IC-68: A Video Bouquet of Phaco Complications Which Should Never Have Occurred: With Tips on Damage Control & Prevention to Optimize Postoperative Outcome

CAPSULE PROBLEMS & COMPLICATIONS

The main problems together with causes, consequences and suggested solutions are summarised in Table 1.

TABLE 1 / Capsule Problems and Complications
Problem / Cause / Consequence / Solution
Poor visibility / Corneal scarring/pterygium/oedema / Poor control of rhexis through reduced visibility. Risk of tear-out. / Optimise coaxial illumination. Use capsular dye. Methylcellulose on cornea.
Reduced red reflex / Dense/white cataract, small pupil. / Lost control of rhexis with risk of tear-out. / Capsular dye. Pupil enlargement.
Collapsing chamber / Positive pressure from vitreous or external origin: speculum pressure, drape tension, retrobulbar haemorrhage. Rarely suprachoroidal haemorrhage. / High risk of peripheral tear-out. / Eliminate external causes. Use Healon 5. Swap from main incision & use needle via sideports.
Loss of view of tear during rhexis / Disturbance of underlying cortex. / High risk of radial tear or peripheral tear-out / Stop immediately. Refill with viscoelastic. Inject capsular dye to visualise tear.
Anterior capsule plaques / Previous blunt trauma. Calcified variety associated with dense/white/hypermature cataracts. / Impossible to tear through tough plaques. Tear around them or cut through with scissors.
Small rhexis / Most commonly results from having a small pupil. Next is surgical inexperience. / High risk of capsule block during hydrodissection and edge tear from phaco tip or second instrument. / If in doubt then enlarge it. Initiate with semi-tangential cut using capsule scissors and continue with forceps.
Diaphanous friable capsule / Very elderly, mature cataracts, PXF / Fragmentation of flap. Extremely delicate and easy to tear out. / The key to control is anticipation. Tear only small segments each time. Healon 5 particularly useful for flap stabilisation.
Double-layered capsule / Capsular schisis. Usually in elderly patients. / Disconcerting but no real danger. Rare but unavoidable. / May need separate rhexis for each layer.
Small radial tear or arrowhead notch. / Inadvertent damage from needle point. Residual notch from inside-out versus outside-in completion of rhexis. / Dangerous only if unseen. Almost inevitable peripheral extension later on. / If suspected then stop and zoom in. Add capsular dye if poor visibility. Needs to be rounded off producing scalloped out-pocket of rhexis.
Peripheral extension (tear-out) / Centrifugal force vector. Usually resulting from chamber shallowing, occasionally due to surgeon error or intumescent lens. / High risk of wrap-around tear and dropped nucleus. / Stop immediately. Refill with viscoelastic. If possible visualise apex of tear ± dye. Irretrievable once into the zonules. Complete the rhexis form opposite direction.
Diametric split across anterior capsule (Argentinian flag sign) / Intumescent lens with high capsular tension. / Unsafe for endocapsular phaco. High risk of wrap-around tear and dropped nucleus. / Reduce risk by first overfilling chamber with viscoelastic to flatten the anterior lens. Then try initial capsule decompression via central perforation to release liquefied cortex.

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