CONSULTATION SECTION
In an eye with a preexisting posterior capsule defect, one may have to resort to a 3-piece PC IOL fixated in the sulcus. In an eye with both zonular dialysis and a posterior capsule defect, an iris-fixated IOL that preferably is fixated to the backside of the iris or a scleral-fixated PC IOL might be the only choices. This patient's eye should be monitored postoperatively for glaucoma and peripheral retinal tears. Suhas Haldipurkar, MD Mumbai, India
- I am assuming that the scheduled surgery is exploratory to assess the extent of the damage, address the cataract and increased IOP, and resolve other issues that are encountered. There is pain with accommodation and the lens is mobile, with the anterior chamber becoming shallower as the lens moves forward when the patient is lying face-down. The lens itself is decentered, too. All these symptoms suggest zonular disruption. The flat anterior chamber includes iris and ciliary body damage and possible angle recession, which are very common findings after blunt trauma.1 The high IOP could have a number of causes, including phacomorphic glaucoma, angle recession, blockage of the trabecular meshwork by red blood cells, and angle closure. If the patient is of African descent, it would make sense to check for sickle cell disease because sickle cells do not pass as readily through the trabecular meshwork. This could explain the blood in the anterior chamber and the IOP remaining high 10 days after the injury. The blunt trauma was severe, and the cornea might have made contact with the natural lens when it was displaced posteriorly. An 8.0 mm posterior movement of the cornea reduces the anteroposterior measurement of the eye by 41% at the time of injury and allows the equatorial sclera to expand by 28%, causing massive traction at the vitreous base.2 Therefore, it is vital to follow up regarding vitreoretinal health. The key risks subsequently are glaucoma and retinal detachment. The contact between the corneal endothelium and the lens might lead to endothelial cell damage, and so doing an endothelial cell count (ECC) might be useful for tracking endothelial cell health. Performing gonioscopy would be important for diagnosing angle recession. Because there are anterior and posterior capsule and subcapsular changes, the surgery would likely be cataract surgery. Replacing the thick crystalline lens (normally approximately 4.5 mm thick at this age) with an IOL (typically less than 1.0 mm thick) would largely decongest the anterior chamber and resolve the
1117
phacomorphic and angle-closure elements that might exist. It would be wise to have a plan to manage zonular dehiscence, including pupil hooks to stabilize the capsulorhexis if needed. The pupil might not dilate well because of iris and ciliary body damage, and the hooks can be used for both. Having the anterior vitrector handy would not be inappropriate because there might be vitreous prolapse into the anterior chamber once the lens has been removed. If it is appropriate to implant an IOL, the following applies: If the capsular bag is intact and stable, a 1piece IOL could be implanted in the bag. If there are concerns about bag stability, it would be best to use a 3-piece IOL and implant it in the sulcus. Occasionally, it might be better to place an aphakic IOL or to consider a glued IOL. Glaucoma stents are probably more appropriate as a secondary intervention if and when required. Arthur Cummings, MB ChB, MMED (Ophth), FCS(SA), FRCS(Ed) Dublin, Ireland
REFERENCES 1. Wolff SM, Zimmerman LE. Chronic secondary glaucoma; association with retrodisplacement of iris root and deepening of the anterior chamber angle secondary to contusion. Am J Ophthalmol 1962; 54:547–763 2. Delori F, Pomerantzeff O, Cox MS. Deformation of the globe under high-speed impact: its relation to contusion injuries. Invest Ophthalmol 1969; 8:290–301. Available at: http://www.iovs.org/ content/8/3/290.full.pdf. Accessed March 9, 2015
- High IOP and a shallow anterior chamber unresponsive to peripheral iridectomy (PI) without phacodonesis or intumescence indicate malignant glaucoma (also called ciliary block glaucoma and aqueous misdirection syndrome). Although seen mostly after incisional glaucoma surgery, malignant glaucoma can occur after trauma. Plateau iris and choroidal hemorrhage must be excluded. Preoperative UBM will show any ciliary body rotation, choroidal effusion, and clear collection of fluid behind the vitreous body. With its shorter AL, the fellow eye should be more hyperopic, yet the eyes' refractions are identical. With an anteriorly displaced lens, the right eye should become more myopic. Possible explanations include inaccurate UBM associated with loculated fluid or a change in sound transmission through dense vitreous, poor refraction because of cataract, or a change in corneal curvature with edema. Because the PI did not deepen the chamber, use preoperative atropine cycloplegia for this to confirm the diagnosis. Check for a relative afferent
J CATARACT REFRACT SURG - VOL 41, MAY 2015
1118
CONSULTATION SECTION
pupillary defect for prognosis. If the ECC is low, use an enhanced balanced salt solution. The malignant glaucoma treatment requires anterior aqueous flow to be reestablished, so performing an irido-zonulo-hyaloidectomy with vitrectomy is indicated while removing the cataract. Give a mannitol 0.25 g/kg push intravenously 15 minutes preoperatively for the deturgescence of the vitreous. If intraoperative gonioscopy confirms a deep chamber, a routine case will ensue except for the last step of the vitrectomy through the completed PI. If the chamber is still shallow with a closed angle, place a sutureless, 23-gauge trocar (transconjunctival using a limbus parallel scleral tunnel technique) 3.5 mm back from the limbus before other incisions, taking advantage of the firm eye and forward lens. In addition to the topical anesthesia, preplace a sub-Tenon bleb of lidocaine in the inferotemporal quadrant over the intended sclerotomy. Place a plug when not in use. Deepen the anterior chamber using preservative-free lidocaine hydrochloride 1.0% and epinephrine 1:4000 through a paracentesis to boost dilation to 5.0 to 6.0 mm, followed by a soft shell of dispersive OVD to flatten the lens dome. If the chamber does not deepen enough to safely perform capsulorhexis, soften the eye and deepen the chamber using a brief, dry pars plana vitrectomy (PPV) with the port facing posterior, avoiding the posterior capsule. Next, perform capsulorhexis, gentle hydrodissection, and vertical-chop phacoemulsification. Instill the OVD through the side port before exiting so the chamber will not shallow while instruments are being removed (inviting effusion or more misdirection). Place a CTR in the clean bag. If there is no significant posterior pressure and no fibrosis beyond the central 5.0 mm, create a posterior capsulorhexis, defining the Berger space using a cohesive OVD inserted through a 30-gauge bevel-up needle opening. Place a 3-piece acrylic IOL in the bag, and use the buttonhole technique to seal the posterior segment and secure the lens centration. Alternatively, if the capsule polishes clean, place the IOL in the bag with the posterior capsule intact. Through the vitrector-enhanced PI, perform the zonulo-hyaloidectomy, making the eye unicameral to cure the malignant glaucoma. Instill an intracameral antibiotic to control inflammation, and confirm the absence of vitreous. Postoperatively, stop the prostaglandin analogue immediately. Check the IOP the same day and 1 day postoperatively to avoid overtreatment and undertreatment. Atropinize initially, stopping at 1 week. As soon as is practical, perform a scleral depression examination of the retina to exclude tears and gonioscopy to look for peripheral anterior synechia and angle recession. The fellow eye is at risk for malignant glaucoma even though trauma was the presumed
inciting factor. When cataract surgery is needed in the fellow eye, consider postoperative cycloplegia and careful observation. Lisa Brothers Arbisser, MD Bettendorf, Iowa, USA
- The right eye of this 70-year-old man suffered blunt trauma during a fist fight. Ten days later the eye had a CDVA of 20/100, a hyphema, pupillary block, and 40 mm Hg IOP, which prompted a laser iridotomy. The lens was slightly decentered but without lentodonesis. The ACD was only half that in the fellow eye; the AL was 23.8 mm and 23.4 mm in the right eye and the left eye, respectively; and the refraction was +1.00 D in both eyes. Anterior chamber OCT showed a closed right angle and a narrow but open left angle. Images from UBM would help to differentiate a normal lens from a subluxated or luxated lens, assess the degree of zonular damage, and identify possible malignant glaucoma; the surgeon should be prepared to deal with all of these. One should attempt lowering the IOP and deepening the anterior chamber using oral acetazolamide, and wide dilation of the pupil using atropine and phenylephrine, but the chronic nature of the problem might prevent success. I would proceed as follows: The first surgical step should be a limited PPV to soften the eye, pull back vitreous that has migrated forward around the lens, and allow deepening of the anterior chamber using a viscoadaptive OVD. Once the eye is softened by the vitrectomy, I would inject a lidocaine hydrochloride [xylocaine]–phenylephrine mixture into the anterior chamber to deepen it. Through the main cataract incision, I would inject a viscoadaptive OVD to further deepen and stabilize the anterior chamber. Then I would use a Koch rotator or microforceps to tease the iris out of the angle, thereby opening it, and then infiltrate the lidocaine hydrochloride–phenylephrine mixture onto the lenticular surface below the OVD (the ultimate soft-shell technique). In this case, with no vitreous observed in the anterior chamber and assuming all went well to this point, I would perform a 5.0 mm central capsulorhexis and very thorough, gentle hydrodissection to sever all capsule attachments. Then I would perform phacoemulsification using a low flow of 15 to 20 mL/min to avoid disturbing the stability of the OVD layer and the lens. After irrigation/aspiration (I/A), if zonular absence is mild (less than 90 degrees), I would insert a CTR (a Cionni type, if greater than 90 degrees) and then implant the IOL. Then, I would remove the OVD, check the wound, and inject an intracameral antibiotic (preferably moxifloxacin). One problem that could occur is that vitreous might protrude around the edge of the lens. Should this
J CATARACT REFRACT SURG - VOL 41, MAY 2015
In an eye with a preexisting posterior capsule defect, one may have to resort to a 3-piece PC IOL fixated in the sulcus. In an eye with both zonular dialysis and a posterior capsule defect, an iris-fixated IOL that preferably is fixated to the backside of the iris or a scleral-fixated PC IOL might be the only choices. This patient's eye should be monitored postoperatively for glaucoma and peripheral retinal tears. Suhas Haldipurkar, MD Mumbai, India
- I am assuming that the scheduled surgery is exploratory to assess the extent of the damage, address the cataract and increased IOP, and resolve other issues that are encountered. There is pain with accommodation and the lens is mobile, with the anterior chamber becoming shallower as the lens moves forward when the patient is lying face-down. The lens itself is decentered, too. All these symptoms suggest zonular disruption. The flat anterior chamber includes iris and ciliary body damage and possible angle recession, which are very common findings after blunt trauma.1 The high IOP could have a number of causes, including phacomorphic glaucoma, angle recession, blockage of the trabecular meshwork by red blood cells, and angle closure. If the patient is of African descent, it would make sense to check for sickle cell disease because sickle cells do not pass as readily through the trabecular meshwork. This could explain the blood in the anterior chamber and the IOP remaining high 10 days after the injury. The blunt trauma was severe, and the cornea might have made contact with the natural lens when it was displaced posteriorly. An 8.0 mm posterior movement of the cornea reduces the anteroposterior measurement of the eye by 41% at the time of injury and allows the equatorial sclera to expand by 28%, causing massive traction at the vitreous base.2 Therefore, it is vital to follow up regarding vitreoretinal health. The key risks subsequently are glaucoma and retinal detachment. The contact between the corneal endothelium and the lens might lead to endothelial cell damage, and so doing an endothelial cell count (ECC) might be useful for tracking endothelial cell health. Performing gonioscopy would be important for diagnosing angle recession. Because there are anterior and posterior capsule and subcapsular changes, the surgery would likely be cataract surgery. Replacing the thick crystalline lens (normally approximately 4.5 mm thick at this age) with an IOL (typically less than 1.0 mm thick) would largely decongest the anterior chamber and resolve the
1117
phacomorphic and angle-closure elements that might exist. It would be wise to have a plan to manage zonular dehiscence, including pupil hooks to stabilize the capsulorhexis if needed. The pupil might not dilate well because of iris and ciliary body damage, and the hooks can be used for both. Having the anterior vitrector handy would not be inappropriate because there might be vitreous prolapse into the anterior chamber once the lens has been removed. If it is appropriate to implant an IOL, the following applies: If the capsular bag is intact and stable, a 1piece IOL could be implanted in the bag. If there are concerns about bag stability, it would be best to use a 3-piece IOL and implant it in the sulcus. Occasionally, it might be better to place an aphakic IOL or to consider a glued IOL. Glaucoma stents are probably more appropriate as a secondary intervention if and when required. Arthur Cummings, MB ChB, MMED (Ophth), FCS(SA), FRCS(Ed) Dublin, Ireland
REFERENCES 1. Wolff SM, Zimmerman LE. Chronic secondary glaucoma; association with retrodisplacement of iris root and deepening of the anterior chamber angle secondary to contusion. Am J Ophthalmol 1962; 54:547–763 2. Delori F, Pomerantzeff O, Cox MS. Deformation of the globe under high-speed impact: its relation to contusion injuries. Invest Ophthalmol 1969; 8:290–301. Available at: http://www.iovs.org/ content/8/3/290.full.pdf. Accessed March 9, 2015
- High IOP and a shallow anterior chamber unresponsive to peripheral iridectomy (PI) without phacodonesis or intumescence indicate malignant glaucoma (also called ciliary block glaucoma and aqueous misdirection syndrome). Although seen mostly after incisional glaucoma surgery, malignant glaucoma can occur after trauma. Plateau iris and choroidal hemorrhage must be excluded. Preoperative UBM will show any ciliary body rotation, choroidal effusion, and clear collection of fluid behind the vitreous body. With its shorter AL, the fellow eye should be more hyperopic, yet the eyes' refractions are identical. With an anteriorly displaced lens, the right eye should become more myopic. Possible explanations include inaccurate UBM associated with loculated fluid or a change in sound transmission through dense vitreous, poor refraction because of cataract, or a change in corneal curvature with edema. Because the PI did not deepen the chamber, use preoperative atropine cycloplegia for this to confirm the diagnosis. Check for a relative afferent
J CATARACT REFRACT SURG - VOL 41, MAY 2015
1118
CONSULTATION SECTION
pupillary defect for prognosis. If the ECC is low, use an enhanced balanced salt solution. The malignant glaucoma treatment requires anterior aqueous flow to be reestablished, so performing an irido-zonulo-hyaloidectomy with vitrectomy is indicated while removing the cataract. Give a mannitol 0.25 g/kg push intravenously 15 minutes preoperatively for the deturgescence of the vitreous. If intraoperative gonioscopy confirms a deep chamber, a routine case will ensue except for the last step of the vitrectomy through the completed PI. If the chamber is still shallow with a closed angle, place a sutureless, 23-gauge trocar (transconjunctival using a limbus parallel scleral tunnel technique) 3.5 mm back from the limbus before other incisions, taking advantage of the firm eye and forward lens. In addition to the topical anesthesia, preplace a sub-Tenon bleb of lidocaine in the inferotemporal quadrant over the intended sclerotomy. Place a plug when not in use. Deepen the anterior chamber using preservative-free lidocaine hydrochloride 1.0% and epinephrine 1:4000 through a paracentesis to boost dilation to 5.0 to 6.0 mm, followed by a soft shell of dispersive OVD to flatten the lens dome. If the chamber does not deepen enough to safely perform capsulorhexis, soften the eye and deepen the chamber using a brief, dry pars plana vitrectomy (PPV) with the port facing posterior, avoiding the posterior capsule. Next, perform capsulorhexis, gentle hydrodissection, and vertical-chop phacoemulsification. Instill the OVD through the side port before exiting so the chamber will not shallow while instruments are being removed (inviting effusion or more misdirection). Place a CTR in the clean bag. If there is no significant posterior pressure and no fibrosis beyond the central 5.0 mm, create a posterior capsulorhexis, defining the Berger space using a cohesive OVD inserted through a 30-gauge bevel-up needle opening. Place a 3-piece acrylic IOL in the bag, and use the buttonhole technique to seal the posterior segment and secure the lens centration. Alternatively, if the capsule polishes clean, place the IOL in the bag with the posterior capsule intact. Through the vitrector-enhanced PI, perform the zonulo-hyaloidectomy, making the eye unicameral to cure the malignant glaucoma. Instill an intracameral antibiotic to control inflammation, and confirm the absence of vitreous. Postoperatively, stop the prostaglandin analogue immediately. Check the IOP the same day and 1 day postoperatively to avoid overtreatment and undertreatment. Atropinize initially, stopping at 1 week. As soon as is practical, perform a scleral depression examination of the retina to exclude tears and gonioscopy to look for peripheral anterior synechia and angle recession. The fellow eye is at risk for malignant glaucoma even though trauma was the presumed
inciting factor. When cataract surgery is needed in the fellow eye, consider postoperative cycloplegia and careful observation. Lisa Brothers Arbisser, MD Bettendorf, Iowa, USA
- The right eye of this 70-year-old man suffered blunt trauma during a fist fight. Ten days later the eye had a CDVA of 20/100, a hyphema, pupillary block, and 40 mm Hg IOP, which prompted a laser iridotomy. The lens was slightly decentered but without lentodonesis. The ACD was only half that in the fellow eye; the AL was 23.8 mm and 23.4 mm in the right eye and the left eye, respectively; and the refraction was +1.00 D in both eyes. Anterior chamber OCT showed a closed right angle and a narrow but open left angle. Images from UBM would help to differentiate a normal lens from a subluxated or luxated lens, assess the degree of zonular damage, and identify possible malignant glaucoma; the surgeon should be prepared to deal with all of these. One should attempt lowering the IOP and deepening the anterior chamber using oral acetazolamide, and wide dilation of the pupil using atropine and phenylephrine, but the chronic nature of the problem might prevent success. I would proceed as follows: The first surgical step should be a limited PPV to soften the eye, pull back vitreous that has migrated forward around the lens, and allow deepening of the anterior chamber using a viscoadaptive OVD. Once the eye is softened by the vitrectomy, I would inject a lidocaine hydrochloride [xylocaine]–phenylephrine mixture into the anterior chamber to deepen it. Through the main cataract incision, I would inject a viscoadaptive OVD to further deepen and stabilize the anterior chamber. Then I would use a Koch rotator or microforceps to tease the iris out of the angle, thereby opening it, and then infiltrate the lidocaine hydrochloride–phenylephrine mixture onto the lenticular surface below the OVD (the ultimate soft-shell technique). In this case, with no vitreous observed in the anterior chamber and assuming all went well to this point, I would perform a 5.0 mm central capsulorhexis and very thorough, gentle hydrodissection to sever all capsule attachments. Then I would perform phacoemulsification using a low flow of 15 to 20 mL/min to avoid disturbing the stability of the OVD layer and the lens. After irrigation/aspiration (I/A), if zonular absence is mild (less than 90 degrees), I would insert a CTR (a Cionni type, if greater than 90 degrees) and then implant the IOL. Then, I would remove the OVD, check the wound, and inject an intracameral antibiotic (preferably moxifloxacin). One problem that could occur is that vitreous might protrude around the edge of the lens. Should this
J CATARACT REFRACT SURG - VOL 41, MAY 2015
