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Rock-hard cataracts require more planning, intraoperative skill
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The cataract with an extremely dense and hard brunescent nucleus, or so-called “catarock,” is challenging surgery for any ophthalmic surgeon. There is often also a reduced endothelial cell count, a poorly dilating pupil, and weak or partially absent zonules. The capsule can be distended in an intumescent lens, normal or even crenated in some very hypermature cases. The lens can be white from opaque cortex, dark brown or in extreme cases even black.
These are always complex cases and can be coded as such. I document the complex nature in the chart and list the probable adjuncts that may be required, the delayed visual recovery and the increased complication rate. All studies, published and presented, confirm increased early corneal edema, postoperative inflammation, anterior and posterior capsular tears, vitreous loss and even endophthalmitis, so appropriate patient counseling is critical. Some of the most challenging cases I have encountered have been on mission and teaching trips abroad, but we all see these cases even in an urban first-world practice. I will share a few thoughts and personal preferences.
I always do a preoperative specular microscopy. I have found extremely low cell counts in some of these eyes. This finding leads me personally to recommend extracapsular cataract extraction (ECCE) rather than phacoemulsification. ECCE for the experienced surgeon is an excellent choice for many of these patients. If I cannot see the fundus, I do a B-scan. Nearly always ultrasonic biometry is required. I like to do a peribulbar block. This is helpful if conversion to ECCE or posterior vitrectomy is required. I do oculopression to soften the eye.
Once in the operating room, I take a deep breath, slow down and realize this will not be a 5- to 7-minute case. I like an IV and anesthesia standby and tell the OR team and anesthetist this will be a longer than average case. I always stain the anterior capsule with trypan blue. I inject a dilute epinephrine/lidocaine solution to enhance pupillary dilation. If needed, my preference for pupil management is four iris hooks, which can be replaced with capsular support devices if there is zonular laxity. For intumescent lenses, I hyperinflate the anterior chamber with a high-viscosity ophthalmic viscosurgical device through a small paracentesis incision and complete the capsulorrhexis with a cystotome on a viscoelastic syringe, injecting more viscoelastic as needed to deepen the anterior chamber and enhance visualization before making the primary incision.
I like a larger capsulorrhexis, at least 5.5 mm. I do not find that a femtosecond laser is required, but many surgeons find it helpful. The Mynosys Zepto capsulorrhexis device has worked well for me in a small number of cases, but I prefer a larger capsulorrhexis than the 5.2 mm allowed today by Zepto. I use Viscoat (chondroitin sulfate, sodium hyaluronate, Alcon) during phacoemulsification and replace it two to three times during the case.
There are many ways to disassemble and remove the nucleus. My favorite is to start with the sculpt setting and debulk the nucleus as much as possible. I then subluxate one pole of the nucleus anterior to the capsular rim with balanced salt solution and blow the posterior capsule back with a dispersive viscoelastic, usually Viscoat, and finish the remaining lens material with a combined supracapsular/chop phaco technique. Recently I have used the miLOOP (Iantech) in a small number of cases with good success. There is often no cortex or epinucleus to protect the posterior capsule from the often hard and sharp edges of the nucleus, so placing a dispersive viscoelastic between the nucleus and capsule as well as between the nucleus and endothelium enhances safety for me. Often the posterior capsule has meaningful opacity. I will polish a little but usually plan on a safer YAG laser in the postoperative period. I am prepared for a vitrectomy, which if discussed is charted preop as a possible “planned vitrectomy.” I watch for wound burns by looking for too much “lens milk” when ultrasound is applied and use reasonable powers applied in a pulsatile mode.
I do not hesitate to place a suture, usually one 10-0 Vicryl with a buried knot. I am an intracameral antibiotic user, and the solution I use from Imprimis also contains dexamethasone and ketorolac. Postoperatively I use more frequent topical steroids and a topical NSAID. In the face of significant corneal edema day 1, I find postoperative hourly steroid drops for 24 to 48 hours followed by an appropriate taper helps. I sometimes follow cornea edema with serial pachymetry and have seen the cornea continue to clear for 3 to 4 months. If I cannot evaluate the macula preoperatively directly or with OCT, I will not place a presbyopia-correcting IOL. I do use toric lenses in these patients.
Helping a patient improve from light perception to good vision remains one of the most gratifying surgeon experiences in medicine, but these cases are challenging and require more planning and intraoperative skill.
Disclosure: Lindstrom reports he is a consultant for Alcon, Iantech, Imprimis, Bausch Health, J&J Vision and Mynosys.