EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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70 EW FEATURE February 2011 Challenging cataract cases October 2012 rePlay online content An open capsule mystery by Enette Ngoei EyeWorld Contributing Writer Dr. Arbisser describes how she successfully dealt with a unique case involving a ruptured anterior capsule O perating on an eye where the capsule inadvertently breaks during surgery is a challenging affair. Even trickier is when the open capsule is a mystery, as in a case described by Lisa Arbisser, M.D., adjunct clinical associate professor, John A. Moran Eye Center, University of Utah, Salt Lake City. A patient, who had a prior vitrectomy, suffered a sudden loss of vision after a trabeculectomy. She AT A GLANCE • When operating on a complicated eye with an open capsule, the surgeon should maintain a closed chamber environment, avoid fluctu- ation of IOP, avoid high levels of infusion and/or aspiration, and maintain chamber volume with viscoelastic materials • In younger patients, gentle auto- mated or manual aspiration of the lens material may be all that is needed to successfully remove the entire cataract. If a posterior cap- sule break is suspected, vigorous irrigation should be avoided to prevent posterior displacement of the lens material into the vitreous cavity Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) presented with a ruptured anterior capsule, no anterior chamber, and an uncontrolled pressure. Dr. Arbisser discusses the case in detail, describing how she found the capsule edges and successfully implanted a lens. The case "A 48-year-old diabetic female had a vitrectomy for a non-clearing vitreous hemorrhage. During the vitrectomy, everything seemed normal—at least there was nothing remarkable in the op report—but following the vitrectomy, she had a high pressure that would not relent and couldn't be controlled with medication. "The patient was referred to a retina and glaucoma surgeon, and they decided that she needed a rela- tively urgent trabeculectomy. At the time, she had a minimal incipient cataract, and there was no evidence of any problem with the lens. The trabeculectomy went in a fairly normal fashion. "However, within a week of the trabeculectomy, the patient's vision started to drop and she was referred to me for that. By the time she got to me in a week, she had hand- motion vision. There was no ante- rior chamber and her pressure was moderately high on her medication, and she clearly had a white cataract that was up against the endothe- lium. There was a break in the capsule somewhere, and it wasn't totally clear how or why. "I presumed that I would find an open capsule and that most likely it had been a result of the entry into the anterior chamber, say for the trabeculectomy, which would be a logical thing to think that could happen when you enter. "The unique thing about it was I had no idea where I would find capsule and whether I would be able to place a lens in so the patient was prepared for being aphakic." The resolution "I went ahead and started to form a little bit of a chamber with disper- sive viscoelastic and immediately began to put trypan blue in as I started to manually clear cortex. I didn't want to use any irrigation. I also didn't know for sure what the status of the back capsule was, though B-scan had been normal and there wasn't any detachment in the back. "With the reinstallation of viscoelastic, I manually took out the lens cortex and went looking for anterior capsule. Little by little, I removed the lens material, which had formed so quickly that there wasn't that much of a nucleus, and I was able to do it all with a 26- and 23-gauge cannula and manually vacuumed with a syringe. "I found one side of the anterior capsule but I couldn't find the other side, and there didn't seem to be any anterior capsule in one half of the chamber. Finally, I realized that the edge of the iris of the pupil was staining dramatically with the try- pan blue, which didn't make a lot of sense. You wouldn't expect any base- ment membrane at the edge of the pupil, and there was staining there. So, I began to explore that edge of the pupil, and it turned out that the anterior capsule was scrolled up and synched to the edge of the pupil. "I was able to relieve that synechia and find an envelope's worth of capsule. I was able to place a lens and got everything completely clean, and the lens haptics were well protected within the two leaves of capsule. "It turned out that the capsule had broken right in the middle, from equator to equator, and by not irrigating and not aspirating other than manually, with total control of the chamber at all times, I was able to prevent breaking the capsule around the zonules. I was also able to have a case that ended up with a nicely placed lens, and the patient's pressure came to normal in time, even though the bleb was not particularly well formed, and the patient regained 20/20 vision." What could have happened While Dr. Arbisser said she doesn't know what caused the intractable glaucoma after the pars plana vitrec- tomy, she said, "I do believe that the center of the capsule was inadver- tently nicked when the chamber was entered with the paracentesis blade during trabeculectomy and then burst open like an Argentinian flag sign over the ensuing week as the cataract became intumescent." Steven D. Vold, M.D., cataract and glaucoma surgery consultant, VoldVision, Fayetteville, Ark., offered some possible etiologies including angle-closure due to ante- rior rotation of the ciliary processes, post-vitrectomy inflammatory glaucoma, hemolytic glaucoma due to retained vitreous hemorrhage, neovascular glaucoma secondary to diabetes mellitus, and phacolytic glaucoma likely due to a break in the capsule at the time of vitrectomy. Discussion "With the rapid development of a white, intumescent cataract follow- ing both vitrectomy and trabeculec- tomy, Dr. Arbisser accurately predicted a break in the lens capsule. Her cautious and thoughtful ap- proach to surgery was appropriate," Dr. Vold said. Louis D. "Skip" Nichamin, M.D., medical director, Laurel Eye Clinic, Brookville, Pa., said this continued on page 72 Small incision entry for control of chamber Trypan blue identification capsule Dry manual removal of cataract Discovering scrolled capsule adherent to pupil edge