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One surgeon’s approach to complex cataract cases
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The cataract surgeon is frequently confronted with a patient with preoperative lax or missing zonules and intraoperative damage to zonules or the posterior capsule. These cases can be associated with an intact vitreous face or vitreous prolapse. In this commentary, I will share a few thoughts on my current approach to these complex cases.
First, I find it important to have available in the OR appropriate surgical adjuncts to manage these cases. For me, these include trypan blue capsular dye; capsular tension rings of standard design and Cionni rings (Morcher/FCI Ophthalmics), Ahmed segments (Morcher/FCI Ophthalmics) or ideally both; an appropriate suture to perform scleral and iris fixation; a dispersive viscoelastic; microforceps and microscissors such as those from MicroSurgical Technology (MST); IOLs compatible with sulcus placement and iris or scleral fixation; a vitrector capable of anterior segment and pars plana vitrectomy with appropriately sized MVR blades to make the self-sealing corneal and scleral incisions; intraocular triamcinolone; and an inventory of anterior chamber IOLs.
A few personal thoughts on their use. I do not find filling the anterior chamber with air valuable or necessary when using trypan blue. I simply fill the anterior chamber with a cohesive viscoelastic and inject the trypan blue slowly under the viscoelastic onto the capsular surface. I will then gently rub the surface with the injection cannula to be sure the capsule is well stained. Further injection of viscoelastic, starting in the distal angle, can be used to clear the view.
If there is zonular absence or a torn capsule with vitreous prolapse, I am careful to avoid injecting trypan blue into the vitreous, as it will reduce or eradicate the red reflex. I prefer to remove the nucleus and cortex before placing a capsular tension ring or segment whenever possible. I will subluxate the nucleus with hydrodissection or viscodissection, utilize a supracapsular phacoemulsification and place a dispersive viscoelastic over areas of vitreous exposure to reduce stress on the zonules and vitreous face.
If vitreous prolapse occurs, I like to remove the nucleus completely before doing any vitrectomy when possible, as the vitreous tends to support nuclear fragments in the anterior chamber. I have found the IOL scaffold approach to work extremely well in the face of an intraoperative capsular tear with residual nucleus. The phacoemulsifier is removed with irrigation on while injecting dispersive viscoelastic through the side port, any nuclear fragments are viscoelevated into the anterior chamber with a dispersive agent, and a three-piece IOL is injected into the anterior chamber under the residual nuclear fragments. The IOL can be rotated into the sulcus to make more room in the anterior chamber, and then the phacoemulsifier is reintroduced, allowing removal of residual nucleus over the IOL optic. The IOL optic can be depressed posterior with a second instrument, creating an optic capture through the capsulorrhexis and in some cases also through the posterior capsular tear as well, tamponading the vitreous in the posterior segment.
In many cases, residual cortex can then be removed with irrigation and aspiration using a lowered bottle height. If vitreous prolapses, I like to place a suture in the wound, firm up the eye with viscoelastic and perform a pars plana vitrectomy. Anesthesia of the conjunctiva can be obtained by holding a Xylocaine- or tetracaine-soaked pledget over the incision area or with a small subconjunctival Xylocaine (lidocaine, AstraZeneca) injection. I set the vitreous cutter speed at the highest setting available on the phaco machine and use a bimanual approach with irrigation into the anterior segment with a May needle or equivalent and vitrectomy through the pars plana. The appropriate-sized MVR blade, usually 19 gauge for most machines, makes the incision less traumatic and easier to create. I close these wounds with 8-0 or 10-0 Vicryl suture. Once vitreous is removed from the anterior segment, cortex is removed with I&A. I find mild posterior pressure on the IOL optic with a second instrument often enhances cortex removal. Anterior chamber placement of triamcinolone, Triesence (Alcon Surgical) for me, helps assure no vitreous strands remain, and I also always sweep with an iris spatula and check the wounds with a Weck-Cel sponge.
In cases of vitreous loss, I routinely place a suture in the wound and treat longer and more aggressively with topical steroids and NSAIDs. A good peripheral retinal examination by the surgeon or a consultative vitreoretinal specialist is wise, and I often perform postoperative optical coherence tomography to monitor for cystoid macular edema.
The ideal suture for iris fixation, scleral fixation and capsular tension ring fixation remains debatable. I favor 10-0 polyester suture on a long PC-7 needle (Alcon Surgical), as I have observed polyester sutures as small as 11-0 retain good tensile strength for 20 years when used after keratoplasty, suggesting to me this suture is resistant to ultraviolet light and biodegradation. It is important to know how to tie a Siepser knot. While I prefer iris fixation or scleral fixation of a posterior chamber IOL, the modern anterior chamber IOLs work well and are a reasonable alternative. When confronting these difficult cases, it is important to slow down and take the time needed to perform meticulous surgery.
Finally, it is also important to consider the skill level required to manage some complex problems is high, and it is often best to abort surgery when one is beyond his or her comfort zone, carefully suture any incisions and refer the patient to a consultative surgeon for reconstruction. Repair of many intraoperative problems can be safely done at a later date in a planned fashion with a good outcome.
Patients know that complications can occur, and they and their family deserve to be promptly informed when they do. This usually requires a brief discussion immediately after surgery and a more extensive discussion the next day when perioperative sedation has worn off. Explaining to the patient, for example, that a small piece of the cataract fell into the back of the eye and is more safely removed at a later date by another surgeon is usually well accepted and almost never creates as many short-term or long-term issues, including medical-legal problems, as does going beyond one’s surgical training or comfort zone and creating untreatable surgical complications such as a giant retinal tear. All surgeons encounter complex cases and intraoperative complications, but proper management generally allows excellent outcomes in ophthalmic surgery.
Disclosure: Lindstrom is a consultant for Alcon Laboratories Inc.