Vitreous prolapse

The patient may or may not have symptoms from pupil distortion. Clinically, the pupil and anterior chamber should be eraluated before dilation. If the pupil is peaked at the first postoperative visit, the examiner may carefiilly examine with gonioscopy, looking for vitreous or iris extending to the wound. Presence of vitreous prolapse in the anterior chamber necessitates a thorough retinal eraluation early in the postoperative period, looking for secondary retinal breaks. lOL position and capsule integrity should be eraluated to further define the source of pupil distortion. 

In patients treated with pegaptanib sodium alone, ocular adverse events considered likely to be associated with intravitreal injection of pegaptanib sodium included vitreous floaters or haze, mild transient anterior chamber inflammation, ocular irritation, increased IOP, intraocular air, subconjunctival hemorrhage, eye pain, lid edema/ erythema, dry eye, and conjunctival injection. In patients treated with pegaptanib sodium and PDT, adverse events probably associated included ptosis (due to the contact lens), mild anterior chamber inflammation, corneal abrasion, eye pain, foreign body sensation, chemosis, subconjunctival hemorrhage, and vitreous prolapse. 

Regarding OVD application with intraoperative complications, tissue stability and movement must be differentiated from selective tissue isolation (Fig. 53). Healon 5, Healon GV, Microvisc (Plus), Morcher Oil (Plus), Viscorneal (Plus) (identical to Allervisc (Plus) in content), and other viscoelastic substances are considered suitable to counter a flattened anterior chamber, widen a small pupil, simplify a complicated capsulorhexis, resolve synechiae, or counter iridal and vitreous prolapse (Fig. 54). Endothelial dystrophy (Fuchs Dystrophy, advanced cornea guttata), torn posterior capsule or vitreous prolapse are particularly well suited for Viscoat application (followed by AMO Vitrax , HPMC Ophta H, Visco Shield , and other HPMC products). These viscoelastics are preferred substances in case of zonular dialysis with vitreous body prolapse or sinking nucleus (Fig. 55). 

Fig. 54. Selective movement and pushback of the vitreous by injection of a dispersive viscoelastic substance in case of a tear in the posterior capsule with vitreous prolapse and intact vitreous humor membrane (best case scenario) ...

The vitreous humor is completely repositioned into the vitreous slightly behind the level of the posterior capsule. The use of a viscous viscoelastic substance with longlasting space maintaining capability is recommended to stabilize this situation and to counteract a repeated vitreous prolapse (e.g., during lOL implantation)... 

Pupil distortion may be caused by many factors. If a wound leak is present, a wick of vitreous or prolapsed iris may become incarcerated in the wound, causing a distorted or peaked pupil. The peak of the pupil often points toward the incarcerated area (Figure 30-6). 

The initial injection around the capsular lesion followed by an injection on the top of the prolapse ensures a backward movement of the vitreous (instead of a possible drift sideways)... 

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