Eyeworld

EW FEATURE 60 by Maxine Lipner Senior EyeWorld Contributing Editor Managing top traumatic cataract issues Tips for emerging unscathed from traumatic cataract cases T raumatic cataract cases occur of course without warning. While undoubt- edly no two cases are alike, EyeWorld asked some lead- ing experts to offer up recommenda- tions on how they might handle perilous situations. Issue 1: What is the best way to approach a traumatic cataract with zonulolysis? Lisa B. Arbisser, M.D., adjunct asso- ciate professor, John A. Moran Eye Center, University of Utah, Salt Lake City, urged practitioners to assume that every traumatic cataract may have zonulolysis. For cases in which there is vitre- ous around the zonules or if the lens is truly subluxated then Dr. Arbisser gives mannitol to reduce any poste- rior pressure and make it easier to prolapse the vitreous backward with viscoelastic. She recommended stay- ing away from Healon 5 (sodium hyaluronate, Abbott Medical Optics, Santa Ana, Calif.) here. "It moves things the best, but we can't afford to leave any behind, and to remove it since it's a viscoelastic requires tur- bulence," she said. "Viscoat (sodium chondroitin sulfate, sodium hyaluronate, Alcon, Fort Worth, Texas) is the safest thing to leave be- hind." One pearl she emphasized is when putting in capsule hooks, find those that distribute the forces in the eye. If there's only one point of pressure she finds that it's possible to rupture the capsule. Dr. Arbisser's preference in trauma cases is to use a vertical chop since that does not transmit a lot of pressure to the zonules. In terms of phacoemulsification, she suggested reducing the flow and vacuum so that there is not as much followabil- ity. Once the bag is evacuated, if there is a significant amount of zonular loss, Dr. Arbisser will some- times resort to a dry cortex removal under cohesive viscoelastic control with no irrigation and use a syringe and cannula to strip the cortex. "It's important to get the entire cortex out because you're going to have added inflammation and fibrosis and more likelihood of CME if you leave material behind," she said. Once the cortex has been re- moved, in cases where there is sub- luxation or zonular loss of more than four clock hours, Dr. Arbisser recommended using either an Ahmed segment with a standard capsular tension ring (CTR) or a Cionni ring. "Once you've got the bag stabilized, you can then put the lens in the bag in the normal way," she said. If it is necessary, the iris can be fixed after. Robert C. Stegmann, M.D., professor emeritus, Medical Univer- sity of Southern Africa, Pretoria, rec- ommended use of capsular tension rings at the time of cataract extrac- tion if there is more than 30 or 40% zonular rupture. "Once those zonules tear, the capsule contracts because it is a dynamic structure, which will contract in on itself," Dr. Stegmann said. "If you have instabil- ity of the lens of the capsule then a capsular tension ring is your best so- lution to that." Chee Soon Phaik, M.D., associ- ate professor of ophthalmology, Na- tional University of Singapore, said that if zonulolysis is detected, practi- tioners should lay the patient down to check the lens position. If the lens is accessible from the anterior segment, depending on the extent of zonulolysis and disruption of the other structures, surgery is planned. "A hand-over-hand technique of capsulorhexis may be required for a lens with poor zonular support using two microforceps," Dr. Chee said. She urged the use of capsular or iris hooks to suspend the bag and stabi- lize the cataract during phacoemulsi- fication. This, she finds, effectively compartmentalizes the eye by hold- ing the lens against the iris, prevent- ing further vitreous presentation. Before beginning phacoemulsifi- cation, she recommended that prac- titioners insert a modified capsular tension ring and secure it with 9-0 or 10-0 prolene sutures. During pha- coemulsification it's important to use reduced parameters and to watch for aqueous misdirection, which causes the posterior to come forward, she stressed. If possible, she urged practition- ers to use a single-piece hydrophobic lens, which unfolds slowly. How- ever, if the capsular bag has been ruptured, or if achieving a complete capsulotomy for insertion of the modified CTR has not been possible, she suggested suturing a three-piece IOL to the iris or sclera for support or using an iris clip or angle-support anterior chamber lens implant where these are available. February 2011 Challenging cataract cases September 2011 AT A GLANCE • Experts agree in cases of zonuloly- sis hooks, capsular tension rings and Ahmed segments play a pivotal role • Practitioners may want to consider using Viscoat in zonulolysis cases since this can be the safest to leave behind • In penetrating injuries, if the blood aqueous barrier is broken down, implantation of an IOL should be delayed by up to 3-5 months • When dealing with a blunt trauma, a team effort with a retinal surgeon may be recommended • Some practitioners favor use of a pars plana approach for anterior segment surgeons in trauma cases while others see this as the purview of the retinal surgeon Iridodialysis and sphincter rupture with subluxated cataract Source: Chee Soon Phaik, M.D. Traumatic cataract with vitreous herniation mixed with blood Source: Chee Soon Phaik, M.D. continued on page 62

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