Silvia Bopp Bremen, Germany

Introduction:

Sudden hardening of the globe and flattening of the anterior chamber during cataract surgery is highly suggestive of incipient expulsive hemorrhage. In the era of small incision cataract surgery and self sealing wound incisions, dreadful consequences of expulsive choroidal detachment, such as extrusion of intraocular tissue, fortunately rarely occur. This report is on 2 patients with suspected expulsive hemorrhage during small incision cataract surgery. Capsular block syndrome (CBS) with posterior capsule rupture and anterior lens nucleus luxation proved to be the cause for pseudoexpulsive symptoms.

Patients & Methods:

Two patients underwent clear cornea cataract surgery. Capsulorhexis and hydro-dissektion were uneventful. Starting with phacoemulsification, the anterior chamber suddenly flattend, IOP rose and iris incarcerated. Surgery was interrupted and the patient immediately re-ferred to a vitreoretinal service for suspected expulsive hemorrhage.

Results:

Since ultrasound findings were normal, revision surgery was performed on the same day. Pars plana vitrectomy was effective to resolve the pressure on the anterior segment. At this stage of surgery, a large posterior capsule defect was detected. Continuing with vitrectomy, the lens nucleus dropped. After removal by endophako, the anterior capsule proved to be intact and an IOL was implanted into the ciliary sulcus. Careful fundus examination showed no signs for choroidal detachment or impending expulsive hemorrhage.

Discussion:

Posterior capsule rupture can result from forceful hydrodissection (hydrorupture) and usually leads to lens nucleus luxation into the vitreous cavity. Prior to hydrorupture, capsular blockage occurs: the injected fluid accumulates in the capsular bag, the lens nucleus occludes the capsular opening created by the capsulorhexis and the capsular bag distends. This phenomenon was described by Miyake et al and named “intraoperative CBS”. The particular constellation reported here, which presented with hydrodissection-related capsule rupture and pseudoexpul-sive choroidal detachment needs further explanation.

Vitreoretinal surgeons know by experience, that the vitreous body shows considerable differences, even in elderly patients. Consistency and viscosity varies from solid gel to low viscosity liquid with fibrous densities. In presence of a compact vitreous mass and despite of a capsule rupture, fluid can accumulate in the space between lens nucleus and anterior vitreous body. CBS occurs with lens displacement anteriorly and instead of luxation posteriorly. Treatment by pars plana vitrectomy/lensectomy has proven safe to manage this complication and allow preservation of the lens capsule for posterior chamber IOL-implantation.

Conclusions:

Intraoperative symptoms typical for impending expulsive hemorrhage can also originate from CBS. B-scan is helpful to differentiate between both entities. Revision surgery with pars plana approach resolves anterior blockage, prevents further anterior segment trauma and enables IOL-implantation.