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EW CATARACT 79 April 2016 by Liz Hillman EyeWorld Staff Writer everything was shallow, I was going to see her in the office the next day and make plans to bring her back in a day, a week, or 2 weeks, whatever it took." Fortunately, the woman's eye softened and Dr. Miller was able to go back through a side port, place the IOL correctly, inject some bal- anced salt solution, and close up the eye. The next day, her vision was better than Dr. Miller expected (2/25-1), considering the trauma and the fact that her cornea was a bit damaged with the lens sitting against it for a time. A week after surgery, the patient's vision was about the same as 1-day postop, but her cornea had healed further. Overall, Dr. Miller called it "a great outcome for a potentially bad complication." But what caused the supracho- roidal hemorrhage in the first place? Dr. Miller speculates that repeat- ed undocking from the femtosecond laser caused several sudden depres- surizations of the eye that could have created a small hole in a vessel in the choroid, thus leading to the hemorrhage. In light of that hypoth- esis, he wonders if suprachoroidal hemorrhage is a previously unre- ported complication associated with this technology. "I bet it's a more common sce- nario than anyone recognizes. Not that we're seeing huge numbers of cases reported, but small hemorrhag- es may be occurring that we are not seeing," he said. This complication was more severe prior to the advent of small incision cataract surgery. 1 As Dr. Miller put it, the pressure buildup due to the hemorrhage can result in the iris, lens, and even the retina being pushed out of the eye, some- thing that is more likely if a larger incision is used. "[The patient goes] blind very quickly, basically on the table," he said. "So we fear this one more than anything else." "While we've made suprachoroi- dal hemorrhage almost a non-issue with small incision cataract surgery, I think this may be the next problem in the saga of cataract surgery," he said, adding that he thinks doctors he called the "single worst intraop- erative complication that a cataract surgeon … can have": a suprachoroi- dal hemorrhage. "I got the lens in and as I was trying to contain it in the capsule, everything was shallowing on me," he said. "The lens wouldn't stay in the capsule. I was getting posterior pressure. I kept working, trying to get the entire optic—not just part of it—to stay inside the capsule, when it dawned on me, this is not normal." Dr. Miller knew it was most likely aqueous misdirection or suprachoroidal hemorrhage. He put a suture in the incision, leaving the lens half in and half out of the capsule and pressed up against the patient's cornea. The eye was hard and the anterior chamber non-exis- tent. Indirect ophthalmoscopy confirmed it was a suprachoroidal hemorrhage. "I didn't know how it was going to play out," he said, explaining that he sent the patient to the recov- ery room for an hour, hoping that her eye would soften up and her anterior chamber would deepen. "I didn't need it to deepen much. I just needed to get the lens inside the capsule. If it was still rock hard and Physician wonders if multiple docking attempts to femtosecond laser caused suprachoroidal hemorrhage I n late December 2015, Kevin M. Miller, MD, chief of the cataract and refractive surgery division, David Geffen School of Medicine, University of California, Los Angeles, was set to perform a routine cataract surgery using a femtosecond laser to create a capsulorhexis, perform the lens seg- mentation, and make the incisions. He docked the 67-year-old female patient once and found air bubbles in the laser-patient interface that would obscure the laser's ability to create a complete capsulorhexis. He undocked the patient's eye from the LenSx laser (Alcon, Fort Worth, Texas), wet her cornea, and redocked her to the laser. Again, air bubbles were in the way. Repeating the process once more, Dr. Miller found that the third time was a charm, and he proceeded with the surgery. It wasn't until he tried to get a multifocal IOL into the capsule that he learned something was wrong. In fact, it was an issue What caused a complication that cataract surgeons fear most? A s the saying goes, "Interesting things happen to interesting people." Or is it, "Bad things happen to good people"? Regardless, something truly astounding happened to Kevin Miller, MD, which he describes in this article; really it could have hap- pened to any of us. It was an unfortunate occurrence, but luckily, early diagnosis and effective management led to a great patient outcome. But we must always pose the ques- tion: Why did this happen? This article has some experts theorizing what the mecha- nism of a well-known but feared compli- cation was in this small incision cataract surgery. All are plausible theories, and I will let you decide which one you think is the ultimate reason. We may never know, but it is always important to reassess the situa- tion, question new technology, decide what might have been done differently (which may be nothing at all), and try to learn from the situation. It is also very important to share our challenges with our colleagues so we may all learn from one another how to prevent or manage these complications. Kudos to Dr. Miller for sharing and teaching. It is amazing how the eye can humble us. I learned a lot from this case. Rosa Braga-Mele, MD, MEd, FRCSC, cataract editor A suprachoroidal hemorrhage (black wedge) on top of optic nerve, pictured a week after initial surgery Source: Kevin M. Miller, MD continued on page 80 Cataract editor's corner of the world

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