Correspondence To our knowledge, this is the first reported case of significant hyperostosis and bone marrow hypertrophy in the orbit, in association with recurrent pleomorphic adenoma. Soroosh Behshad, Pooja Sethi, Alejandra A. Valenzuela Tulane University School of Medicine, New Orleans, La Correspondence to: Soroosh Behshad, MD: [email protected] REFERENCES 1. Lai T, Prabhakaran VC, Malhotra R, et al. Pleomorphic adenoma of the lacrimal gland: is there a role for biopsy? Eye. 2009;23:2-6. 2. Font RL, Gamel JW. Epithelial tumors of the lacrimal gland: an analysis of 265 cases. In: Jakobiec FA, ed. Ocular and Adnexal Tumors. Birmingham, Al.: Aesculapius; 1978. 787-805. 3. Rinna C, Reale G, Calvani F, et al. Pleomorphic adenoma of the lacrimal gland: two clinical cases. Eur Rev Med Pharmacol Sci. 2012; 16(suppl 4):90-4.
Iris spatula-guided epinuclear cleavage in posterior polar cataracts Posterior polar cataracts pose a challenge to every cataract surgeon even today in the era of advanced phacoemulsification and improved instrumentation. They are transmitted as an autosomal dominant trait and represent a weak or pre-existing dehiscent posterior capsule leading to complications during phacoemulsification. They classically are described as having a “rosette or ring onion” posterior capsular opacity.1 Pre-existing capsular dehiscence can sometimes be appreciated as having a “fish tail sign” in anterior vitreous or an oval defect in the posterior capsule on retro illumination.1 According to understood pathology of posterior polar cataracts, various modifications have been introduced in the conventional methods of phacoemulsification surgery with the aim of reducing surgical complications including low-power, slow-motion phacoemulsification,2 avoiding hydrodissection and nuclear rotation,3 Y-quadrant phacoemulsification,4 and inside-out hydrodelineation.5 However, in the absence of hydrodissection, epinuclear removal remains a difficulty in some cases after phacoemulsification. It sometimes requires a lot of the surgeon’s time and patience to remove the sticky epinucleus and the cortex. We describe a technique for easy and safe removal of this adherent epinuclear rim, which we have been practicing in our cases. Peribulbar anaesthesia is administered. Temporal clear corneal incision is made and dye-assisted capsulorrhexis measuring approximately 5 mm is performed. Classical cortical cleaving hydrodissection is not performed because it might lead to the hydraulic rupture of the weak posterior capsule. Hydrodelineation is performed using a 26-G cannula, taking care to keep it as centrally as possible
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4. Rose GE, Wright JE. Pleomorphic adenoma of the lacrimal gland. Br J Ophthalmol. 1992;76:395-400. 5. Prabhakaran VC, Cannon PS, McNab A, et al. Lesions mimicking lacrimal gland pleomorphic adenoma. Br J Ophthalmol. 2010;94: 1509-12. 6. Tse D. Clinical and microdissection genotyping analyses of the effect of intra-arterial cytoreductive chemotherapy in the treatment of lacrimal gland adenoid cystic carcinoma. Trans Am Ophthalmol Soc. 2005;103:337-67. 7. Kawaguchi O, Kunieda E, Fujii H, et al. Adenoid cystic carcinoma with hyperostosis after stereotactic radiosurgery. Radiat Med. 2004;22:198-200. 8. Stefko S, DiBernardo C, Green W, Merbs SL. Pleomorphic adenoma of the lacrimal gland with extensive calcification. Arch Ophthalmol. 2004;122:778-80. 9. Foucar K, Viswanatha DS, Wilson CS. Non-Neoplastic Disorders of Bone Marrow. Atlas of Nontumor Pathology 6. Washington, DC: American Registry of Pathology, Armed Forces Institute of Pathology; 2008. Can J Ophthalmol 2015;50:e104–e106 0008-4182/15/$-see front matter & 2015 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2015.08.004
and using a very small amount of fluid (Video 1, available online). A golden ring is observed on completion of hydrodelineation. Central endonucleus is gently rocked to facilitate further separation from the epinuclear cushion. Any rotational manoeuvre is avoided. Care is taken at each step to avoid letting the stream of fluid go behind the posterior capsule. The central core of the soft nucleus is sculpted with the phaco handpiece to create a central gutter (Infiniti Vision System, Alcon Inc, Fort Worth, Tex.) (Video 1, available online). The epinucleus removal is fraught with difficulty because of lack of performance of cortical cleaving hydrodissection. At this point, the Barraquer fine iris spatula (Appasamy Associates, Chennai, India) is introduced from the side port with the left hand and by blunt dissection a plane is created in the doughnut of epinucleus inside the bag in the clock-hour opposite the side port from where the spatula is introduced (Fig. 1A). As the epinucleus is dissected, caution is exercised to avoid stripping of the most posterior epinucleus off the posterior capsule, thus leaving the central epinuclear cushion attached to the posterior capsule. After this, the epinucleus is dissected in the same quadrant at a more posterior plane, thus allowing layer-by-layer loosening of the epinucleus with the aid of the iris spatula (Fig. 1B). The phaco probe is then grasped using the left hand, and the iris spatula is introduced through the second side port situated toward the right of the main incision (Fig. 1C). Similar multiplanar epinuclear dissection is aided by the spatula’s tangential movement all around 360 degrees. Removal of the central posterior plaque is attempted toward the end (Fig. 1D). For cleaving the peripheral lower half of the epinucleus, that is, the epinucleus in the clock-hours opposite the main incision from where the probe is introduced, it is stripped
CAN J OPHTHALMOL — VOL. 50, NO. 6, DECEMBER 2015
Correspondence
Fig. 1 — A, Barraquer iris spatula is introduced through the left side port and tangential splitting of the peripheral and anterior epinuclear shell is made. B, A more posterior tangential split is created in the same quadrant. C, The spatula is introduced through the right side port and right hand to create cleavage in the inferior quadrant, first at the anterior plane and then more posteriorly. D, Care is exercised to aspirate the peripheral epinuclear shell the first and central plaque toward the end.
off the capsule with the probe, leaving the central area attached. Irrigation/aspiration of the separated epinuclear rim is performed simultaneously with the coaxial probe. Posterior polar cataracts may be associated with 7% to 36% risk for posterior capsular rupture even in the hands of a skilled ophthalmic surgeon.6,7 The factors identified for increased risk for capsular rupture include soft nucleus with large capsular opacification and younger patient age.8 Hydrodissection plays a paramount role in phacoemulsification of age-related cataracts by achieving loosening of the adherent cortical fibres from the capsular bag. Hydrodissection allows irrigation/aspiration to proceed significantly faster, less stressfully, and more conveniently, with less fluid requirement and causing lesser posterior capsular rents.9,10 However, hydrodissection is a forbidden step in the phacoemulsification of posterior polar cataracts. Although there are no direct studies on posterior polar cataracts, it can be derived from earlier in this article and as has been observed by the authors that without the essential hydrodissection step, it takes much longer for cortical cleanup in a case of posterior polar cataract. To address these concerns, we performed layer-by-layer phacoaspiration of epinucleus loosened by the tangential movement of the iris spatula under the anterior capsular rim. Care was taken to remove 1 layer at a time with the posterior-most layer being removed toward the end to avoid early opening of the posterior capsule in cases with a deficient capsule. This technique offered easier aspiration without the need for repeated withdrawal of the
phacoemulsification handpiece from the anterior chamber, thus requiring lesser time and lesser anterior chamber collapse. The technique described here is of maximum benefit in soft cataracts because of the presence of a thick epinuclear shell. In the past, Allen11 and colleagues and Fine et al.12 proposed epinuclear viscodissection to facilitate loosening of the epinucleus from the posterior capsule. It was performed by injecting a viscoelastic under the anterior capsular edge to aid mobilization of the peripheral epinuclear rim followed by coaxial aspiration. However, this procedure entails the risk of increasing pressure on the weak and possibly dehiscent posterior capsule. Further, it requires repeated removal of probe from the anterior chamber to enable layer-by-layer viscodissection of the peripheral epinuclear rim, thus increasing the surgical time significantly. Lee and Lee4 suggested manual dry aspiration of the epinucleus with Simcoe cannula, which again is time-consuming in the era of fast phacoemulsification surgeries. Nagappa et al.13 performed hydrodissection of the subincisional epinucleus from the cortex after nuclear removal. This procedure again would require removal of the phaco-handpiece to facilitate the dissection from the underlying capsule. Hence iris spatula-guided epinuclear shell removal allows faster surgery without compromising the safety of the posterior capsule. Video 1 can be found on the CJO web site at eyesite.ca. It is linked to this article in the online contents of the December 2015 issue.
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Correspondence APPENDIX A. SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j. jcjo.2015.07.014. Sudarshan Khokhar, Shikha Gupta, Varun Gogia Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India Correspondence to: Shikha Gupta, MD: [email protected] REFERENCES 1. Vasavada AR, Raj SM, Vasavada V, Shrivastav S. Surgical approaches to posterior polar cataract: a review. Eye (Lond). 2012;26:761-70. 2. Osher RH, Yu BC, Koch DD. Posterior polar cataracts: a predisposition to intraoperative posterior capsular rupture. J Cataract Refract Surg. 1990;16:157-62. 3. Siatiri H, Moghimi S. Posterior polar cataract: minimizing risk of posterior capsule rupture. Eye. 2006;20:814-6. 4. Lee MW, Lee YC. Phacoemulsification of posterior polar cataracts: a surgical challenge. Br J Ophthalmol. 2003;87:1426-7.
Iatrogenic retinal detachment secondary to inadvertent subretinal injection of triamcinolone during cataract surgery Sub-Tenon injection of triamcinolone has been widely used to effectively control inflammation in intermediate uveitis for decades.1 Perioperatively, sub-Tenon triamcinolone can be used for patients with uveitis as an adjuvant during cataract surgery.2 Planning for cataract surgery in these patients also involves preoperative topical or systemic steroids.2 Although the local delivery of triamcinolone avoids systemic side effects of steroids, a number of complications can occur, including increase in intraocular pressure,3–5 rapidly progressive cataracts,3,6 ptosis,5,6 and globe penetration.3,7,8 Inadvertent globe penetration is a rare but sight-threatening complication that can occur with any sub-Tenon approach, possibly because the needle is placed close to the sclera.3 We present the case of a 66-year-old male who was referred to our clinic with cataracts. He had a diagnosis of anterior and intermediate uveitis with a background of sarcoidosis. He had been treated with topical and systemic steroids and methotrexate, and he had been in remission for several years. On examination he had visual acuities of 6/6 OD and 6/5 OS, no anterior chamber activity, and extensive posterior synechiae involving the pupillary margin of 2701 on the right and 1801 on the left. He also had significant posterior subcapsular cataracts, dense on the right and moderate on the left. The funduscopy did not highlight any sign of posterior segment inflammation.
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5. Vasavada AR, Raj SM. Inside-out delineation. J Cataract Refract Surg. 2004;30:1167-9. 6. Vasavada AR, Singh R. Phacoemulsification with posterior polar cataract. J Cataract Refract Surg. 1999;25:238-45. 7. Hayashi K, Hayashi H, Nakao F, et al. Outcomes of surgery for posterior polar cataract. J Cataract Refract Surg. 2003;29:45-9. 8. Stanić R, Bućan K, Stanić-Jurasin K, Kovacić Z. Phacoemulsification in eyes with posterior polar cataract. Acta Clin Croat. 2012;51:55-8. 9. Vasavada AR, Singh R, Apple DJ, Trivedi RH, Pandey SK, Werner L. Effect of hydrodissection on intraoperative performance: randomized study. J Cataract Refract Surg. 2002;28:1623-8. 10. Peng Q, Apple DJ, Visessook N, et al. Surgical prevention of posterior capsule opacification. Part 2: enhancement of cortical cleanup by focusing on hydrodissection. J Cataract Refract Surg. 2000;26:188-97. 11. Allen D, Wood C. Minimizing risk to the capsule during surgery for posterior polar cataract. J Cataract Refract Surg. 2002;28:742-4. 12. Fine IH, Packer M, Hoffman RS. Management of posterior polar cataract. J Cataract Refract Surg. 2003;29:16-9. 13. Nagappa S, Das S, Kurian M, Braganza A, Shetty R, Shetty B. Modified technique for epinucleus removal in posterior polar cataract. Ophthalmic Surg Lasers Imaging. 2011;42:78-80. Can J Ophthalmol 2015;50:e106–e108 0008-4182/15/$-see front matter & 2015 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2015.07.014
The decision was made to do surgery for the right eye and he underwent synechialysis, use of vital dye (vision blue), Malyugin ring, and microincision phacoemulsification with insertion of 3-piece intraocular lens. At the end of the surgery sub-Tenon triamcinolone 40 mg (Kenalog 40mg/ml in 1 ml) was to be injected on the superotemporal quadrant with a 27G needle. After 0.5 mL had been injected, inadvertent globe penetration was detected via indirect signs: red reflex became white, severe shallowing of the anterior chamber, iris prolapse through both incisions impossible to reposition, and a rock-hard eye on digital inspection. Immediate peritomy with sclerotomy (microvitreoretinal 20-gauge) 901 away from the injection site and 3.5 mm from the limbus was done, with exit of scant transparent fluid. This was followed by 1-port pars plana vitrectomy (Stellaris PC, Stellaris, Bausch & Lomb, Rochester, New York, USA) for decompression. The anterior chamber was re-formed with balanced salt solution, prolapse reduced, and the cornea sutured. Exploration of the surgical site of injection was done, with a puncture site detected 8 mm from the limbus. The penetration was contained, with no vitreous or chorioretinal prolapse. Sites of injection and vitrectomy were sutured. Immediate indirect ophthalmoscopy detected a superotemporal retinal detachment 3 clock hours, turbid, edge bordering on arcade, and no macula involvement (Fig. 1). Over a period of 8 weeks, migration of the triamcinolone was observed over the temporal to the inferior periphery, with eventual resolution (Fig. 2). The last examination showed pigmentation and atrophy of the retina in the involved areas, and no tears or residual retinal
CAN J OPHTHALMOL — VOL. 50, NO. 6, DECEMBER 2015
Iris spatula-guided epinuclear cleavage in posterior polar cataracts Posterior polar cataracts pose a challenge to every cataract surgeon even today in the era of advanced phacoemulsification and improved instrumentation. They are transmitted as an autosomal dominant trait and represent a weak or pre-existing dehiscent posterior capsule leading to complications during phacoemulsification. They classically are described as having a “rosette or ring onion” posterior capsular opacity.1 Pre-existing capsular dehiscence can sometimes be appreciated as having a “fish tail sign” in anterior vitreous or an oval defect in the posterior capsule on retro illumination.1 According to understood pathology of posterior polar cataracts, various modifications have been introduced in the conventional methods of phacoemulsification surgery with the aim of reducing surgical complications including low-power, slow-motion phacoemulsification,2 avoiding hydrodissection and nuclear rotation,3 Y-quadrant phacoemulsification,4 and inside-out hydrodelineation.5 However, in the absence of hydrodissection, epinuclear removal remains a difficulty in some cases after phacoemulsification. It sometimes requires a lot of the surgeon’s time and patience to remove the sticky epinucleus and the cortex. We describe a technique for easy and safe removal of this adherent epinuclear rim, which we have been practicing in our cases. Peribulbar anaesthesia is administered. Temporal clear corneal incision is made and dye-assisted capsulorrhexis measuring approximately 5 mm is performed. Classical cortical cleaving hydrodissection is not performed because it might lead to the hydraulic rupture of the weak posterior capsule. Hydrodelineation is performed using a 26-G cannula, taking care to keep it as centrally as possible
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4. Rose GE, Wright JE. Pleomorphic adenoma of the lacrimal gland. Br J Ophthalmol. 1992;76:395-400. 5. Prabhakaran VC, Cannon PS, McNab A, et al. Lesions mimicking lacrimal gland pleomorphic adenoma. Br J Ophthalmol. 2010;94: 1509-12. 6. Tse D. Clinical and microdissection genotyping analyses of the effect of intra-arterial cytoreductive chemotherapy in the treatment of lacrimal gland adenoid cystic carcinoma. Trans Am Ophthalmol Soc. 2005;103:337-67. 7. Kawaguchi O, Kunieda E, Fujii H, et al. Adenoid cystic carcinoma with hyperostosis after stereotactic radiosurgery. Radiat Med. 2004;22:198-200. 8. Stefko S, DiBernardo C, Green W, Merbs SL. Pleomorphic adenoma of the lacrimal gland with extensive calcification. Arch Ophthalmol. 2004;122:778-80. 9. Foucar K, Viswanatha DS, Wilson CS. Non-Neoplastic Disorders of Bone Marrow. Atlas of Nontumor Pathology 6. Washington, DC: American Registry of Pathology, Armed Forces Institute of Pathology; 2008. Can J Ophthalmol 2015;50:e104–e106 0008-4182/15/$-see front matter & 2015 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2015.08.004
and using a very small amount of fluid (Video 1, available online). A golden ring is observed on completion of hydrodelineation. Central endonucleus is gently rocked to facilitate further separation from the epinuclear cushion. Any rotational manoeuvre is avoided. Care is taken at each step to avoid letting the stream of fluid go behind the posterior capsule. The central core of the soft nucleus is sculpted with the phaco handpiece to create a central gutter (Infiniti Vision System, Alcon Inc, Fort Worth, Tex.) (Video 1, available online). The epinucleus removal is fraught with difficulty because of lack of performance of cortical cleaving hydrodissection. At this point, the Barraquer fine iris spatula (Appasamy Associates, Chennai, India) is introduced from the side port with the left hand and by blunt dissection a plane is created in the doughnut of epinucleus inside the bag in the clock-hour opposite the side port from where the spatula is introduced (Fig. 1A). As the epinucleus is dissected, caution is exercised to avoid stripping of the most posterior epinucleus off the posterior capsule, thus leaving the central epinuclear cushion attached to the posterior capsule. After this, the epinucleus is dissected in the same quadrant at a more posterior plane, thus allowing layer-by-layer loosening of the epinucleus with the aid of the iris spatula (Fig. 1B). The phaco probe is then grasped using the left hand, and the iris spatula is introduced through the second side port situated toward the right of the main incision (Fig. 1C). Similar multiplanar epinuclear dissection is aided by the spatula’s tangential movement all around 360 degrees. Removal of the central posterior plaque is attempted toward the end (Fig. 1D). For cleaving the peripheral lower half of the epinucleus, that is, the epinucleus in the clock-hours opposite the main incision from where the probe is introduced, it is stripped
CAN J OPHTHALMOL — VOL. 50, NO. 6, DECEMBER 2015
Correspondence
Fig. 1 — A, Barraquer iris spatula is introduced through the left side port and tangential splitting of the peripheral and anterior epinuclear shell is made. B, A more posterior tangential split is created in the same quadrant. C, The spatula is introduced through the right side port and right hand to create cleavage in the inferior quadrant, first at the anterior plane and then more posteriorly. D, Care is exercised to aspirate the peripheral epinuclear shell the first and central plaque toward the end.
off the capsule with the probe, leaving the central area attached. Irrigation/aspiration of the separated epinuclear rim is performed simultaneously with the coaxial probe. Posterior polar cataracts may be associated with 7% to 36% risk for posterior capsular rupture even in the hands of a skilled ophthalmic surgeon.6,7 The factors identified for increased risk for capsular rupture include soft nucleus with large capsular opacification and younger patient age.8 Hydrodissection plays a paramount role in phacoemulsification of age-related cataracts by achieving loosening of the adherent cortical fibres from the capsular bag. Hydrodissection allows irrigation/aspiration to proceed significantly faster, less stressfully, and more conveniently, with less fluid requirement and causing lesser posterior capsular rents.9,10 However, hydrodissection is a forbidden step in the phacoemulsification of posterior polar cataracts. Although there are no direct studies on posterior polar cataracts, it can be derived from earlier in this article and as has been observed by the authors that without the essential hydrodissection step, it takes much longer for cortical cleanup in a case of posterior polar cataract. To address these concerns, we performed layer-by-layer phacoaspiration of epinucleus loosened by the tangential movement of the iris spatula under the anterior capsular rim. Care was taken to remove 1 layer at a time with the posterior-most layer being removed toward the end to avoid early opening of the posterior capsule in cases with a deficient capsule. This technique offered easier aspiration without the need for repeated withdrawal of the
phacoemulsification handpiece from the anterior chamber, thus requiring lesser time and lesser anterior chamber collapse. The technique described here is of maximum benefit in soft cataracts because of the presence of a thick epinuclear shell. In the past, Allen11 and colleagues and Fine et al.12 proposed epinuclear viscodissection to facilitate loosening of the epinucleus from the posterior capsule. It was performed by injecting a viscoelastic under the anterior capsular edge to aid mobilization of the peripheral epinuclear rim followed by coaxial aspiration. However, this procedure entails the risk of increasing pressure on the weak and possibly dehiscent posterior capsule. Further, it requires repeated removal of probe from the anterior chamber to enable layer-by-layer viscodissection of the peripheral epinuclear rim, thus increasing the surgical time significantly. Lee and Lee4 suggested manual dry aspiration of the epinucleus with Simcoe cannula, which again is time-consuming in the era of fast phacoemulsification surgeries. Nagappa et al.13 performed hydrodissection of the subincisional epinucleus from the cortex after nuclear removal. This procedure again would require removal of the phaco-handpiece to facilitate the dissection from the underlying capsule. Hence iris spatula-guided epinuclear shell removal allows faster surgery without compromising the safety of the posterior capsule. Video 1 can be found on the CJO web site at eyesite.ca. It is linked to this article in the online contents of the December 2015 issue.
CAN J OPHTHALMOL — VOL. 50, NO. 6, DECEMBER 2015
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Correspondence APPENDIX A. SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j. jcjo.2015.07.014. Sudarshan Khokhar, Shikha Gupta, Varun Gogia Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India Correspondence to: Shikha Gupta, MD: [email protected] REFERENCES 1. Vasavada AR, Raj SM, Vasavada V, Shrivastav S. Surgical approaches to posterior polar cataract: a review. Eye (Lond). 2012;26:761-70. 2. Osher RH, Yu BC, Koch DD. Posterior polar cataracts: a predisposition to intraoperative posterior capsular rupture. J Cataract Refract Surg. 1990;16:157-62. 3. Siatiri H, Moghimi S. Posterior polar cataract: minimizing risk of posterior capsule rupture. Eye. 2006;20:814-6. 4. Lee MW, Lee YC. Phacoemulsification of posterior polar cataracts: a surgical challenge. Br J Ophthalmol. 2003;87:1426-7.
Iatrogenic retinal detachment secondary to inadvertent subretinal injection of triamcinolone during cataract surgery Sub-Tenon injection of triamcinolone has been widely used to effectively control inflammation in intermediate uveitis for decades.1 Perioperatively, sub-Tenon triamcinolone can be used for patients with uveitis as an adjuvant during cataract surgery.2 Planning for cataract surgery in these patients also involves preoperative topical or systemic steroids.2 Although the local delivery of triamcinolone avoids systemic side effects of steroids, a number of complications can occur, including increase in intraocular pressure,3–5 rapidly progressive cataracts,3,6 ptosis,5,6 and globe penetration.3,7,8 Inadvertent globe penetration is a rare but sight-threatening complication that can occur with any sub-Tenon approach, possibly because the needle is placed close to the sclera.3 We present the case of a 66-year-old male who was referred to our clinic with cataracts. He had a diagnosis of anterior and intermediate uveitis with a background of sarcoidosis. He had been treated with topical and systemic steroids and methotrexate, and he had been in remission for several years. On examination he had visual acuities of 6/6 OD and 6/5 OS, no anterior chamber activity, and extensive posterior synechiae involving the pupillary margin of 2701 on the right and 1801 on the left. He also had significant posterior subcapsular cataracts, dense on the right and moderate on the left. The funduscopy did not highlight any sign of posterior segment inflammation.
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5. Vasavada AR, Raj SM. Inside-out delineation. J Cataract Refract Surg. 2004;30:1167-9. 6. Vasavada AR, Singh R. Phacoemulsification with posterior polar cataract. J Cataract Refract Surg. 1999;25:238-45. 7. Hayashi K, Hayashi H, Nakao F, et al. Outcomes of surgery for posterior polar cataract. J Cataract Refract Surg. 2003;29:45-9. 8. Stanić R, Bućan K, Stanić-Jurasin K, Kovacić Z. Phacoemulsification in eyes with posterior polar cataract. Acta Clin Croat. 2012;51:55-8. 9. Vasavada AR, Singh R, Apple DJ, Trivedi RH, Pandey SK, Werner L. Effect of hydrodissection on intraoperative performance: randomized study. J Cataract Refract Surg. 2002;28:1623-8. 10. Peng Q, Apple DJ, Visessook N, et al. Surgical prevention of posterior capsule opacification. Part 2: enhancement of cortical cleanup by focusing on hydrodissection. J Cataract Refract Surg. 2000;26:188-97. 11. Allen D, Wood C. Minimizing risk to the capsule during surgery for posterior polar cataract. J Cataract Refract Surg. 2002;28:742-4. 12. Fine IH, Packer M, Hoffman RS. Management of posterior polar cataract. J Cataract Refract Surg. 2003;29:16-9. 13. Nagappa S, Das S, Kurian M, Braganza A, Shetty R, Shetty B. Modified technique for epinucleus removal in posterior polar cataract. Ophthalmic Surg Lasers Imaging. 2011;42:78-80. Can J Ophthalmol 2015;50:e106–e108 0008-4182/15/$-see front matter & 2015 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2015.07.014
The decision was made to do surgery for the right eye and he underwent synechialysis, use of vital dye (vision blue), Malyugin ring, and microincision phacoemulsification with insertion of 3-piece intraocular lens. At the end of the surgery sub-Tenon triamcinolone 40 mg (Kenalog 40mg/ml in 1 ml) was to be injected on the superotemporal quadrant with a 27G needle. After 0.5 mL had been injected, inadvertent globe penetration was detected via indirect signs: red reflex became white, severe shallowing of the anterior chamber, iris prolapse through both incisions impossible to reposition, and a rock-hard eye on digital inspection. Immediate peritomy with sclerotomy (microvitreoretinal 20-gauge) 901 away from the injection site and 3.5 mm from the limbus was done, with exit of scant transparent fluid. This was followed by 1-port pars plana vitrectomy (Stellaris PC, Stellaris, Bausch & Lomb, Rochester, New York, USA) for decompression. The anterior chamber was re-formed with balanced salt solution, prolapse reduced, and the cornea sutured. Exploration of the surgical site of injection was done, with a puncture site detected 8 mm from the limbus. The penetration was contained, with no vitreous or chorioretinal prolapse. Sites of injection and vitrectomy were sutured. Immediate indirect ophthalmoscopy detected a superotemporal retinal detachment 3 clock hours, turbid, edge bordering on arcade, and no macula involvement (Fig. 1). Over a period of 8 weeks, migration of the triamcinolone was observed over the temporal to the inferior periphery, with eventual resolution (Fig. 2). The last examination showed pigmentation and atrophy of the retina in the involved areas, and no tears or residual retinal
CAN J OPHTHALMOL — VOL. 50, NO. 6, DECEMBER 2015
