Eyeworld

EW CATARACT 32 June 2016 by Liz Hillman EyeWorld Staff Writer Narrow angle, floppy iris led to severe iris damage during attempted cataract extraction W hen Kevin M. Miller, MD, professor of clin- ical ophthalmology, University of Califor- nia, Los Angeles, first saw this patient—his iris amputated and ragged, a mature cataract still intact—he thought "Oh, another one." Unfazed by many a complicat- ed case, Dr. Miller said this situation involving a 91-year-old patient referred to him for a cataract ex- traction, iris repair, and possible vit- rectomy in his right eye could have been prevented from the get-go. "It should have been avoid- able," Dr. Miller said. "In my entire career, even as a resident, I have seldom seen an eye like this. It's just sad that it happened." iris, and used a highly cohesive vis- coelastic. He was prepared to use iris hooks but did not end up needing them. He was able to extract the cata- ract without too much trouble, but did produce an accidental tear in the posterior capsule due to the shallow chamber and a floppy capsule. He converted this tear into a posterior capsulorhexis, placed a capsule ten- sion ring, and successfully implant- ed a lens in the bag. From there, he completed the tedious task of placing 10 Prolene sutures to repair the iris. One month postop, the patient's vision was 20/30 –2 uncorrected. "I thought he did quite well. He was very happy with his vision," Dr. Miller said, noting that the patient didn't have issues with glare or blur- ring. "You can tell from the postop- erative picture, [obtained 8 months postop], that the pupil was not perfectly round, but a perfect pupil was somewhat elusive because there was tissue missing. Cosmetically, it's not the greatest when you consider what he probably looked like before surgery, but functionally, he's fine." Complicated referral has positive outcome I n this month's "Cataract editor's corner of the world," Kevin Miller, MD, describes an interesting case of multiple ocular pathologies leading to a potentially devastating cataract surgical outcome. He and Steven Siepser, MD, describe appropriate ways to deal with challenging eyes and suggest having an armamentarium of techniques and technol- ogies to help cataract surgeons deal with these challenging cases should they arise. More important is the fact that we should all try our best to recognize in advance that a case may be challenging, either due to the nature of the eye or to medications the patient may be on. We need to have a plan going into surgery. Even more so, we need to recognize those cases that we perhaps are unable to manage ourselves and refer them to a more appropriate surgeon for care—for our best interests and especially those of the patient. Rosa Braga-Mele, MD, cataract editor A 91-year-old, borderline glaucoma patient with narrow angles on tamsulosin, which caused floppy iris syndrome, suffered a complication during attempted cataract surgery. His iris came out of the incision, so the initial surgeon decided to close it up and refer the patient to Dr. Miller for cataract removal and iris repair. Cataract editor's corner of the world The patient's eye 8 months postop after Dr. Miller's repair Source: Kevin Miller, MD Going into his first operation prior to seeing Dr. Miller for a 3+ nuclear and 2+ cortical cataract, this patient had an anatomically narrow angle and borderline glaucoma in both eyes. He had undergone laser iridotomies in both eyes and was on the drug tamsulosin. The corrected distance visual acuity of his right eye was 20/200. This patient's anterior chamber was very shallow. As Dr. Miller put it, "You could barely get a phaco probe into that space." This was the first problem. "When there's no space, often times the iris will just plop out of the incision, which is probably what happened here," he said. The second problem was that tamsulosin created floppy iris syndrome. "It's a situation where the iris is probably going to flop onto the incision just because it's so close to the cornea, but then if you make it floppy on top of that, you have a double hit," Dr. Miller said. "The surgeon should have known. There are things that could have been done to prepare for that." Without the operative report, Dr. Miller speculates the primary surgeon made the incision and tried several times to push the iris back into place when it came out. In do- ing so, the iris was badly damaged, leading the surgeon to close up the wound and refer the patient to Dr. Miller. Dr. Miller thinks the referring ophthalmologist should have stabi- lized the iris in the first place using phenylephrine or epinephrine to stiffen it, in addition to injecting a highly cohesive viscoelastic agent. Iris hooks or a Malyugin ring could have been used for pupil manage- ment as well. If more space was truly needed to complete the extraction, Dr. Miller said the surgeon could have performed a dry vitreous tap. "I doubt any of these things were done for this gentleman," he said. Dr. Miller saw the patient 2 days after the attempted cataract extraction. Following much of the advice suggested above, Dr. Miller said he opened the same incision, injected epinephrine to stiffen the

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