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lowing Pupillary Capture" (J Cataract Refract Surg 1991; 17:843-847), we would like to add our experience with a similar maneuver.l A very important step in our experience is to have the patient lying down and under microscope control before instilling the mydriatic drops. We start with phenylephrine 2.5% which is easier to reverse. 2 After 30 minutes if the lens is still captured, we add a drop of tropicamide 5% (Mydriacyl®). As soon as the lens optic is released, a drop of a topical anesthetic, a strong miotic such as demecarium (Humorsol®), and blefarostasis is instilled. Under direct microscopic control with two fingers or preferably with two cotton swabs, gentle pressure is applied near the limbus to keep the lens back and permit the iris to cover the IOL in its way to miosis. Since publication of the technique, we have had six cases, with permanent repositioning in all but one case-a myopic eye of -10 diopters preoperatively with large pupils, in which the lens dislocated twice after repositioning. Eduardo Arenas, M.D. Larry Iglesias, M.D. Bogota, Columbia

REFERENCES 1. Arenas EA, Iglesias L. External digital manoeuvre for repositioning an anterior chamber IOL with pupil capture syndrome. Implants Ophthalmol 1988; 2: 157158 2. Havener WHo Ocular Pharmacology. St. Louis, CV Mosby Co, 1978; 279-309

CAPSULAR RUPTURE AT HYDRODISSECTION To the Editor: I read with interest the letter describing inadvertent posterior capsular rupture following hydrodissection of the nucleus (Hurvitz LM. Posterior capsular rupture at hydrodissection. J Cataract Refract Surg 1991; 17:866). To my knowledge, this is the first reported case of capsular rupture occurring at the time of hydrodissection. I have not seen this complication in my surgical experience. Posterior capsular rupture at the time of hydrodissection would appear to be extremely rare. This is because performing the anterior capsulotomy prior to hydrodissection allows decompression of the hydrodissection fluid through the capsulotomy. Unless the hydrodissection cannula is placed posterior to the lens and punctures the capsule directly, fluid pressure cannot build within the bag unless the lens is prolapsed anteriorly, occluding the capsular opening. For this reason when teach-

ing phacoemulsification I stress that the hydrodissection fluid be dissected slowly and that decompression be allowed to occur through the capsulotomy. Should the lens dislocate anteriorly, gentle pressure on the anterior lens surface will reposition it into the capsular bag. Hydrodissection should never be performed with viscoelastics or strong infusion pressures. I would suggest that the capsular rupture described by Dr. Hurvitz either was pre-existing from inadvertent capsular tear occurring during the peripheral iridectomy at the original filtration surgery or that it occurred during capsulorhexis at the time of cataract extraction. It then would only become apparent during the hydrodissection maneuver. Robert M. Kershner, M.D. Tucson, AZ

Lawrence M. Hurvitz, M.D., replies: I share Dr. Kershner's feeling that this is a rare complication. I pointed this out in my original letter. Dr. Kershner's comments that perhaps the anterior capsule was damaged during the previous filtering surgery is a rather unlikely possibility. The filtering surgery performed on the patient was a punch sclerectomy in the superior quadrant. Anatomically it would be very difficult to reach the capsule with the lens from this position unless an extremely large iridectomy was created. Dr. Kershner seems to discount the possibility of this as a primary event. My purpose in writing the letter was to elicit comments from other surgeons who have had this same complication. If someone else has experienced this complication, please let me know. REMOVAL OF VISCOELASTICS To the Editor: Your comments (Postoperative pressure elevation: A rational approach to its prevention and management. J Cataract Refract Surg 1992; 18:1) concerning the use of viscoelastics in cataract surgery were well taken. The troublesome rise in lOP following their use is certainly best avoided. Aspiration of these materials at the end of each case is known to reduce the incidence of this problem. I have found over the past two years that this can further be reduced by flushing out the chamber angles with BSS following the aspiration. It is truly amazing how much material swirls into the red reflex after one thinks the aspiration has done the job. This was alluded to in an article by Fry (Comparison of the postoperative intraocular pressure with

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