Be Prepared for a Challenge
Even a routine cataract case can become complex. A surgeon’s readiness makes successful management more likely.
There are many different types of complex cataracts: a “routine” case that becomes complex (eg, pseudoexfoliation with loose zonules), congenital cases like Marfan syndrome with an ectopic lens, and of course, zonular or capsular compromise from trauma or previous surgery. Each has its own unique challenges, but there are basic rules and devices common to all of them with which surgeons should be familiar.
A STOCKED TOOLKIT
As a basic rule, the surgeon should have a plan that includes back-up options. When I approach surgery, I make sure that the following are in the OR: trypan blue, adaptive viscoelastics (eg, Healon5 [Abbott Medical Optics Inc., Santa Ana, CA] and/or DisCoVisc [Alcon Laboratories, Inc., Fort Worth, TX]), and capsular support devices (eg, from MicroSurgical Technology [Redmond, WA] and the Mackool Cataract Support System [Duckworth & Kent Ltd., Hertfordshire, United Kingdom; distributed in the United States by FCI Ophthalmics, Inc., Marshfield Hills, MA]). I also have on hand Ahmed Capsular Tension Segments and Cionni Rings for Sclera Fixation (new G.I variation; both devices manufactured by Morcher GmbH, Stuttgart, Germany; distributed in the United States by FCI Ophthalmics, Inc.). Also available are vitreous stain (dilute Kenalog [Bristol-Myers Squibb Co.]), sutures for fixating the lens (8–0 Gore-Tex [W.L. Gore & Associates, Inc., Newark, DE] or 9–0 Prolene [Ethicon, Inc. Somerville, NJ]), and the vitrector unit for the anterior segment. Lastly, I have microinstruments for intraocular use at the ready (either from ASICO [Westmont, IL] or MicroSurgical Technology).
I may need all or none of these supplies, but they must be readily available.
The following case exemplifies the need for the surgical plan. A 39-year-old woman was in an automobile accident and suffered a direct blunt injury to her left eye. The initial ocular examination revealed a choroidal rupture and peripheral retinal detachment posteriorly as well as nasal zonular dialysis (difficult to determine the number of clock hours) anteriorly. Initial surgery included retinal detachment repair and the placement of silicone oil. Approximately 4 months postoperatively, the silicone oil was removed. Soon after, the patient developed a white cataract. She presented to me 3 weeks later.
Approaching this case surgically, I could not be certain of the status of the posterior capsule. Had it been nicked inadvertently during the retinal detachment repair? I therefore had to assume that the posterior capsule was open.
I stained the anterior capsule with trypan blue. After initiating the capsulorhexis with a sharp cystotome, I completed a relatively small tear to facilitate later stabilization of the bag and the fixation of the IOL if the posterior capsule indeed were open. Superficial cortex was removed under low flow. I performed viscodissection without rotating the nucleus. Under low flow, the nucleus was hemisected, raised, and phacoemulsified. I used bimanual I/A to minimize stress on the capsular bag and zonule.
After I found the bag to be intact posteriorly, I preserved and secured it with a Cionni Ring using a 9–0 Prolene suture. Because the zonular defect was temporal, I needed to employ a technique of docking a 26-gauge needle passed through the sclera nasally and then passing it temporally (the suture was preplaced through the eyelet of the Cionni Ring). I inserted the modified Cionni Ring into the bag and rotated the device toward the area of zonular weakness. Next, I placed a single-piece IOL in the bag and tied the suture to center the lens. I instilled a vitreous stain and Miochol-E (Bausch + Lomb) and used the anterior vitrector to remove viscoelastic, because the previous vitrectomy could have left anterior vitreous. I find it is wise to use a vitrector to remove the visocelastic at the end of cases such as this one instead of bimanual handpieces in order to reduce stress on the system.
In the presented case, capsular support was not needed during phacoemulsification. It is wise, however, to have this instrumentation available in such situations. Surgeons should also allow themselves a significantly longer time slot in the OR so that they are under no pressure to hurry. For complex cases, I recommend the use of acetazolamide to reduce the IOP in addition to the surgeon’s standard postoperative regimen of antiinflammatory drugs and antibiotics.
A video of this complex case is available at http://eyetube.net/?v=jafiq.
Alan S. Crandall, MD, is a professor, the senior vice chair of ophthalmology and visual sciences, and the director of glaucoma and cataract for the John A. Moran Eye Center at the University of Utah in Salt Lake City. He is a consultant to Alcon Laboratories, Inc. Dr. Crandall may be reached at (801) 585-3071; email@example.com.
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