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Updated intracapsular cataract surgery for an unusual eye
A surgeon describes his technique for management of traumatic anterior chamber lens dislocation after an airbag-related injury.
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Traumatic lens subluxation is an ocular emergency that needs to be attended to in a timely fashion with surgical intervention to obtain the best possible visual result postoperatively.
In a case series of 71 eyes with traumatic lens subluxation, blunt trauma was more common (89%) than penetrating injury (11%). Sports-related injury was the most common cause of traumatic lens subluxation, and inferior subluxation accounted for nearly half (46%) of these cases.
When we focus our attention to motor-vehicle-related accidents in the United States, the mortality and morbidity figures have improved, largely due to the improvements from the automobile industry as a whole with advanced technology directed to lessening bodily injuries in situations of automobile-related sudden impact. While airbags have been a significant step in preventing major bodily injuries, the deployment of airbags in motor vehicle accidents can contribute to ocular trauma in some of these cases. However, in motor vehicle accidents, the rate of ocular trauma increases 2.5 times in non-airbag-equipped cars compared with airbag-equipped vehicles, and usually the ocular trauma in airbag-equipped vehicles is closed-globe injury.
When the crystalline lens is housed in the anterior chamber, surgical techniques may include anterior chamber phacoemulsification via a small-incision approach, or removing the lens as whole using an intracapsular cataract extraction technique. If phacoemulsification is carried out, it is important to take precautionary steps in preventing lens material from visiting the posterior segment, such as the IOL scaffold technique and other techniques. Removing the lens using an intracapsular technique usually eliminates the risk of dropping lens material into the posterior segment.
Preoperative focus should include complete ocular evaluation in traumatic lens subluxation to check for trauma-related injury to other ocular tissues. Proper documentation, including preoperative visual acuity in the patient chart, is essential from a medico-legal perspective. Intraoperatively, the endothelium needs to be protected from iatrogenic trauma by using viscoelastic, and vitreous needs to be eliminated from the anterior chamber. Choice of IOL technique would be influenced by the tissue anatomy and surgeon preference.
Postoperatively, reevaluation of the posterior segment under improved view after lens removal should help detect any macular edema, secondary trauma-related retinal damage and any vitreous hemorrhage. Long-term follow-up is important to check for secondary glaucoma, especially in the presence of angle recession.
In this column, Dr. Devgan describes his surgical technique in the management of traumatic anterior chamber lens dislocation secondary to motor-vehicle-accident-related airbag injury.
Thomas “TJ” John, MD
OSN Surgical Maneuvers Editor
Although performing intracapsular cataract surgery was the norm many decades ago, it is rare for an ophthalmologist to perform one now. Things progressed to manual extracapsular cataract surgery and then to phacoemulsification, and intracapsular surgery was retired.
Uday Devgan
In some unusual cases, however, there is still utility in performing intracapsular cataract surgery.
Case presentation
A 68-year-old patient presented to our county hospital emergency room after sustaining an airbag injury to the face during an automobile accident. Upon examination, his vision was reduced to hand motions, and I was surprised to see the entire crystalline lens in his anterior chamber. The central cornea was edematous from the injury, but at the time of injury, the crystalline lens was in close proximity to, but not touching, the corneal endothelial cells. His zonular apparatus was absent for the most part, and what little remained was severely compromised.
After quieting the eye, ruling out other injuries and recovering from the initial trauma, the patient was scheduled for intracapsular cataract surgery. Preoperative measurements showed 2 D of with-the-rule corneal astigmatism bilaterally, for which the patient wore glasses, a normal endothelial cell count despite the trauma and an average axial length.
Traditional intracapsular cataract extraction, as routinely performed many years ago, involved surgical steps that I wanted to eliminate or update for this patient. I wanted to make this patient’s surgery less invasive and less traumatic by making a better-sealing, smaller incision. In addition, I had the benefit of viscoelastics to compartmentalize the eye, protect ocular structures and prevent vitreous prolapse.
Surgical technique
Retrobulbar anesthesia was given to achieve analgesia and akinesia during surgery. A superior scleral tunnel incision was made in a shelved manner so that it would provide a better seal and more surface area for long-term healing. This type of incision is structurally superior to simply using corneo-scleral scissors to cut along the limbus. The incision was made with an arc length of approximately 8 mm to 9 mm and a tunnel length of about 3 mm.
Figure 1. This 68-year-old patient suffered an airbag injury that resulted in his crystalline lens becoming entirely displaced into the anterior chamber. There was no evidence of ruptured globe or other injury.
Images: Devgan U
Figure 2. (A) Viscoelastic was placed in front of the lens to protect the corneal endothelium, as well as behind the lens to create a barrier to prevent vitreous prolapse. (B) After rotating the lens in the anterior chamber to ensure absence of zonular adhesions, a lens loop was used to remove the lens through a shelved superior scleral tunnel incision. (C) Further viscoelastic was injected to compartmentalize the eye and protect the anterior hyaloid face, which remained intact. (D) Acetylcholine chloride solution was injected to induce pupillary miosis.
Figure 3. (A) A small superior peripheral iridotomy was created using Colibri forceps and Vannas scissors. (B) The anterior chamber IOL was placed on top of the iris and rotated into position at the horizontal meridian. (C) The superior incision was then closed with sutures to ensure a water-tight globe. (D) Finally, a small amount of triamcinolone was placed into the anterior chamber for inflammation control and to look for any prolapsed vitreous, although there was none in this case.
Prior to removing the crystalline lens, dispersive viscoelastic was used to protect the corneal endothelium and create more working room in the anterior chamber. Additional dispersive viscoelastic was injected behind the lens to create a barrier in front of the anterior hyaloid face to prevent vitreous prolapse. The lens was then spun in the anterior chamber to ensure that there were no remaining zonular adhesions. The cataract was removed using the lens loop and the anterior chamber was reformed with viscoelastic. Acetylcholine chloride solution was instilled to cause pupillary constriction and then a superior peripheral iridotomy was made.
There are different IOL options available for this patient: suture fixation of a suitable IOL to the back of the iris, scleral fixation with the Amar Agarwal glued IOL technique using intrascleral tunnels, or placement of an anterior chamber IOL. We elected to go with the anterior chamber IOL for simplicity and placed it on top of the iris. It was rotated to the horizontal meridian with the haptics placed securely in position without entrapment of iris tissue. The viscoelastic was irrigated out of the eye and the incision was closed with interrupted 10-0 nylon sutures and confirmed to be water-tight. A small amount of triamcinolone was instilled into the anterior chamber to confirm the absence of vitreous and to aid in postoperative inflammation control.
Another potential way to perform this case is the Soosan Jacob glued IOL scaffold technique, wherein a sclerally fixated IOL is placed first to act as a scaffold, and then the cataract can be phacoemulsified in the anterior chamber with a minimized risk of posterior displacement of lens fragments. We chose to use this modified intracapsular cataract extraction technique, and postoperatively the patient did very well, with excellent recovery of vision. This case emphasizes the point that, although surgical techniques evolve and change with time, there is a benefit to understanding seemingly historical procedures. No two patients are ever identical, and we need to be able to tailor our surgical techniques to each specific eye to achieve the best results.