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Do you change your intraoperative and postoperative management if you lose vitreous during cataract surgery?
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Continue postop use of nonsteroidals
 Douglas A. Katsev |
Certainly I make sure I do a good vitrectomy and no vitreous strands are captured in the wound or stretching the iris. I usually keep the haptics in the sulcus and capture the optic behind the capsulorrhexis. By doing optic capture, I do not have to change the power of the IOL.
For postoperative medicine, I always use a nonsteroidal for 4 weeks, but in a vitreous loss case, for at least 6 weeks I prefer a once-a-day NSAID for patient convenience and would not have a problem increasing this to twice a day if CME develops. I prefer to use a strong steroid, Durezol (0.05% difluprednate ophthalmic emulsion, Alcon), for at least 6 weeks and switch to Pred Forte (prednisolone acetate, Allergan) if IOP increases. If the pressure rises with longer use, on occasion I change to Lotemax (loteprednol etabonate, Bausch + Lomb). I like the benefit from a steroid in combination with a once-a-day NSAID, Bromday (bromfenac ophthalmic solution 0.09%, Ista Pharmaceuticals), to prevent CME in these higher-risk cases.
I watch these patients closely. I give out my cell phone number, and if there is a problem, I want to know about it early. The patient knowing they can reach you and that you can see them if new issues arise is the most important thing. Having good retina people as backup is key; they can help you out when issues happen, so the problems stay small.
Douglas A. Katsev, MD, can be reached at Sansum Santa Barbara Medical Foundation Clinic, Santa Barbara, Calif. Disclosure: Dr. Katsev is a consultant for Abbott Medical Optics and Ista Pharmaceuticals, and has ownership interest in TrueVision.
Perform intraoperative steroid injection and/or postoperative laser vitreolysis
 Kenneth R. Kenyon |
In the setting of vitreous loss during phacoemulsification, two strategies can be employed.
First, while still intraoperative, intracameral injection of triamcinolone, either non-preserved generic or Triesence (triamcinolone acetonide, Alcon), in small quantity of 25 mL to 100 mL affords a true “twofer.” (The latter is approved by the U.S. Food and Drug Administration for visualization during vitrectomy and hence is used off label.) The steroid suspension avidly adheres to prolapsed and incarcerated vitreous, facilitating its visualization and hence vitrectomy, and the steroid’s anti-inflammatory action may suppress development of CME. (The same triamcinolone preparations can also be introduced via pars plana injection for more direct CME prevention, again off label and recognizing the potential caveats of increasing IOP and/or infection risk.)
Second, if vitreous strands to the phaco incisions remain evident postoperatively, and especially if there is consequent pupil distortion, IOL displacement and/or CME, then YAG laser vitreolysis, optimally during the first month postop, is indicated. The technique is straightforward, utilizing the standard posterior capsulotomy contact lens but requiring higher magnification for precise visualization and higher energy (approximately 6 mJ to 8 mJ) for strand lysis.
Not incidentally, these same strategies are also applicable for various other situations of secondary IOL implantation, IOL exchange, and repositioning of subluxated or dislocated IOLs that require manipulation, iris-fixation, synechiolysis/iridoplasty and/or anterior vitrectomy. The prevention or reduction of CME is often dramatic.
Kenneth R. Kenyon, MD, is OSN Cornea/External Disease Editor Emeritus. Disclosure: Dr. Kenyon has no relevant financial disclosures.