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Cataract surgery technique addresses challenges of Stevens-Johnson syndrome
Modifications in the phacoemulsification procedure aid in successful cataract surgery in cases of hazy corneas and poorly dilating pupils.
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A modified surgical technique has been developed to treat cataract patients with Stevens-Johnson syndrome, a disease characterized by blistering of the skin and mucous membranes.
Study results
The modified technique, published in the Journal of Cataract and Refractive Surgery, addresses the difficulties surgeons face operating on patients with the disease.
The authors focused on 21 eyes of 16 patients with Stevens-Johnson syndrome. The mean patient age was 32 ± 12 years, and the mean time lapse from diagnosis of the disease to cataract surgery was 7.83 ± 4.8 years. Mean preoperative corrected distance visual acuity was 2.29 ± 3.78 logMAR.
The technique was attempted in 21 eyes and completed successfully in 18, in which an in-the-bag IOL was placed. A large-incision cataract extraction was performed in the remaining three eyes, which were left aphakic.
At 1 month, the mean postoperative corrected distance visual acuity was 0.84 ± 0.46 logMAR.
Regarding complications, exaggerated conjunctival inflammation was discovered in three eyes at a mean of 11 months after surgery. Two eyes experienced epithelial defects at a mean of 1 week, but they healed as lubrication was applied more frequently. Filamentary keratitis affected two eyes at 1 month, and the condition improved with treatment.
Modifications of traditional technique
Lead author Namrata Sharma, MD, described the measures that distinguish the new technique from the traditional.
“Various modifications at each step of phacoemulsification make a significant contribution toward simplifying cataract surgery in difficult situations such as Stevens-Johnson syndrome,” according to Sharma, who is a professor at the Dr. Rajendra Prasad Centre for Ophthalmic Sciences in New Delhi, India.
“In cases in which significant partial corneal haze is present due to overlying conjunctivalization or vascularization of the cornea, or in which the pupil does not dilate, nylon hooks are used to stretch the pupil to improve visualization of the cataract,” she said.
Sharma said she injects VisionBlue (trypan blue dye 0.06%, D.O.R.C. International) into the anterior chamber, beneath the iris margin. It is kept for at least 30 seconds to sufficiently stain the anterior capsule.
“While creating the [continuous curvilinear capsulorrhexis] with the forceps, it is important not to leave the edge of the CCC under the area of corneal haze, as relocating and regrasping the lost edge would be difficult due to poor visibility,” Sharma said.
A 25-gauge endoilluminator inserted intracamerally can significantly improve visualization in such cases in which a large capsulorrhexis is preferred, which may enable prolapse of the nucleus out of the bag, she said.
The nucleus prolapses into the anterior chamber, and Sharma said she performs phacoemulsification in the iris plane to avoid posterior capsule tear, “the risk of which is increased multifold in hazy corneas.”
In cases of asymmetric corneal opacification, Sharma makes an eccentric crater, followed by nuclear chopping in an area of clear cornea.
Such steps can help confront the difficulties Stevens-Johnson syndrome poses in performing cataract surgery, Sharma said, among them being symblepharon formation, “which interferes with lid opening, poorly dilating pupil due to the previous episode of intraocular inflammation and poor cooperation from patients under topical anesthesia due to photophobia from the microscope light.”
In any case, she said that cataract surgery in patients with the disease is a difficult task and that experienced surgeons who routinely carry out phacoemulsification should manage such cases.
“For beginners, phacoemulsification in such cases should be carried out under assistance, especially for the first 15 to 20 cases,” Sharma said. “The new surgical approach definitely makes the procedure easier to perform and shortens the learning curve both for the beginners and the expert surgeons.” – by Joe Green
- Reference:
- Sharma N, et al. J Cataract Refract Surg. 2016;doi:10.1016/j.jcrs.2016.09.012.
- For more information:
- Namrata Sharma, MD, can be reached at Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India; email: namrata.sharma@gmail.com.
Disclosure: Sharma reports no relevant financial disclosures.