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Keep appropriate instruments at hand to address cataract surgery complications
The OR should be equipped to manage any complication, and the staff should be well prepared.
When complications occur during cataract surgery, being prepared is one of the keys to achieving good outcomes. This entails not only being technically and psychologically equipped, but also having the right instruments at hand.
“The most basic equipment would be to have capsular tension rings or segments, Prolene 10-0 for iris suturing and 9-0 for rescuing a dislocated lens with the lasso technique. Gore-Tex off label is very important to have for securing any eyelet, whether of capsular tension segments or of the Cionni modified capsular tension ring (FCI Ophthalmics) as well as scleral fixation of intraocular lenses; 10-0 nylon should be handy for incision management,” Lisa B. Arbisser, MD, said.
MST produces a set of fine instruments for microincision surgery, consisting of a handle and a variety of exchangeable heads including intraocular forceps, scissors and an IOL cutter.
“It is nice to have an intraocular device that can do a capsulorrhexis through a very small incision, and laser markings help determine size. The grasper allows you to manage the iris and stabilize an IOL. The MST scissors are tiny but have a very high cutting power, while the MacKool scissor is larger but more versatile,” Arbisser said. Vannas scissors or intraocular capsule scissors allow modification of a too small capsulorrhexis or starting a tag to convert a tear.
Managing unplanned vitrectomy
Inadvertent opening of the posterior capsule occurs rarely in expert hands, but when it does, surgeons must be prepared to perform an anterior vitrectomy, which avoids intraoperative and postoperative traction. Machine settings must be well understood. Although the procedure can be performed through an anterior paracentesis, every cataract surgeon should learn how to perform a safe pars plana incision, Arbisser said. Instruments should be biaxial, with irrigation always provided through a side port and the main cataract incision closed. Maintaining normotension is an important goal throughout the procedure.
“A one-port pars plana approach is more efficient in severing anterior-posterior vitreous connections and is far less likely to extend the capsular tear. The incision can be done directly with an MVR blade after measuring with a caliper requiring suturing,” she said.
“The use of a transconjunctival trocar system is controversial though all agree it can only be used when the eye is firm and/or all incisions are secured due to entrance pressure. Off label for anterior vitrectomy, trocar systems are packaged individually (outside a retina pack) by few companies (Mani from Crestpoint is one). The technique requires learning how to perform an appropriate 30° angled scleral tunnel through-and-through incision with the trocar system at the pars plana. Timing of cutting and irrigation along with close of the tunnel so the sutureless opening does not allow vitreous incarceration is essential,” Arbisser said.
Chamber maintainers can be helpful as an alternative to the standard 23-gauge cannula for irrigation. The Arbisser-Snyder-Riemann chamber maintainer (Epsilon) is a trocar-like chamber maintainer that can be inserted through the anterior paracentesis during biaxial vitrectomy and reduces pressure fluctuation.
Loose zonules, narrow pupils, dropped nuclei
It is advisable for every OR to have capsule expansion hooks available for the management of loose zonules.
“The MST Chang-modified capsule retractors support the capsule equator as well as the capsulorrhexis edge and distribute forces so that we are less likely to break the capsulorrhexis edge. They can be absolutely essential in abnormal zonule cases, though segments with iris hooks as ‘coat hangers’ can suffice but don’t support the equator, requiring a CTR to be placed early to tension the posterior capsule. I prefer to place a CTR in the emptied bag,” Arbisser said.
But for cost, Omidria (phenylephrine 1% and ketorolac 0.3% intraocular solution, Omeros) or other pupil management medications should be routine, she said.
Iris hooks and the Malyugin ring (MST) are invaluable tools in eyes with narrow pupils. Arbisser prefers the Malyugin ring, unless there are reasons not to introduce a foreign body into the eye, in which case iris hooks are preferable, arranged in a diamond configuration.
Cataract removal using a reduced amount of energy is now possible with the miLOOP (IanTECH/Zeiss), a simple device that uses a thin nitinol filament wire to wrap around and cut the nucleus.
“This is an extremely valuable tool for disassembly of a dense lens, though my circumferential cross-action chop technique works well for me,” Arbisser said.
An irrigating vectis is also useful to help remove nucleus fragments, combining mechanical and hydrostatic forces so long as the capsule is intact, she said.
When the nucleus threatens to drop into the posterior segment, the Arbisser nuclear spears (Epsilon) can be used to lift the nucleus into the anterior chamber without having to go to the pars plana.
“I am not a fan of visco-levitation, believing that the only instrument we should place through the pars plana is a vitrector. I would rather use Arbisser nuclear spears through anterior paracenteses 180° apart to lift the nucleus above the iris plane for safe removal,” Arbisser said. Should the nucleus fall below the posterior capsule, it should be referred for planned three-port vitrectomy and lensectomy.
Other instruments to have at hand should include a variety of needles, including a 26-gauge hollow-bore needle for ab externo docking, a 30-gauge needle for initiating a hyaloid-sparing posterior capsulorrhexis and the TSK ultra thin wall needle for flange scleral haptic fixation. Crescent blades for scleral tunneling as well as blades or scissors to extend incisions are also a must-have. The Arbisser-Fine Triamond blade (Mastel) can make incisions of any size, starting from 0.3 mm to any size.
“Last but not least, it is essential to have trypan blue for visualization, PF epinephrine, Miochol-E (acetylcholine chloride intraocular solution, Bausch + Lomb) and Triesence (triamcinolone acetonide injectable suspension, Alcon) for particulate identification of vitreous. Having and understanding the use of multiple OVDs — dispersive, cohesive and viscoadaptive — are an essential part of our armamentarium,” Arbisser said. Intravenous mannitol given as a bolus preoperatively can help avoid complications as well.
Reverse optic capture
There is another specific instrument Robert H. Osher, MD, recommends having at hand when doing cataract surgery. It is the Osher Reverse Optic Capture Hook (Bausch + Lomb), designed to facilitate reverse optic capture when the posterior capsule is torn (Figure 1).
“Most surgeons are familiar with traditional optic capture where the surgeon implants a three-piece lens placing the haptics into the ciliary sulcus then pushing the optic backward through the capsulorrhexis opening. Reverse optic capture is very helpful when a single-piece or three-piece lens is in a torn bag and there is a question about either centration, stability or adequate fixation,” Osher said.
The hook is placed beneath the lens to lift the optic forward through the capsulorrhexis opening. The lens becomes both centered and stable with the haptics still in the torn bag but the optic outside, through the intact capsulorrhexis opening.
Source: Robert H. Osher, MD
“The instrument slips under the optic, assisting its atraumatic elevation through the rhexis, capturing the optic and leaving the haptics behind the anterior capsule,” Osher said.
Positive pressure
One other instrument Osher developed is the Osher Air Bubble remover cannula (Bausch + Lomb), specifically designed to manage challenging cases of positive pressure (Figure 2).
“When positive pressure occurs, it becomes difficult to maintain the anterior chamber, which wants to collapse near the end of the procedure. There are many possible causes, but it is always a dangerous situation because the intraocular lens can abruptly crash into the iris or cornea,” Osher said.
Management of this complication entails injecting an air bubble to maintain the anterior chamber space until the incision can be hydrated and the chamber refilled with balanced salt solution through the stab incision. Then the air bubble can be removed in small aliquots in exchange for either balanced salt solution or acetylcholine chloride to constrict the pupil.
“I designed a 30-gauge cannula that is curved upward into the dome of the cornea to facilitate easy air removal without distorting the stab incision,” Osher said.
Prepare with practice
Complications with cataract surgery are not frequent these days, and there is a risk that surgeons and their staff are not well prepared for those rare events.
“I always make the point that we practice for a myocardial infarction or fire but not for vitreous loss,” Arbisser said.
Arbisser recommends occasionally calling a “code V,” using a clean vitreous pack saved for this purpose, going through the motions of setting up the machine, understanding parameters and knowing where the tools are for any eventuality.
“There is more to preparation than just having the right equipment. Practicing every now and then allows us not to get into a panic when complications occur. It is important to know where it is, what to do with it and to do it calmly and methodically with ‘vocal local’ to soothe both patient and staff,” Arbisser said. – by Michela Cimberle
- For more information:
- Lisa B. Arbisser, MD, can be reached at John A. Moran Center, 65 Mario Capecchi Drive, Salt Lake City, UT 84132; email: drlisa@arbisser.com.
- Robert H. Osher, MD, can be reached at University of Cincinnati, Stetson Building, Suite 5300, Cincinnati, OH 45267; email: robert.osher@uc.edu.
Disclosures: Arbisser reports no relevant financial disclosures. Osher reports he is a consultant for Bausch + Lomb.