Technique for removing OVD to prevent CBS

In their article,1 Kim and Shin highlighted anterior chamber inflammation as a cause of capsular block syndrome (CBS) and suggest conservative management, thus alleviating the need for neodymium:YAG capsulotomy in such cases. We have the following observations. 1. There are various techniques for removing an ophthalmic viscosurgical device (OVD).2,3 The OVD removal technique in the Kim and Shin article was not clearly explained. In “Patients and Methods,” it said the OVD was removed by introducing an aspiration cannula behind the intraocular lens (IOL) in all cases. In “Discussion,” however, it says that in cases in which the Akreos Adapt IOL (Bausch & Lomb) was used, the rocking motion (rock ‘n’ roll technique2) of irrigation/aspiration (I/A) was limited because of the IOL design. Does this mean that passing the I/A cannula behind the IOL to remove the OVD was not attempted in these cases? This would imply that instead of the IOL being the risk factor in the development of CBS, the OVD removal technique is the culprit. 2. In all the patients who developed noncellular CBS, sodium hyaluronate 1.4% (Healon GV) was used during surgery. In terms of OVD removal, Healon GV, which is cohesive in nature, is one of the easiest to remove, especially if one is attempting to remove it by going beneath the IOL.4 If the rock ‘n’ roll technique2 was used in these patients, intraoperative CBS may have been a result of the entrapment of OVD caused by the anterior capsule sticking to the IOL optic for 360 degrees. Intraoperative visualization of the OVD entrapment may be marred because of factors such as the development of corneal haze (prolonged or difficult surgery) or the loss of pupil mydriasis. 3. We think noncellular CBS can be prevented by a simple maneuver to aspirate the OVD (sodium hyaluronate 1% in our setting) behind the IOL. We introduce a coaxial I/A cannula over the IOL to aspirate the OVD over the IOL. Then, through the left side-port entry, we introduce the IOL dialer. The knee of the dialer is used to lift the edge of the IOL, and coaxial I/A cannula is passed behind the IOL to aspirate the OVD (Figure 1). Our end points are the presence of posterior striae and centration of the IOL.5 We have not encountered a case of CBS because of retained OVD in the more than 3 years that we have been using this technique.Figure 1: Ophthalmic viscosurgical device is removed by lifting the IOL edge using an IOL dialer and passing the I/A cannula behind the IOL.