Cataract surgery in small eyes poses challenges, rewards

In addition to correcting a high degree of hyperopia, it can also restore the angle anatomy and lower IOP.

Uday Devgan

Small eyes have anatomic features that can complicate cataract surgery. These eyes have a shorter axial length, often associated with a shallower anterior chamber. In addition, the corneal diameter may be less and the effective lens position of an IOL more difficult to calculate. But there is one great upside: These are hyperopic eyes, often highly hyperopic, and are dependent on glasses for all activities. When successfully performed, cataract surgery can provide these patients with the best vision of their lives.

Preop evaluation

Small eyes have a shorter axial length, typically less than 22 mm, and accompanying hyperopia of +3 D or more. The anterior chamber can be shallow, with measured depths of 2 mm or less and associated narrow angles. In cases in which there are advanced cataractous changes, the lens can swell and further narrow the angles.

The cornea should be carefully evaluated for endothelial weakness because there is a higher chance of phaco-induced cell loss due to the closer proximity of the phaco probe. Small corneal size can also mean that the standard-sized phaco incision may induce more astigmatic change at the time of cataract surgery.

When measuring the axial length, small errors can result in more of a refractive shift than in normal or large eyes. While an axial length that is wrong by 1 mm in a normal eye may induce 3 D of error, in a short eye this can be increased to 4 D or even 5 D. Difficulty predicting the final effective lens position of the IOL also means that the lens calculations are more like estimations. Certain formulae have been shown to be more accurate in these short eyes. Of the two variable formulae, the Hoffer Q tends to do better in the setting of axial lengths less than 22 mm. However, it is advisable to use newer formulae such as the Holladay 2, which incorporates data such as white-to-white size, refraction, and anterior chamber depth, in order to produce more accurate results.

An eye with a less than 1-mm deep anterior chamber and a history of angle closure with white cataract formation. Images: Devgan U

A limited 25-gauge pars plana anterior vitrectomy is performed with the right hand as viscoelastic is injected into the anterior chamber with the left hand to achieve a normal depth.

With a deepened anterior chamber the capsule was stained with trypan blue and a capsulorrhexis was created. Iris hooks were needed to enlarge the pupil for cataract surgery.

At the end of the case a +40 D IOL is in the capsular bag, the iris hooks are discarded, and the 25-gauge trocar (seen in blue) is about to be removed.

Single-piece acrylic IOLs as well as three-piece acrylic and silicone IOLs are appropriate choices because they all have flexible haptics that allow placement within the smaller than usual capsular bag. In some situations, eyes with very short axial lengths may need an IOL power that is particularly high, such as +30 D, +35 D or even more. Because different IOL designs come in different ranges, every effort should be made to source the appropriate lens. It is better to have a single IOL with the correct power than to piggyback using two IOLs to achieve the same dioptric strength. In the U.S., there is at least one single-piece acrylic IOL that is available in powers up to +40 D.

In the rare eyes in which a power of more than +40 D is indicated, it may be advisable to do the surgery in two stages: cataract surgery with implantation of the maximum power IOL (+40 D) in the capsular bag, followed by a second surgery with implantation of a piggyback lens in the ciliary sulcus. This provides greater refractive accuracy because the power of the second IOL, which is placed in the sulcus, is determined based on the postoperative refraction after the initial cataract surgery.

Surgical technique

There are certain risks, such as choroidal hemorrhage, that are more common in these smaller eyes. In addition, the shallow anterior chamber can make it more difficult to complete the capsulorrhexis and atraumatically remove the nucleus. After creation of an initial paracentesis, the anterior chamber can be inflated with a cohesive viscoelastic in order to create space and deepen the anterior chamber.

In some small eyes, particularly those with coexisting pathology, the anterior chamber can be so shallow as to preclude capsulorrhexis creation. A partial pars plana anterior vitrectomy can be done in order to help deepen the anterior chamber. This procedure, however, is not without risk because it involves creation of a sclerotomy to access the vitreous cavity in a crowded eye. Using a small-gauge vitrectomy unit, a little vitreous can be removed at a time. It is important not to remove too much vitreous because this can result in too deep of an anterior chamber. Slowly injecting viscoelastic while performing the anterior vitrectomy will allow precise control.

The corneal endothelium should then be protected with a dispersive viscoelastic. Because the volume of the anterior chamber is less, there is a limited amount of working room during phacoemulsification. The closer the phaco probe is to the cornea, the greater the potential for endothelial damage. For this reason, phaco techniques that are performed within the capsular bag are preferred to supracapsular methods. Once the cataract is removed and the new IOL is inserted in the capsular bag, care should be taken to ensure that the incisions are watertight. Because these small eyes often have smaller corneas, the standard-sized phaco incisions may encompass a larger area and arc length and may not seal as well.

Postop follow-up

These patients tend to be particularly happy in the postoperative period because their high degree of hyperopia has been corrected. But there are additional benefits such as restoration of the angle anatomy and lowering of IOP, which occurs because the 4-mm thick cataract has been replaced by a 1-mm thin IOL. With careful preoperative planning and appropriate intraoperative techniques, we can successfully perform cataract surgery on these small eyes.

• Uday Devgan, MD, FACS, FRCS, can be reached at Devgan Eye, 11600 Wilshire Blvd., Suite 200, Los Angeles, CA 90025; 800-337-1969; fax: 310-388-3028; email: devgan@gmail.com.
• Disclosure: No products or companies are mentioned that would require financial disclosure.