EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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E W RESIDENTS 84 February 2014 Wound too short Grace Sun, MD Director, ophthalmology residency program Assistant professor of ophthalmology Weill Cornell Medical College, New York This case brings me back to the days I was a medical student, where my b ig moment in general surgery was to cut the suture. It seemed that I could never cut it quite right—it was either "too long" or "too short"— until one day the attending re- marked that indeed, it was finally "perfect!" Similarly, the wounds in cataract surgery can be too long or too short, too anterior or too posterior. Each misstep will bring its set of unique complexities to the surgery. Wound construction is a critical skill to master as a begin- ning phaco surgeon. As seen here, a short main wound facilitates iris prolapse. As the resident instructor, as soon as you detect this short wound, you are already thinking steps ahead, as you know what may ensue. While the iris prolapse described here o ccurs during hydrodissection, this may occur again in each subsequent step of the surgery—phaco, cortical removal, lens insertion and wound closure. There may be loss of iris tissue, iris sphincter damage, transillumination defects, hyphema, and perhaps even an iridodialysis potentially leading to functional and cosmetic defects. W hen dealing with iris prolapse, three possibilities come to mind: 1. Abandon a short wound Depending on the complexity of the case, the level of experience of the resident surgeon, and your own level of comfort, one option is to create a new main wound. However, I think many of us w ould use the original wound and see how the case progresses. 2. Iris hooks Another solution is to use iris hooks. One hook can be placed directly under the wound to ade- quately hold the iris back. If there is a small pupil, up to five hooks may need to be placed to finish the case safely. 3. Use a heavy viscoelastic Given that the iris prolapse occurs during hydrodissection, one cause may be high posterior pressure. Fluid flows toward the path of least resistance, and the iris will follow toward this easily accessible exit, our short, main wound. For that reason, it is recommended that excess OVD be removed prior to hydrodissection, and to gently t ap down on the lens to release any fluid that may be trapped under the lens before the second wave of hydrodissection. If that were the culprit, I would attempt to decompress the eye by removing excess fluid or viscoelas- tic through the paracentesis. Once the eye is decompressed, insert a cyclodialysis spatula or the vis- c oelastic cannula through the paracentesis and sweep the iris back into the anterior chamber. Maintain the iris back by injecting a heavier, adaptive viscoelastic such as Healon5 (Abbott Medical Optics, Santa Ana, Calif.) right under the main wound. Note: Take care in the sweep as you can d isinsert the iris. Once the iris is reposited, you can insert your phaco tip and keep the handpiece steady in the eye. Do not come in and out of the eye, as the iris will likely want to prolapse once again, as the pressure gradients vary in the eye during the pha- coemulsification. For cortical re- moval, I would even consider a bimanual approach as the iris may prolapse with any excess move- ments of the single handpiece, particularly with the subincisional cortex. This case illustrates that how one starts the case can drastically af- fect the course of the surgery. Every step of surgery affects the subse- quent step. Let us all strive to make that "perfect" wound. Aravind Haripriya, MD Head of cataract and IOL services Aravind Eye Hospital Madurai, India This situation is not uncommon es- pecially during the learning phase. A short tunnel with an overzealous hy- drodissection can cause iris prolapse. Ideally incisions should be more of a square, especially incisions 2.2 mm and less. With larger wounds, Cataract M&M rounds T his month we have a very simple case that I hope will provide material f or some important teaching points. During a routine case, our resident was having some trouble with fixation of the eye and controlling the keratome while making the main incision.LThe keratome enters too soon and the wound is too short (Figure 1).LThe iris prolapses during hydrodissec- tion (Figure 2). We are fortunate to have three very experienced faculty to comment o n this case and specifically address the following questions: 1) How would you move forward from this point in the case, and 2) would you coach the resident to make a better wound? Thomas Oetting, MD, Cataract M&M rounds editor Figure 1: The wound is too anterior and too short. Source: Thomas Oetting, MD 84-90 Residents_EW February 2014-DL2_Layout 1 1/30/14 11:13 AM Page 84