EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/129516
The Steinert* Mini LRI & AK Diamond Knife Day one postop: IOL is placed with haptics in sulcus and optic in the bag, and the "parenthesis shaped" posterior capsule tears can clearly be seen corresponding to the splits in the capsule in the images taken prior to surgery. VI EW Another retroillumination image showing what I though could be a split in the posterior capsule through which the cataract was possibly herniated. 2 be done as soon as possible. There was a slight delay as the family decided they wanted another opinion, but we were able to get him to the OR one week after his injury. In the OR, as soon as I attempted to puncture the anterior capsule, it was clear that there was lack of the usual tension on the capsule and that the lens was very soft and did not provide much resistance under it. I was able to complete the capsulorhexis, but as soon as the eye was entered with an I/A probe to aspirate the lens, the lens started to herniate through what was now clear was a large opening in the posterior capsule. The retina surgeon took over and performed a pars plana lensectomy and a somewhat conservative vitrectomy, trying to preserve as much posterior vitreous as possible. We then switched again and I performed the cortical cleanup and placed the lens with the haptics in the sulcus but captured the optic behind the posterior capsule. The patient did extremely well initially with uncorrected vision of 20/40 on day one postop with an IOP of 20. On the day one postoperative image, one can clearly see the rhexis over the optic and the split in the posterior capsule behind it. Notice how the split in the posterior capsule corresponds with the border of the whitening of the lens in the preop images. Unfortunately, one week later the patient took a severe turn for the worse with his vision dropping to hand motion (HM) and his IOP rising to 46. He also developed cornea OP "Treatment should be conservative at first, in the absence of an acute problem such as retinal detachment or ruptured globe. Give a cycloplegic agent such as atropine and a topical steroid until the hyphema clears. Shield the eye and limit patient activity for the first few days to minimize the chance of rebleeding. Monitor and treat elevated IOP if necessary." Dr. Ayres had additional concerns: "Blunt trauma, especially in younger patients, has been known to cause posterior capsular tears, thereby inducing a rapid onset of cataract. I understand that the Bscan showed no posterior pathology, but a small posterior capsular tear could easily be overlooked. The blunt trauma also could have caused focal or generalized zonular instability leading to posterior dislocation of the cataract, poor support for IOL placement, and/or vitreous prolapse during surgery." Dr. Ayres' instincts about this case were correct. Dilated retroillumination views demonstrated a distinct border between where there was a white cataract and a clear area adjacent to it on both sides of the opacification of the lens. I felt that this central whitening of the lens with an arc-like border on each side strongly suggested a split in the posterior capsule with the lens partially herniating through it. Although I had never seen this before, my clinical suspicions were very strong. I arranged for the boy to see a retina specialist who agreed to be present in the OR should the need for a pars plana lensectomy arise. I felt that the surgery should P 4O VI EW Source (all): Steven G. Safran, MD D CTE TRA E SIO TEN X &ULL % N 4 s 4HE 0ERFECT ,2) !+ +NIFE &OR %ITHER 3UPINE /R 5PRIGHT 0ATIENTS s 3HORTER (ANDLE !LLOWS )NCISION #REATION !T 4HE 3LIT ,AMP s !LSO )DEAL &OR 5SE 5NDER !N /PERATING -ICROSCOPE s 5NIQUE $OUBLE &OOTPLATE )NSURES !CCURATE 0RECISE $EPTH 3ETTINGS 2ESULTS s 3TEP MM 7IDE "LADE %XTENSIONS OF -ICRONS 0LUS &ULL % X TE N S IO N 2 E TRA C TIO N s 4ITANIUM (ANDLE -ADE )N 4HE 53! !ND !VAILABLE &OR ! 3URGICAL %VALUATION 7ITHOUT /BLIGATION #ALL &OR -ORE )NFORMATION /R 'O 4O /UR 7EBSITE 3360 Scherer Drive, Suite B, St. Petersburg, FL 33716 s 4EL s &AX %MAIL )NFO 2HEIN-EDICALCOM s 7EBSITE WWW2HEIN-EDICALCOM $EVELOPED )N #OORDINATION 7ITH 2OGER & 3TEINERT -$ continued on page 14 Mantegna, Dancing Muse 1334 Rev.A BBBC