Eyeworld

EW CATARACT 34 October 2018 Cataract editor's corner of the world by Rich Daly EyeWorld Contributing Writer A deaf monocular vision patient needed a surgeon to preserve his little remaining vision and his only way to communicate with the world V isually significant pos- terior polar cataracts are always complex surgical cases. But that condition may have been the least complex component of a patient referred to Kevin M. Miller, MD, chief, cataract and refractive surgery division, David Geffen School of Medicine, University of California, Los Angeles. The 62-year-old cataract patient also had neurofibromatosis type 2, was bilaterally deaf, and limited to light perception in the non-surgical OS eye. A tumor in the vestibular section of his left ear caused a facial nerve paralysis, which left him un- able to close his left eye. The result was corneal ulceration, scarring, and light perception vision. "He was able to hear at one point so he learned to read lips. He also learned sign language. These communication skills require vision, however, and his vision for doing so had gone down steadily," Dr. Miller said. In the right eye, the patient had glaucoma with high pressures, sig- nificant cupping of the optic nerve, a tiny field of vision—16 degrees in always use topical anesthesia," Dr. Miller said. "Because of the complexity of the polar cataract situation and the total inability to communicate under the operating microscope, it was a no-brainer that we would be doing this case under general anesthesia." Dr. Miller told the patient preop he would wait until he was fully awake to remove the patch and see if he had some vision. The posterior polar cataract led Dr. Miller to prioritize the creation of a perfectly sized capsulorhexis in case the posterior capsule blew out. That led him to use a femtosecond laser to ensure a perfect rhexis, despite the complexity of using it under general anesthesia. Use of a femtosecond laser in a general anesthesia patient requires the surgeon to accommodate the tube coming out of the mouth. Additionally, generally anesthetized patients cannot fixate on the light of the docking device as it's coming down and sometimes the eye rolls off to the side. "What you end up doing is moving the patient's head under the laser gantry to get the eye pointing straight up toward the docking device as it's being low- ered," Dr. Miller said. During surgery, instead of a cap- sular rent, Dr. Miller found a small amount of plaque material. He left a little of the plaque on the posterior capsule after learning from previous attempts that polishing such materi- al can rip open the capsule. Complex case: Deaf monocular patient with a posterior polar cataract T he gift of sight is remarkable, and many of us take it for granted. We depend on our vision for so much that we do in our lives everyday, but some people truly require their vision to be able to communicate. Such is this case as pre- sented by Kevin Miller, MD. He describes a monocular cataract patient who relies on his vision to be able to read lips as he is completely deaf. Dr. Miller navigates us through the nuances of this very interesting and challenging case of doing surgery on a deaf patient with one eye who relies on that eye to be able to communicate with the world. Read on as we delve into the nuances of this complex case. Rosa Braga-Mele, MD, Cataract editor diameter—and somewhat eccentric fixation. He had difficulty closing his right eye as well, for reasons that were not clear. He had a 3 mm area of exposure when he blinked, unless he squeezed hard. A visually significant posterior polar cataract in the OD was the final component. "Essentially, he was sleeping with both eyes open and he had all the usual problems that you see in the corneas from the exposure, so it wasn't even clear what was affecting the right eye the most," Dr. Miller said. "The deck was stacked against him." Surgical issues The 2.5 mm-plus posterior cataract occurred with congenital dehiscence in the posterior capsule, which left the possibility of a large capsular hole when that part of the cataract was removed. The patient's lack of hearing, which limited his communication to sign language, led Dr. Miller to prioritize the return of vision as soon as possible postop. That elim- inated the use of a regional block and extended eye patching, which would have left the patient with no ability to communicate. Dr. Miller also wanted to avoid the remote possibility of optic nerve or artery damage from the use of a needle in the posterior orbit. "When I perform surgery on a person who is monocular, I almost This image shows the anterior capsule being removed. The capsule opening was made with a femtosecond laser. The patient was under general anesthesia. The white posterior polar cataract can be seen on the back side of the lens. It was important to have a centered and appropriately sized capsulorhexis in case the capsule ruptured and it became necessary to place an IOL in the sulcus. With a good capsulorhexis, the optic could have been captured behind the anterior capsule if needed. This image shows the final piece of the cataract about to be removed. Note the white "manhole cover" that is the posterior polar cataract near the phaco probe.

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