CONSULTATION SECTION
Glaucoma Surgical Problem Edited by Thomas W. Samuelson, MD
A 77-year-old woman presents with a chief complaint of a recent-onset, persistent, left-sided headache and poor vision in the left eye. Her corrected distance visual acuity (CDVA) is light perception, and slitlamp examination shows a brown native lens nucleus decentered inferiorly in the pupillary space that is surrounded by liquefied, white cortical material (Figure 1). There is a low-grade anterior chamber reaction but no hypopyon. The intraocular pressure (IOP) without ocular medications is 19 mm Hg in the right eye and 41 mm Hg in the left eye. Gonioscopy shows wide-open angles in both eyes. There is no neovascularization of the iris or angle. The right eye has a moderate cataract and low myopia with CDVA of 20/40; the examination is otherwise normal. Neither eye had previous ocular surgery or trauma. By history, both eyes have had excellent visual function in the past, although no results from previous ophthalmic examinations are available for confirmation. The patient only recently became aware of the poor vision in the left eye when the right eye was inadvertently covered. Please describe your management of this patient. Address your preoperative assessment, including any recommended diagnostic testing, as well as a description of your recommended surgical technique. For purposes of this discussion, assume reasonable visual potential; however, please address how you would attempt to determine the visual prognosis.
Figure 1. The dark brown nucleus of this Morgagnian cataract stands out in stark relief to the surrounding white, liquefied cortex. Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
- Preoperative examination should include assessment of light projection in all quadrants as well as ultrasound biomicroscopy to ensure there is no retinal detachment. This would be followed by a careful slitlamp examination looking for capsule and zonule issues. In many of these eyes the capsule bag is fragile; it may be intumescent. I still use topical anesthesia. I stain the capsule with trypan blue, start the capsulorhexis centrally, and have a syringe available so I can decompress the pressure by removing the flocculent material and prevent a tear out. I prefer a continuous curvilinear capsulorhexis (CCC) for intraocular lens (IOL) placement. It is important to realize that there is often retained liquid cortex behind the capsule, which can lead to the capsulorhexis tearing out. Once the CCC is completed, there are 3 approaches to removing the nucleus. The first is small-incision extracapsular cataract extraction (ECCE). The nucleus is very hard; fortunately it can be thinner and smaller than a regular nucleus and can be removed through a smallerthan-usual incision. However, the lens can also be large, so I usually make an incision as if planning for smallincision cataract surgery; that is, 6.0 mm in length, half scleral thickness, 1.5 mm behind the limbus, dissected at least 1.5 to 2.0 mm into clear cornea, and opening internally to 9.5 mm. One could consider making the capsulorhexis with a femtosecond laser, which I have done successfully in eyes with white cataract. However, because the nucleus will likely be loose, the femtosecond laser cannot soften the nucleus. The capsulorhexis may have to be enlarged depending on the nucleus size. An ophthalmic viscosurgical device (OVD) is placed above and below the lens to facilitate hydroexpression of the nucleus. A poly(methyl methacrylate) or any 3-piece IOL is preferred. I like to use Dr. Sanduk Ruit’s trick of placing the IOL before expressing the older lens to protect the posterior capsule. Another option is to use an ultrachopper to preform a groove because it can impale the nucleus and split it into hemi pieces, which can then be removed through a smaller extracapsular incision. Standard phacoemulsification would not likely be efficient enough to remove the cataract without an extreme amount of energy and danger to the endothelium. Also, the zonular fibers are often weak, making phacoemulsification more difficult. Alan S. Crandall, MD Salt Lake City, Utah, USA 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2014.05.020
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Glaucoma Surgical Problem Edited by Thomas W. Samuelson, MD
A 77-year-old woman presents with a chief complaint of a recent-onset, persistent, left-sided headache and poor vision in the left eye. Her corrected distance visual acuity (CDVA) is light perception, and slitlamp examination shows a brown native lens nucleus decentered inferiorly in the pupillary space that is surrounded by liquefied, white cortical material (Figure 1). There is a low-grade anterior chamber reaction but no hypopyon. The intraocular pressure (IOP) without ocular medications is 19 mm Hg in the right eye and 41 mm Hg in the left eye. Gonioscopy shows wide-open angles in both eyes. There is no neovascularization of the iris or angle. The right eye has a moderate cataract and low myopia with CDVA of 20/40; the examination is otherwise normal. Neither eye had previous ocular surgery or trauma. By history, both eyes have had excellent visual function in the past, although no results from previous ophthalmic examinations are available for confirmation. The patient only recently became aware of the poor vision in the left eye when the right eye was inadvertently covered. Please describe your management of this patient. Address your preoperative assessment, including any recommended diagnostic testing, as well as a description of your recommended surgical technique. For purposes of this discussion, assume reasonable visual potential; however, please address how you would attempt to determine the visual prognosis.
Figure 1. The dark brown nucleus of this Morgagnian cataract stands out in stark relief to the surrounding white, liquefied cortex. Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
- Preoperative examination should include assessment of light projection in all quadrants as well as ultrasound biomicroscopy to ensure there is no retinal detachment. This would be followed by a careful slitlamp examination looking for capsule and zonule issues. In many of these eyes the capsule bag is fragile; it may be intumescent. I still use topical anesthesia. I stain the capsule with trypan blue, start the capsulorhexis centrally, and have a syringe available so I can decompress the pressure by removing the flocculent material and prevent a tear out. I prefer a continuous curvilinear capsulorhexis (CCC) for intraocular lens (IOL) placement. It is important to realize that there is often retained liquid cortex behind the capsule, which can lead to the capsulorhexis tearing out. Once the CCC is completed, there are 3 approaches to removing the nucleus. The first is small-incision extracapsular cataract extraction (ECCE). The nucleus is very hard; fortunately it can be thinner and smaller than a regular nucleus and can be removed through a smallerthan-usual incision. However, the lens can also be large, so I usually make an incision as if planning for smallincision cataract surgery; that is, 6.0 mm in length, half scleral thickness, 1.5 mm behind the limbus, dissected at least 1.5 to 2.0 mm into clear cornea, and opening internally to 9.5 mm. One could consider making the capsulorhexis with a femtosecond laser, which I have done successfully in eyes with white cataract. However, because the nucleus will likely be loose, the femtosecond laser cannot soften the nucleus. The capsulorhexis may have to be enlarged depending on the nucleus size. An ophthalmic viscosurgical device (OVD) is placed above and below the lens to facilitate hydroexpression of the nucleus. A poly(methyl methacrylate) or any 3-piece IOL is preferred. I like to use Dr. Sanduk Ruit’s trick of placing the IOL before expressing the older lens to protect the posterior capsule. Another option is to use an ultrachopper to preform a groove because it can impale the nucleus and split it into hemi pieces, which can then be removed through a smaller extracapsular incision. Standard phacoemulsification would not likely be efficient enough to remove the cataract without an extreme amount of energy and danger to the endothelium. Also, the zonular fibers are often weak, making phacoemulsification more difficult. Alan S. Crandall, MD Salt Lake City, Utah, USA 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2014.05.020
1241
