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CONSULTATION SECTION
macrophages that ingest them, and other inflammatory cells are obstructing aqueous outflow through the trabecular meshwork, resulting in acute secondary open-angle glaucoma. Phacolytic glaucoma can be distinguished from phacoantigenic glaucoma by the absence of antecedent trauma or surgery, an intact capsule, and a lack of keratic or lenticular precipitates in phacolytic glaucoma. Cataract surgery restores visual potential and resolves the glaucoma most of the time. We are told this patient has good visual potential. Nevertheless, with recent high pressures, the eye should be checked for an afferent pupillary defect. I also find it useful to check for entoptic phenomena. The patient’s ability to describe the shadows from their own retinal vessels as a penlight is moved in a circular pattern across closed eyelids is particularly helpful. Aqueous suppressants should be started immediately, and the IOP should be monitored until the patient can be taken to the operating room. I would have 3 primary concerns during cataract surgery and 1 after surgery. Intraoperative concerns include the capsulorhexis, nucleus removal, and zonular integrity. The capsulorhexis is not likely to blow open or produce an Argentinean flag sign, as it might with a mature white cortical cataract. However, it might be difficult to visualize the capsule as liquid cortex spills out. Trypan blue staining of the anterior capsule is usually helpful before the anterior capsule puncture, as is injecting plenty of high-viscosity OVD to flatten the anterior dome of the lens. Some surgeons find a femtosecond laser helpful in Morgagnian cases. Liquid cortex can be aspirated after the puncture to improve visibility. Emulsification of the nucleus will have to proceed with little or no cortex to cushion the nucleus and keep it away from the capsule. Here, it is helpful to inject a dispersive OVD to inflate the bag and push back the posterior capsule. The brown central nucleus of a Morgagnian cataract is not usually as physically dense as it might be in a typical brunescent or black cataract. Horizontal chop is the preferred method of nucleus disassembly. Last, the surgeon should be prepared to manage weak zonular fibers. At a minimum, a standard CTR should be available. If significant zonular laxity is noted on slitlamp biomicroscopy before surgery, it might be helpful to have capsule support devices available and a modified CTR that can be suture fixated to the sclera. Postoperatively, the treating physician should monitor the IOP. If it is not back in the physiologic range with or without topical glaucoma therapy by several months after surgery, the patient should be offered a glaucoma filter or stent procedure. Kevin M. Miller, MD Los Angeles, California, USA
- This 77-year-old woman has a Morgagnian cataract in her left eye with secondary phacolytic glaucoma and a moderate cataract in the right eye. An attempt to control her IOP before surgery should be made with topical aqueous suppressants and systemic carbonic anhydrase inhibitors. Topical miotics and prostaglandin drugs should be avoided due to their potential to worsen intraocular inflammation. In addition, the patient should be treated with both topical steroids and nonsteroidal medications before surgery to control the intraocular inflammation. Preoperative evaluation should include testing for an afferent pupillary defect, color discrimination, and a B-scan if the fundus cannot be visualized. Regardless of the retinal findings, she will require lens extraction. Removal of the hypermature cataract will prevent future episodes of phacolytic-induced macrophage blockage of trabecular outflow. This should be sufficient to control the IOP over the long term because gonioscopy shows an open angle and a combined procedure is not needed. Immediately before surgery, the IOP should be reassessed and systemic hyperosmotic agents, such as intravenous mannitol, can be given if the IOP is still elevated. Trypan blue to stain the anterior capsule will help visualization of the capsulorhexis. Increased hydrostatic pressure in the capsular bag is likely; therefore, steps must be taken in anticipation of a complicated capsulorhexis. Dual OVDs (Viscoat [sodium hyaluronate 3.0%–chondroitin sulfate 4.0%] and Healon5) can be used to flatten the anterior capsule in an attempt to prevent capsule extension when the capsulorhexis is initiated. A small central anterior capsule opening should be made with a 25-gauge needle connected to a syringe. If there is evidence of capsule extension, the 25-gauge cystotome should be used to quickly aspirate liquefied cortex to reduce the intracapsular hydrostatic pressure. Phacoemulsification of the lens nucleus can proceed once the capsulorhexis is completed. The sandwich of the dual OVDs will provide maximum endothelial protection. There should be a minimal amount of cortex remaining after nucleus removal. The IOL can then be implanted in the capsular bag. If the capsulorhexis cannot be performed in the usual manner, a 3-piece silicone IOL should be available for sulcus placement. Ronald L. Fellman, MD T. Jeff Russell, MD Dallas, Texas, USA - Although this patient presents with a classic Morgagnian cataract and secondary phacolytic glaucoma, it is important to rule out secondary causes of glaucoma including phacomorphic angle closure, angle recession, or neovascular glaucoma with gonioscopy. In addition, vitreous hemorrhage (ie, ghost cell glaucoma)
J CATARACT REFRACT SURG - VOL 40, JULY 2014
CONSULTATION SECTION
macrophages that ingest them, and other inflammatory cells are obstructing aqueous outflow through the trabecular meshwork, resulting in acute secondary open-angle glaucoma. Phacolytic glaucoma can be distinguished from phacoantigenic glaucoma by the absence of antecedent trauma or surgery, an intact capsule, and a lack of keratic or lenticular precipitates in phacolytic glaucoma. Cataract surgery restores visual potential and resolves the glaucoma most of the time. We are told this patient has good visual potential. Nevertheless, with recent high pressures, the eye should be checked for an afferent pupillary defect. I also find it useful to check for entoptic phenomena. The patient’s ability to describe the shadows from their own retinal vessels as a penlight is moved in a circular pattern across closed eyelids is particularly helpful. Aqueous suppressants should be started immediately, and the IOP should be monitored until the patient can be taken to the operating room. I would have 3 primary concerns during cataract surgery and 1 after surgery. Intraoperative concerns include the capsulorhexis, nucleus removal, and zonular integrity. The capsulorhexis is not likely to blow open or produce an Argentinean flag sign, as it might with a mature white cortical cataract. However, it might be difficult to visualize the capsule as liquid cortex spills out. Trypan blue staining of the anterior capsule is usually helpful before the anterior capsule puncture, as is injecting plenty of high-viscosity OVD to flatten the anterior dome of the lens. Some surgeons find a femtosecond laser helpful in Morgagnian cases. Liquid cortex can be aspirated after the puncture to improve visibility. Emulsification of the nucleus will have to proceed with little or no cortex to cushion the nucleus and keep it away from the capsule. Here, it is helpful to inject a dispersive OVD to inflate the bag and push back the posterior capsule. The brown central nucleus of a Morgagnian cataract is not usually as physically dense as it might be in a typical brunescent or black cataract. Horizontal chop is the preferred method of nucleus disassembly. Last, the surgeon should be prepared to manage weak zonular fibers. At a minimum, a standard CTR should be available. If significant zonular laxity is noted on slitlamp biomicroscopy before surgery, it might be helpful to have capsule support devices available and a modified CTR that can be suture fixated to the sclera. Postoperatively, the treating physician should monitor the IOP. If it is not back in the physiologic range with or without topical glaucoma therapy by several months after surgery, the patient should be offered a glaucoma filter or stent procedure. Kevin M. Miller, MD Los Angeles, California, USA
- This 77-year-old woman has a Morgagnian cataract in her left eye with secondary phacolytic glaucoma and a moderate cataract in the right eye. An attempt to control her IOP before surgery should be made with topical aqueous suppressants and systemic carbonic anhydrase inhibitors. Topical miotics and prostaglandin drugs should be avoided due to their potential to worsen intraocular inflammation. In addition, the patient should be treated with both topical steroids and nonsteroidal medications before surgery to control the intraocular inflammation. Preoperative evaluation should include testing for an afferent pupillary defect, color discrimination, and a B-scan if the fundus cannot be visualized. Regardless of the retinal findings, she will require lens extraction. Removal of the hypermature cataract will prevent future episodes of phacolytic-induced macrophage blockage of trabecular outflow. This should be sufficient to control the IOP over the long term because gonioscopy shows an open angle and a combined procedure is not needed. Immediately before surgery, the IOP should be reassessed and systemic hyperosmotic agents, such as intravenous mannitol, can be given if the IOP is still elevated. Trypan blue to stain the anterior capsule will help visualization of the capsulorhexis. Increased hydrostatic pressure in the capsular bag is likely; therefore, steps must be taken in anticipation of a complicated capsulorhexis. Dual OVDs (Viscoat [sodium hyaluronate 3.0%–chondroitin sulfate 4.0%] and Healon5) can be used to flatten the anterior capsule in an attempt to prevent capsule extension when the capsulorhexis is initiated. A small central anterior capsule opening should be made with a 25-gauge needle connected to a syringe. If there is evidence of capsule extension, the 25-gauge cystotome should be used to quickly aspirate liquefied cortex to reduce the intracapsular hydrostatic pressure. Phacoemulsification of the lens nucleus can proceed once the capsulorhexis is completed. The sandwich of the dual OVDs will provide maximum endothelial protection. There should be a minimal amount of cortex remaining after nucleus removal. The IOL can then be implanted in the capsular bag. If the capsulorhexis cannot be performed in the usual manner, a 3-piece silicone IOL should be available for sulcus placement. Ronald L. Fellman, MD T. Jeff Russell, MD Dallas, Texas, USA - Although this patient presents with a classic Morgagnian cataract and secondary phacolytic glaucoma, it is important to rule out secondary causes of glaucoma including phacomorphic angle closure, angle recession, or neovascular glaucoma with gonioscopy. In addition, vitreous hemorrhage (ie, ghost cell glaucoma)
J CATARACT REFRACT SURG - VOL 40, JULY 2014
