guillotine cutting,
aspiration
23-gauge vitrector •Large soft lens Guillotine cutting,
•Dense material <50% of total aspiration
lens
20-gauge fragmatome Standard PPL Phacoemulsification,
aspiration
Ozil (20-gauge) Large, dense lens fragments Phacoemulsification,
aspiration
SURGICAL TECHNIQUE
The vitreous cutter is optimal for
removal of residual cortical
fragments still adherent to the
posterior capsular bag or IOL
In circumstances where the
phacofragmatome is required,
three-dimensional mode with pulse
ultrasound is frequently preferable.
While maintaining aspiration, the
light pipe can be used in a bimanual
fashion to physically chop large
fragments
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
SURGICAL TECHNIQUE
pursued.The safety of this step is maximized if performed after vitreous removal since
inadvertent vitreous traction during fragmentation is minimized
An important principle in effective nuclear removal is to use the lowest effective
fragmentation power and relatively high aspiration settings to avoid the intermittent
launching of smaller fragments away from the fragmentation tip.
It is important to search carefully along the retinal surface and vitreous skirt to ensure that
smaller chips of nuclear material have not escaped detection.
SURGICAL TECHNIQUE
Some have reported the use of perfluorocarbon liquids in this setting.
Theoretical advantages include floating the material to a more accessible, anterior
location.
This will position it further away from the retina and offer a barrier function from retinal
trauma.
This may be more helpful for large and particularly firm fragments
perfluorocarbon may direct some fragments more peripherally where they are more
difficult to remove, or may escape detection.
The most helpful setting for its use may be in certain cases presenting with coexisting
retinal detachment
SURGICAL TECHNIQUE
IOL PLACEMENT
The peripheral anterior capsule is often intact despite the breach in the posterior capsule
and, in such cases, sulcus fixation of a standard PCIOL can usually be safely pursued, if not
already present.
The power of the IOL should be decreased by at least a half diopter from calculations made
for capsular bag fixation
Alternatively, an anterior chamber lens implant can be placed, especially if there is a
broader capsular breach
POSTOPERATIVE MANAGEMENT AND
COMPLICATIONS
Inflammation and elevated intraocular pressure are the most common postoperative
conditions requiring attention.
Probably the most common postoperative consequence of inflammation limiting visual
acuity is cystoid macular edema.
Frequent and aggressive perioperative topical steroids and non-steroidal anti-inflammatory
drugs are the first line treatment. Sub-Tenon’s or intravitreal corticosteroid injections may
enhance treatment of refractory cases.
medical measures are sufficient to control the IOP either directly or via control of
inflammation. However, one indication for more urgent vitrectomy is elevated IOP which
may be due to lens fragments
The END
