Eyeworld

EW CATARACT 30 July 2016 Anterior segment grand rounds (ASGR) by Steven Safran, MD A patient moves suddenly toward the end of his cataract procedure causing unfortunate trauma to the capsular bag. Can the damage be undone? I asked some esteemed colleagues how they would proceed with managing this difficult situa- tion. Here are their comments. Samuel Masket, MD, Los Angeles, commented: "A 'peaked' pupil, as in this case, is pathog- nomonic for a vitreous strand to an incision. The first task is to determine whether vitreous has come fully through the incision, is exposed to the environment, in turn creating a pathway for microbes and risking intraocular infection. A sterile cellulose sponge can be gently swabbed across the incision to make that determination. If positive, infection prophylaxis is mandatory, and surgery should not be delayed. Alternatively, the vitreous strand may be cut by Nd:YAG laser at the internal aspect of the incision and the exposed vitreous swabbed away from the incision under topical po- vidone-iodine prophylaxis, allowing corrective surgery to be planned electively. "Surgery should include tri- amcinolone-assisted vitrectomy, expanding the capsule bag with OVD, supporting the bag with capsular hooks if needed, bimanual aspiration of the residual cortex, placement of a CTR (Cionni type) or standard CTR with an Ahmed seg- ment with scleral suture fixation us- ing Gore-Tex suture. I would employ a 25-gauge pars plana trocar system for the limited vitrectomy. While a standard CTR might be adequate, the clinical photo demonstrates that the temporal equatorial capsule bag is dehisced for 4 to 5 clock hours, warranting scleral fixation of the capsule bag/IOL/CTR complex." Mark Pyfer, MD, Jenkintown, Pennsylvania, said: "It is fortunate that this case was referred early, before fibrosis of the capsule occurs. The time to act is now. The peaked pupil almost certainly indicates at least a strand of vitreous to the tem- poral wound. There is marked zonu- lar dehiscence temporally, perhaps 4 to 6 clock hours. The temporal Patient peeked and now pupil's peaked T his is a 53-year-old gentleman who was referred in after complicated cataract surgery done 1 week pre- viously. According to the referring surgeon, the patient had difficulty remaining still during the surgery. Toward the end of the procedure he suddenly moved, leading to a large zonular dehiscence. He came in with the complaint of glare and decreased vision in his OD, the post-surgical eye. On examination he sees 20/50 uncorrected in this eye, and it is clear that he has a peak- ed pupil at 10:00 (Figure 1). He was a +6.0 hyperope by history, and the other eye sees 20/40 with this correction in place due to cortical cataract changes. After dilation of the OD, the IOL can be seen in the capsular bag, but the whole lens and capsular bag complex is dislocated nasally a few milli- meters. There is residual cortical material fluffing up within the bag superiorly (Figure 2). The IOL used here was a 31 D ZCB00 1-piece acrylic lens (Abbott Medical Optics, Abbott Park, Illinois), and it appears to be the correct power for this 21 mm eye to achieve close to a plano outcome. There is no pseudophacodonesis seen before or af- ter dilation. Figure 1 shows a peaked pupil in pre-dilated state, and Figure 2 shows the same eye after dilation with a decentered IOL capsular bag complex, retained cortex, and zonular dialysis. Steven Safran, MD, ASGR editor Figure 1. Peaked pupil in pre-dilated state haptic is compressed, likely by vitre- ous prolapsing around the capsular bag. There are folds in the posterior capsule, and it is difficult to tell in the photo if there is a peripheral tear or just an overlap of capsular folds. This is not a stable situation, and the IOL malpositioning will likely wors- en over time if not corrected. "We need to address the vitre- ous, and a limited pars plana vitrec- tomy with anterior infusion to push the prolapsed vitreous posteriorly is best. Luckily, the anterior capsulot- omy is intact and smaller than the optic. If the peripheral bag is intact, reopening gently with dispersive viscoelastic should allow placement of a capsular tension segment in the area of zonular dehiscence. An iris hook could be used to hold the CTS temporarily to recenter and support the bag, while any remaining vitre- ous strands and the residual cortex are removed using an anterior ap- proach. If the IOL recenters well and the bag is intact, I would also gently place a CTR, then suture the CTS to the sclera with 8-0 Gore-Tex. "If there is a significant tear in the peripheral capsule, the 1-piece IOL should be removed and re- placed with a 3-piece in the sulcus with optic capture as long as the bag is centered and stabilized after the vitrectomy and sutured CTS. If unable to recenter the bag or if the tear extends while removing the IOL, I would perform a more extensive pars plana vitrectomy and remove the bag entirely, then place a scleral sutured Akreos lens [Bausch + Lomb, Bridgewater, New Jersey] or an intrascleral fixated ('glued') 3-piece IOL." Christian Hester, MD, Little Rock, Arkansas, shared his thoughts on the management of this case. "For this 'rambunctious' 53-year-old gentleman, I would recommend general anesthesia. I would begin the surgery by staining the vitreous with triamcinolone diluted 1:10 with balanced salt solution and proceed with a 25-gauge pars plana vitrectomy. Once the pars plana vit- rectomy has created more working space and pulled some vitreous from the anterior chamber, I would leave the pars plana infusion line in place and carefully remove any remaining vitreous in the anterior chamber by placing the vitrector through a side port incision. Next, I would tamponade the space between the posterior segment and anterior segment with a dispersive OVD even though it is likely to float away if a thorough pars plana vitrectomy has been performed. I would then

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