1242
CONSULTATION SECTION
- When treating a white cataract, it is wise to determine whether the white of its anterior surface is pearly or continuous. The correct way of treating a pearly white cataract has been described.1 The patient in this case has a hypermature Morgagnian cataract associated with phacolytic glaucoma. In these cataracts, unlike in pearly white cataracts, the nucleus is small and there is only 1 continuous intralenticular pressurized compartment inside the capsular bag.1 Therefore, as the anterior capsule is being perforated, precaution must be taken to keep the pressure high in the anterior chamber using an OVD and then wait a while for pressure to equalize inside and outside the capsular bag. Then, one can proceed with capsulorhexis creation without risking a radial tear in the anterior capsule. In this case, the anterior capsule is fibrosed and has calcium deposits. The risk for the appearance of the Argentinean flag sign is thus reduced. The surgeon must have at hand a vitrectomy probe, which may be necessary for the completion of a CCC. In addition, the hard nucleus requires special treatment. My technique of choice in these cases is the donut prechop.A The stability of the small nucleus must be preserved by placing a dispersive OVD in front of it and behind it. This can be facilitated using the max pro phaco technique.B,C The main step preoperatively would be to attempt to reduce the IOP. The use of endovenous mannitol may be required. My experience with phacolytic glaucoma with wide angles is that the pressure becomes normal right after surgery. However, this is not definite and IOP control in the hours after the procedure is necessary. The visual prognosis will depend on the length of time and the level of the ocular pressure during the crisis period. A preoperative ultrasound examination can help the surgeon determine this difficult prognosis. The extent to which a femtosecond laser would help in capsulorhexis creation in these cases remains to be seen. I have not yet been able to try our femtosecond laser in eyes with a Morgagnian cataract because when a patient presents with such advanced cataract, it is usually because he or she cannot afford conventional surgery let alone the high cost of the laser procedure, which is not covered by any health insurance plan in Brazil. Carlos Gabriel Figueiredo, MD S~ao Paulo, Brazil
REFERENCE 1. Figueiredo CG, Figueiredo J, Figueiredo GB. Brazilian technique for prevention of the Argentine flag sign in white cataract. J Cataract Refract Surg 2012; 38:1531–1536
OTHER CITED MATERIAL A. Figueiredo CG, “The Donut Prechop,” presented at the ASCRS Symposium on Cataract, Intraocular Lens and Refractive Surgery, San Diego, California, USA, April 2001. Available at: http://www.youtube.com/watch?v=gdYRc2KE_rg. Accessed April 15, 2014 B. Figueiredo CG, “MaxPro Phaco Technique,” presented at the XXVII Congress of the European Society of Cataract and Refractive Surgeons, Barcelona, Spain, September 2009. Available at: https://www.youtube.com/watch?v=1G-av8Zk-KQ. Accessed April 15, 2014 C. Figueiredo CG, “MaxPro: an Underestimated Technique,” presented at the ASCRS Symposium on Cataract, Intraocular Lens and Refractive Surgery, Chicago, Illinois, USA, April 2012. Available at: https://www.youtube.com/watch?v=TirTDqmufE. Accessed April 15, 2014
- This 77-year-old woman presents with a Morgagnian cataract and presumed phacolytic glaucoma of recent onset. During the initial consultation, her potential vision could be assessed by a pupillary examination, confrontation testing to light in all quadrants, and a Purkinje entoptic phenomenon test. The patient’s elevated eye pressure is most likely related to liquefied lens proteins leaking out through an intact but permeable capsule. These proteins, as well as macrophages, are thought to block the trabecular meshwork and elevate the IOP. White flocculent material adhering to the lens capsule is seen in the photograph of this patient’s eye and is characteristic of phacolytic glaucoma.1 To control the IOP before surgery, the patient would be started on a timereleased oral carbonic anhydrase inhibitor (acetazolamide XR) 2 times a day, a topical b-blocker 2 times a day (assuming no contraindication), and brimonidine 0.1% 2 times a day. Ultimately, removal of the cataract is the treatment for phacolytic glaucoma and should resolve the elevated IOP. A mild topical steroid would be started for the anterior chamber reaction. An immersion rather than optical A-scan would have to be performed because of the white nature of the cataract. The surgical approach is based on the fact that this cataract is probably hypertumescent, with the intracapsular pressure being high, and this can lead to radialization of the initial capsule puncture. Therefore, the capsulotomy in this hypertumescent cataract is probably best performed with a femtosecond laser.A The laser creates such a rapid capsulotomy that a peripheral capsule tear is unlikely. Trypan blue dye should still be instilled after the laser to ensure a complete capsulotomy. Because I do not yet have a femtosecond laser, I would proceed as follows: (1) Paint the anterior capsule through a paracentesis with trypan blue dye under sodium hyaluronate 2.3% (Healon5) or a retentive dispersive OVD rather than under air because using the latter technique can result in staining the
J CATARACT REFRACT SURG - VOL 40, JULY 2014
CONSULTATION SECTION
anterior vitreous face if there is zonular loss. This can result in a significantly reduced red reflex, making visualization more difficult once the liquid cortex is removed. (2) Make sure the anterior chamber is well pressurized with additional OVD because some invariably leaks out during trypan blue staining. (3) Puncture the anterior capsule centrally with a 25-gauge needle, bevel-down, attached to a 3 cc syringe with the needle passed through a paracentesis.2 Withdraw some liquid cortex by pulling on the plunger of the syringe, staying anterior to the nucleus. (4) Once the bag is decompressed, create a capsulorhexis with a forceps. Aim for a slightly smaller capsulorhexis (4.0 mm) so that if radialization occurs, recovery can be achieved. (5) Perform phacoemulsification with a vertical chopping technique. Horizontal chopping should probably be avoided because there is no solid cortex protecting the posterior capsule. A dispersive OVD could be injected behind the nucleus to protect the posterior capsule during phacoemulsification. (6) After IOL insertion, perform very complete irrigation/aspiration (I/A) to remove all OVD and as much residual lens protein and cellular debris as possible. Brock K. Bakewell, MD Tucson, Arizona, USA REFERENCES 1. American Academy of Ophthalmology. Basic and Clinical Science Course. Lens and Cataract, Section 11, 2008–2009. San Francisco, CA, American Academy of Ophthalmology, 2008 2. Figueiredo CG, Figueiredo J, Figueiredo GB. Brazilian technique for prevention of the Argentine flag sign in white cataract. J Cataract Refract Surg 2012; 38:1531–1536
OTHER CITED MATERIAL A. Alan S. Crandall, MD and Robert J. Cionni, MD, personal communication, November 2013 and February 2014, respectively
- This patient presents with elevated IOP and an anterior chamber reaction in the setting of a hypermature cataract. Although other processes, such as phacomorphic or uveitic glaucoma, should be considered, this presentation is most consistent with a diagnosis of phacolytic glaucoma. In phacolytic glaucoma, highmolecular-weight lens proteins from a hypermature cataract leak through an intact lens capsule, inciting an anterior chamber reaction through the recruitment of a large number of macrophages. The lens protein and engorged macrophages subsequently obstruct conventional outflow through the trabecular meshwork, resulting in markedly elevated IOP and glaucomatous damage to the optic nerve. The definitive treatment for this type of glaucoma is removal of the lens. Preoperatively, keratometry, an A-scan ultrasound, and a complete ophthalmic examination should be performed with close attention to any amount of
1243
phacodonesis. Because no view of the posterior segment can likely be obtained with ophthalmoscopy, we would also perform a B-scan ultrasound to rule out gross pathology, such as retinal detachment or an intraocular mass. The presence of severe optic nerve cupping may also be noted on B-scan and would provide some means of estimating the severity of glaucoma and visual potential of the eye. We would try to obtain old records to help define the patient’s history and determine the visual prognosis. We would also initiate topical aqueous suppressants and aggressive topical corticosteroids to reduce the IOP and calm the anterior chamber inflammation. Surgically, we would anticipate poor zonular stability and a fragile, potentially pressurized capsule. We would choose retrobulbar, rather than topical, anesthesia in preparation for a more complex case. To aide with visualization of the capsulorhexis, we would stain the capsule with trypan blue. We would then completely fill the anterior chamber with a cohesive OVD to flatten the anterior capsule as much as possible and minimize radial tension in the region of the planned capsulorhexis. A 27-gauge needle on a syringe would then be used to puncture the capsule centrally and depressurize the bag via controlled suction of liquefied cortex. These steps would likely decrease the risk for sudden splitting of a pressurized capsule with posterior tear extension. After capsulorhexis creation, the liquefied cortical material would likely be easily aspirated, leaving little, if any, cortex and the extremely dense nucleus in the capsular bag. We would reapply a dispersive OVD to protect the endothelium and capsular bag before phacoemulsification. If zonular integrity were in question, a capsular tension ring (CTR) would be placed. We would proceed with manual disassembly of the nucleus with horizontal chop maneuvers to minimize the amount of phacoemulsification used inside the eye. If the nucleus were too dense to disassemble safely inside the eye, we would convert to a small-incision ECCE technique. We would then place a posterior chamber IOL. At the conclusion of such a case, we would administer a subconjunctival–sub-Tenon steroid and plan for a prolonged course of topical steroids postoperatively, with close monitoring of the IOP. Zachary Zavodni, MD Sherman Reeves, MD, MPH Minneapolis, Minnesota, USA - This patient has typical findings of phacolytic glaucoma in an eye with a Morgagnian cataract. Liquefied lens proteins are leaking through the intact lens capsule and causing the IOP to rise. These proteins,
J CATARACT REFRACT SURG - VOL 40, JULY 2014
CONSULTATION SECTION
- When treating a white cataract, it is wise to determine whether the white of its anterior surface is pearly or continuous. The correct way of treating a pearly white cataract has been described.1 The patient in this case has a hypermature Morgagnian cataract associated with phacolytic glaucoma. In these cataracts, unlike in pearly white cataracts, the nucleus is small and there is only 1 continuous intralenticular pressurized compartment inside the capsular bag.1 Therefore, as the anterior capsule is being perforated, precaution must be taken to keep the pressure high in the anterior chamber using an OVD and then wait a while for pressure to equalize inside and outside the capsular bag. Then, one can proceed with capsulorhexis creation without risking a radial tear in the anterior capsule. In this case, the anterior capsule is fibrosed and has calcium deposits. The risk for the appearance of the Argentinean flag sign is thus reduced. The surgeon must have at hand a vitrectomy probe, which may be necessary for the completion of a CCC. In addition, the hard nucleus requires special treatment. My technique of choice in these cases is the donut prechop.A The stability of the small nucleus must be preserved by placing a dispersive OVD in front of it and behind it. This can be facilitated using the max pro phaco technique.B,C The main step preoperatively would be to attempt to reduce the IOP. The use of endovenous mannitol may be required. My experience with phacolytic glaucoma with wide angles is that the pressure becomes normal right after surgery. However, this is not definite and IOP control in the hours after the procedure is necessary. The visual prognosis will depend on the length of time and the level of the ocular pressure during the crisis period. A preoperative ultrasound examination can help the surgeon determine this difficult prognosis. The extent to which a femtosecond laser would help in capsulorhexis creation in these cases remains to be seen. I have not yet been able to try our femtosecond laser in eyes with a Morgagnian cataract because when a patient presents with such advanced cataract, it is usually because he or she cannot afford conventional surgery let alone the high cost of the laser procedure, which is not covered by any health insurance plan in Brazil. Carlos Gabriel Figueiredo, MD S~ao Paulo, Brazil
REFERENCE 1. Figueiredo CG, Figueiredo J, Figueiredo GB. Brazilian technique for prevention of the Argentine flag sign in white cataract. J Cataract Refract Surg 2012; 38:1531–1536
OTHER CITED MATERIAL A. Figueiredo CG, “The Donut Prechop,” presented at the ASCRS Symposium on Cataract, Intraocular Lens and Refractive Surgery, San Diego, California, USA, April 2001. Available at: http://www.youtube.com/watch?v=gdYRc2KE_rg. Accessed April 15, 2014 B. Figueiredo CG, “MaxPro Phaco Technique,” presented at the XXVII Congress of the European Society of Cataract and Refractive Surgeons, Barcelona, Spain, September 2009. Available at: https://www.youtube.com/watch?v=1G-av8Zk-KQ. Accessed April 15, 2014 C. Figueiredo CG, “MaxPro: an Underestimated Technique,” presented at the ASCRS Symposium on Cataract, Intraocular Lens and Refractive Surgery, Chicago, Illinois, USA, April 2012. Available at: https://www.youtube.com/watch?v=TirTDqmufE. Accessed April 15, 2014
- This 77-year-old woman presents with a Morgagnian cataract and presumed phacolytic glaucoma of recent onset. During the initial consultation, her potential vision could be assessed by a pupillary examination, confrontation testing to light in all quadrants, and a Purkinje entoptic phenomenon test. The patient’s elevated eye pressure is most likely related to liquefied lens proteins leaking out through an intact but permeable capsule. These proteins, as well as macrophages, are thought to block the trabecular meshwork and elevate the IOP. White flocculent material adhering to the lens capsule is seen in the photograph of this patient’s eye and is characteristic of phacolytic glaucoma.1 To control the IOP before surgery, the patient would be started on a timereleased oral carbonic anhydrase inhibitor (acetazolamide XR) 2 times a day, a topical b-blocker 2 times a day (assuming no contraindication), and brimonidine 0.1% 2 times a day. Ultimately, removal of the cataract is the treatment for phacolytic glaucoma and should resolve the elevated IOP. A mild topical steroid would be started for the anterior chamber reaction. An immersion rather than optical A-scan would have to be performed because of the white nature of the cataract. The surgical approach is based on the fact that this cataract is probably hypertumescent, with the intracapsular pressure being high, and this can lead to radialization of the initial capsule puncture. Therefore, the capsulotomy in this hypertumescent cataract is probably best performed with a femtosecond laser.A The laser creates such a rapid capsulotomy that a peripheral capsule tear is unlikely. Trypan blue dye should still be instilled after the laser to ensure a complete capsulotomy. Because I do not yet have a femtosecond laser, I would proceed as follows: (1) Paint the anterior capsule through a paracentesis with trypan blue dye under sodium hyaluronate 2.3% (Healon5) or a retentive dispersive OVD rather than under air because using the latter technique can result in staining the
J CATARACT REFRACT SURG - VOL 40, JULY 2014
CONSULTATION SECTION
anterior vitreous face if there is zonular loss. This can result in a significantly reduced red reflex, making visualization more difficult once the liquid cortex is removed. (2) Make sure the anterior chamber is well pressurized with additional OVD because some invariably leaks out during trypan blue staining. (3) Puncture the anterior capsule centrally with a 25-gauge needle, bevel-down, attached to a 3 cc syringe with the needle passed through a paracentesis.2 Withdraw some liquid cortex by pulling on the plunger of the syringe, staying anterior to the nucleus. (4) Once the bag is decompressed, create a capsulorhexis with a forceps. Aim for a slightly smaller capsulorhexis (4.0 mm) so that if radialization occurs, recovery can be achieved. (5) Perform phacoemulsification with a vertical chopping technique. Horizontal chopping should probably be avoided because there is no solid cortex protecting the posterior capsule. A dispersive OVD could be injected behind the nucleus to protect the posterior capsule during phacoemulsification. (6) After IOL insertion, perform very complete irrigation/aspiration (I/A) to remove all OVD and as much residual lens protein and cellular debris as possible. Brock K. Bakewell, MD Tucson, Arizona, USA REFERENCES 1. American Academy of Ophthalmology. Basic and Clinical Science Course. Lens and Cataract, Section 11, 2008–2009. San Francisco, CA, American Academy of Ophthalmology, 2008 2. Figueiredo CG, Figueiredo J, Figueiredo GB. Brazilian technique for prevention of the Argentine flag sign in white cataract. J Cataract Refract Surg 2012; 38:1531–1536
OTHER CITED MATERIAL A. Alan S. Crandall, MD and Robert J. Cionni, MD, personal communication, November 2013 and February 2014, respectively
- This patient presents with elevated IOP and an anterior chamber reaction in the setting of a hypermature cataract. Although other processes, such as phacomorphic or uveitic glaucoma, should be considered, this presentation is most consistent with a diagnosis of phacolytic glaucoma. In phacolytic glaucoma, highmolecular-weight lens proteins from a hypermature cataract leak through an intact lens capsule, inciting an anterior chamber reaction through the recruitment of a large number of macrophages. The lens protein and engorged macrophages subsequently obstruct conventional outflow through the trabecular meshwork, resulting in markedly elevated IOP and glaucomatous damage to the optic nerve. The definitive treatment for this type of glaucoma is removal of the lens. Preoperatively, keratometry, an A-scan ultrasound, and a complete ophthalmic examination should be performed with close attention to any amount of
1243
phacodonesis. Because no view of the posterior segment can likely be obtained with ophthalmoscopy, we would also perform a B-scan ultrasound to rule out gross pathology, such as retinal detachment or an intraocular mass. The presence of severe optic nerve cupping may also be noted on B-scan and would provide some means of estimating the severity of glaucoma and visual potential of the eye. We would try to obtain old records to help define the patient’s history and determine the visual prognosis. We would also initiate topical aqueous suppressants and aggressive topical corticosteroids to reduce the IOP and calm the anterior chamber inflammation. Surgically, we would anticipate poor zonular stability and a fragile, potentially pressurized capsule. We would choose retrobulbar, rather than topical, anesthesia in preparation for a more complex case. To aide with visualization of the capsulorhexis, we would stain the capsule with trypan blue. We would then completely fill the anterior chamber with a cohesive OVD to flatten the anterior capsule as much as possible and minimize radial tension in the region of the planned capsulorhexis. A 27-gauge needle on a syringe would then be used to puncture the capsule centrally and depressurize the bag via controlled suction of liquefied cortex. These steps would likely decrease the risk for sudden splitting of a pressurized capsule with posterior tear extension. After capsulorhexis creation, the liquefied cortical material would likely be easily aspirated, leaving little, if any, cortex and the extremely dense nucleus in the capsular bag. We would reapply a dispersive OVD to protect the endothelium and capsular bag before phacoemulsification. If zonular integrity were in question, a capsular tension ring (CTR) would be placed. We would proceed with manual disassembly of the nucleus with horizontal chop maneuvers to minimize the amount of phacoemulsification used inside the eye. If the nucleus were too dense to disassemble safely inside the eye, we would convert to a small-incision ECCE technique. We would then place a posterior chamber IOL. At the conclusion of such a case, we would administer a subconjunctival–sub-Tenon steroid and plan for a prolonged course of topical steroids postoperatively, with close monitoring of the IOP. Zachary Zavodni, MD Sherman Reeves, MD, MPH Minneapolis, Minnesota, USA - This patient has typical findings of phacolytic glaucoma in an eye with a Morgagnian cataract. Liquefied lens proteins are leaking through the intact lens capsule and causing the IOP to rise. These proteins,
J CATARACT REFRACT SURG - VOL 40, JULY 2014
