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
CONSULTATION SECTION
happen at any time, push it back using the soft-shell technique; but it still might necessitate more PPV after the IOL is implanted and checking the outcome using triamcinolone acetonide. If aqueous misdirection recurs postoperatively, a large PI penetrating the lens capsule and anterior vitreous will be necessary to ensure that the eye is left unicameral. Another potential problem is that the lens might be totally luxated because of extensive traumatic zonular damage, causing aqueous misdirection and in turn precipitating angle closure. If this happens, the UBM images will show it, and it will be apparent when the vitrectomy has begun. Capsule hooks or iris hooks might be necessary to complete the surgery, as well as a Cionni ring or Ahmed segments to suspend the IOL–capsule complex using sutures. Steve Arshinoff, MD Toronto, Ontario, Canada
- This case of blunt trauma with secondary cataract presents significant, specific surgical challenges. The first step is to counsel the patient about the higher risk for intraoperative complications and to manage the expectations about the postoperative vision prognosis. It is good that the macula is structurally intact and the retina attached, with no suprachoroidal or subretinal hemorrhage. The pupil shows traumatic mydriasis and is typically semidilated and likely to remain so because of sphincter ruptures, which the slitlamp examination showed. Glare and dysphotopsia might therefore be a problem. For an eye injured by blunt trauma, gonioscopy is a key component to preoperatively assess the presence and extent of angle recession. The risk for developing glaucoma is related to the extent of the recession, so lifelong annual follow-up for glaucoma surveillance is advisable if recession is present over more than 90 degrees. If it extends for 360 degrees, the assessment can be ambiguous because the angle appears uniform and resembles a wide uveal band. Always look at the angle in the fellow eye for reference. Using an angle-supported AC IOL is contraindicated when angle recession is present but could be preferred in eyes with diffuse zonular damage and lens instability. Typically the anterior chamber deepens after significant diffuse zonular rupture from blunt trauma, although the lens can move forward under gravitational influence, as in this case, and cause capsular block. The mobile lens reduces the predictability of the effective lens position and therefore also of the target refraction if the IOL is placed in the capsular bag. I would make the main incision and 2 side ports and then 4 paracenteses in a diamond configuration
1119
relative to the incision in preparation for the iris hooks, which will also be useful as capsule anchors to stabilize the lens to the sclera during phacoemulsification. Before injecting the OVD, I would flush the anterior chamber using triamcinolone to check for prolapsed vitreous. Next, I would inject phenylephrine if the pupil had not opened enough to perform a 4.0 to 5.0 mm capsulorhexis. Trypan blue staining at this stage is a useful adjunct, particularly to enhance the visibility of the edge of the capsulorhexis for later, when engaging the capsule anchors. With the capsule stained and iris hooks in place, the capsulorhexis will likely be straightforward unless the lens instability is extreme, when countertraction is minimal and the bag must be stabilized by using the hooks to anchor the capsulorhexis edge as the capsulorhexis progresses. Thorough subcapsular cortical cleaving hydrodissection will mobilize the nucleus in the bag to allow easy rotation with minimum zonular stress. The subcapsular plane then can be opened using an OVD to prepare for the implantation of a CTR to support the damaged zonular complex and also drum-skin the inevitably lax posterior capsule. This will facilitate the cortical stripping and reduce the risk for posterior capsule aspiration and rupture. In cases such as this one, when zonular instability is an issue, a sulcus-mounted 3-piece IOL is the best option. There is no point in risking decentration or dislocation of the IOL by implanting it in the capsular bag. Brian Little, MD London, United Kingdom
- I would consider treating this patient with phacoemulsification and in-the-bag IOL implantation. Preoperatively, UBM is needed to assess the location and extent of the zonular defects. Insufficient zonular support will make the surgery challenging because of the lens mobility, the higher risk for vitreous prolapse, and the capsule rupture. Intraoperatively I would expect a mobile lens and a capsule lacking usual tension from the zonular fibers, which will make the initiation of the anterior capsulorhexis difficult. Therefore, puncture of the capsule should be done with a sharp bent needle, thus creating a flap to grasp with the forceps to complete the capsulorhexis. If the lens is very mobile, I would consider using hooks to support it.1 My preference is special capsule hooks made of double thread with a rounded triangular loop at the tip and elongated hooked portions that bluntly support the equator of the capsular bag rather than exert localized pressure on the anterior capsule edge. After removing the lens, I would judge the extent of the zonular defect. If it comprises less than 3 clock hours,
J CATARACT REFRACT SURG - VOL 41, MAY 2015
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
CONSULTATION SECTION
happen at any time, push it back using the soft-shell technique; but it still might necessitate more PPV after the IOL is implanted and checking the outcome using triamcinolone acetonide. If aqueous misdirection recurs postoperatively, a large PI penetrating the lens capsule and anterior vitreous will be necessary to ensure that the eye is left unicameral. Another potential problem is that the lens might be totally luxated because of extensive traumatic zonular damage, causing aqueous misdirection and in turn precipitating angle closure. If this happens, the UBM images will show it, and it will be apparent when the vitrectomy has begun. Capsule hooks or iris hooks might be necessary to complete the surgery, as well as a Cionni ring or Ahmed segments to suspend the IOL–capsule complex using sutures. Steve Arshinoff, MD Toronto, Ontario, Canada
- This case of blunt trauma with secondary cataract presents significant, specific surgical challenges. The first step is to counsel the patient about the higher risk for intraoperative complications and to manage the expectations about the postoperative vision prognosis. It is good that the macula is structurally intact and the retina attached, with no suprachoroidal or subretinal hemorrhage. The pupil shows traumatic mydriasis and is typically semidilated and likely to remain so because of sphincter ruptures, which the slitlamp examination showed. Glare and dysphotopsia might therefore be a problem. For an eye injured by blunt trauma, gonioscopy is a key component to preoperatively assess the presence and extent of angle recession. The risk for developing glaucoma is related to the extent of the recession, so lifelong annual follow-up for glaucoma surveillance is advisable if recession is present over more than 90 degrees. If it extends for 360 degrees, the assessment can be ambiguous because the angle appears uniform and resembles a wide uveal band. Always look at the angle in the fellow eye for reference. Using an angle-supported AC IOL is contraindicated when angle recession is present but could be preferred in eyes with diffuse zonular damage and lens instability. Typically the anterior chamber deepens after significant diffuse zonular rupture from blunt trauma, although the lens can move forward under gravitational influence, as in this case, and cause capsular block. The mobile lens reduces the predictability of the effective lens position and therefore also of the target refraction if the IOL is placed in the capsular bag. I would make the main incision and 2 side ports and then 4 paracenteses in a diamond configuration
1119
relative to the incision in preparation for the iris hooks, which will also be useful as capsule anchors to stabilize the lens to the sclera during phacoemulsification. Before injecting the OVD, I would flush the anterior chamber using triamcinolone to check for prolapsed vitreous. Next, I would inject phenylephrine if the pupil had not opened enough to perform a 4.0 to 5.0 mm capsulorhexis. Trypan blue staining at this stage is a useful adjunct, particularly to enhance the visibility of the edge of the capsulorhexis for later, when engaging the capsule anchors. With the capsule stained and iris hooks in place, the capsulorhexis will likely be straightforward unless the lens instability is extreme, when countertraction is minimal and the bag must be stabilized by using the hooks to anchor the capsulorhexis edge as the capsulorhexis progresses. Thorough subcapsular cortical cleaving hydrodissection will mobilize the nucleus in the bag to allow easy rotation with minimum zonular stress. The subcapsular plane then can be opened using an OVD to prepare for the implantation of a CTR to support the damaged zonular complex and also drum-skin the inevitably lax posterior capsule. This will facilitate the cortical stripping and reduce the risk for posterior capsule aspiration and rupture. In cases such as this one, when zonular instability is an issue, a sulcus-mounted 3-piece IOL is the best option. There is no point in risking decentration or dislocation of the IOL by implanting it in the capsular bag. Brian Little, MD London, United Kingdom
- I would consider treating this patient with phacoemulsification and in-the-bag IOL implantation. Preoperatively, UBM is needed to assess the location and extent of the zonular defects. Insufficient zonular support will make the surgery challenging because of the lens mobility, the higher risk for vitreous prolapse, and the capsule rupture. Intraoperatively I would expect a mobile lens and a capsule lacking usual tension from the zonular fibers, which will make the initiation of the anterior capsulorhexis difficult. Therefore, puncture of the capsule should be done with a sharp bent needle, thus creating a flap to grasp with the forceps to complete the capsulorhexis. If the lens is very mobile, I would consider using hooks to support it.1 My preference is special capsule hooks made of double thread with a rounded triangular loop at the tip and elongated hooked portions that bluntly support the equator of the capsular bag rather than exert localized pressure on the anterior capsule edge. After removing the lens, I would judge the extent of the zonular defect. If it comprises less than 3 clock hours,
J CATARACT REFRACT SURG - VOL 41, MAY 2015
