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Cataract surgeon shares personal experience with the post-vitrectomized eye
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 Rosa Braga-Mele |
WAILEA, Hawaii — A cataract expert offered tips on performing successful cataract surgery in a post-vitrectomy eye.
In a talk that awarded her best speaker of the day at Hawaiian Eye 2009, Rosa Braga-Mele, MD, MEd, FRCSC, began her instruction with the need to use intracameral lidocaine in all of these cases, followed by a square beveled wound that is not too long.
"As you go down deeper and deeper into the pit of hell, as I call it, you don't want to have the wrinkling of the cornea," she explained.
Next, during hydrodissection, surgeons must be aware of possible lack of integrity of the posterior capsule.
"Sometimes I'll even do a viscodissection ... so you have a pushing behind the lens. If there is lack of the capsule there, it will bring this lens forward," she said.
This requires advanced planning. Dr. Braga-Mele advised considering a posterior fluid maintainer and possibly working with a retina surgeon.
"What I prefer to do is to flip the nucleus out of the bag. If you can do that, you'll need a good-sized capsulorrhexis, at least 5 mm to 5.5 mm in size. You flip that nucleus out of the bag and sandwich it. ... You're going to negate the need to work deep," she said.
If working in the bag, it is important to optimize fluidics by lowering the bottle height, decreasing aspiration flow rate and vacuum, and performing "slow motion" phaco. It is best to quick chop and bring hemi-nuclei out, but Dr. Braga-Mele warned that the zonular integrity could have been affected by the vitrectomy ports.
"You may want to plan to put the lens in the sulcus or fixate it," she said. "Just remember all of those pearls, and hopefully you'll have a better time than I have had on some of my cases."
Surgeons should always try to avoid contact of the phaco needle with any second instrument placed in the sideport incision. Any contact that takes place during active phacoemulsification can result in minimal damage (ie, small metal shards from the second instrument) or major damage (ie, fracture of a phaco chopper tip or other tip). If this occurs, the surgeon should immediately stop phaco and assess the degree of damage.
In this case, injection of a dispersive viscoelastic, removal of the fractured phaco chopper tip and, finally, careful inspection of the capsular bag status could have avoided further surgical complications.
– Terry Kim, MD
OSN Cornea/External Disease Board Member
Eyes that have undergone vitrectomy require special attention and care during cataract surgery, as they are more prone to complications, especially hypotony, zonular laxity or posterior capsular problems. They may require help from our vitreoretinal colleagues, and special techniques that decrease pressure on the posterior capsule and zonules should be utilized during surgery. The awareness of these potential problems, as well as these helpful tips to prevent or approach intraoperative complications, such as making a shorter wound and maximizing patient comfort, slowing the flow rate and vacuum and lowering the bottle, and performing a supranuclear technique if necessary, should help surgeons prepare and formulate an approach to these eyes that have undergone vitrectomy.
– Helen K. Wu, MD
New England Eye Center, Tufts University School of
Medicine, Boston