Recommended OVD for Posterior Capsule Rupture During Phacoemulsification
Use a cohesive OVD (such as sodium hyaluronate 1.0-1.4%) to stabilize a posterior capsule rupture during phacoemulsification, as it provides adequate space maintenance while being easily and completely removable at the end of surgery.
Rationale for Cohesive OVD Selection
Primary Considerations During PCR
When posterior capsule rupture occurs, the surgical priorities shift dramatically toward:
- Maintaining anterior chamber depth and stability to prevent vitreous prolapse and allow safe completion of the procedure 1
- Ensuring complete OVD removal at surgery's end, as retained viscoelastic increases the risk of postoperative IOP elevation and inflammation
- Minimizing additional surgical time and complexity in an already compromised situation
Why Cohesive OVDs Are Preferred
Cohesive OVDs (sodium hyaluronate 1.0-1.4%, such as Healon or Healon GV) offer the optimal balance for managing PCR because:
- They provide excellent space maintenance during the critical period when you need to stabilize the eye and assess the extent of capsular damage 2
- They are rapidly and completely removed with irrigation/aspiration, with removal times under 4 seconds, compared to 10-20+ seconds for dispersive or viscoadaptive agents 3
- Their cohesive properties allow them to remain as a single bolus that can be manipulated to tamponade the posterior capsule defect and push vitreous posteriorly 3
Why NOT Dispersive or Viscoadaptive OVDs
While dispersive OVDs (like Viscoat) and viscoadaptive OVDs (like Healon5 or DisCoVisc) have superior endothelial protection properties, they are problematic in PCR situations:
- Dispersive OVDs (sodium hyaluronate 3%-chondroitin sulfate 4%) have significantly longer removal times (up to 20+ seconds) and tend to trap nuclear fragments and air bubbles, decreasing surgical visibility 2
- Residual dispersive material is much more difficult to completely remove, with studies showing residual thickness of 251-324 microns compared to essentially zero for cohesive agents 4
- In a PCR scenario where you may need to perform anterior vitrectomy, incomplete OVD removal becomes a significant concern for postoperative complications 3
Surgical Algorithm for OVD Use in PCR
Immediate Steps Upon Recognizing PCR
Stop all phacoemulsification immediately and withdraw instruments 1
Inject cohesive OVD (sodium hyaluronate 1.0-1.4%) to:
Reassess the situation with the stable anterior chamber to determine:
- Extent of capsular rupture
- Presence of vitreous in anterior chamber
- Remaining capsular support for IOL placement
Completing the Surgery
If anterior vitrectomy is needed, maintain the anterior chamber with cohesive OVD between passes 1
Avoid anterior capsule polishing after PCR, as this may destabilize remaining capsular support 1
At surgery completion, ensure meticulous and complete removal of all OVD using bimanual irrigation/aspiration, as the cohesive properties allow for efficient removal 5, 3
Critical Pitfalls to Avoid
Do not use viscoadaptive OVDs (like Healon5) in PCR situations despite their excellent space maintenance, as their removal time is 10-15 seconds and incomplete removal is more likely 3, 6
Do not use dispersive OVDs as your primary agent for PCR management, as they significantly impair visibility by trapping debris and are extremely difficult to remove completely 4, 2
Do not leave any residual OVD, as vitreous loss already increases inflammation risk, and retained viscoelastic compounds this problem with potential IOP spikes 3