Eyeworld

EW CATARACT 34 November 2016 Anterior segment grand rounds (ASGR) by Steven Safran, MD Denville, New Jersey] helpful for this technique. "A one-piece acrylic toric IOL can be placed in the capsular bag. ORA [Alcon, Fort Worth, Texas] may be helpful in proper orientation of the IOL. "In the unlikely event that the capsular compromise is extensive enough to obviate the use of a one- piece IOL in the bag, a toric IOL can be sutured using through the haptic, suture fixation or an intrascleral fix- ation of a one-piece IOL. A specially cannula with viscoelastic or Sinskey hook. The epinuclear/cortical rem- nant can then be carefully removed under low flow aspiration, while placing retentive viscoelastic behind it as soon as the posterior capsule can be exposed. "If the posterior capsular rup- ture is irregular, a needle posterior capsulorhexis can be performed to create a CCC, thus reducing the risk of posterior capsular extension. I find the 30 g Giannetti posteri- or capsulorhexis needle [Katena, Residual issues from previous nail injury to the cornea present a challenging case I consulted with three experts on complicated cataract surgery to get some ideas about how to best manage this patient. Kenneth Rosenthal, MD, Great Neck, New York, commented, "The patient has what appears to be a through and through penetrating injury involving the cornea, iris, anterior lens capsule, and quite probably the posterior lens capsule. Preoperatively a UBM may help determine whether there is in fact a posterior capsular rent, but this is by no means required. "The first concern is to preserve as much of the posterior capsule as possible. To this end, a valved pars plana trochar should be placed, and through this a retentive viscoelastic should be placed, to tamponade the hyaloid space, thus preventing 'leak- age' of lens contents during the case. Through this, viscoelastic can be reinstilled as needed throughout the case. While I generally prefer pars plana vitrectomy to remove anterior chamber vitreous prolapse, in this case, an anterior approach should be considered to avoid further exten- sion of the posterior capsule, which may result from removal of posterior vitreous/hyaloid face support. "Synechiolysis of the irido-cor- neal adhesion should be performed using scissors if necessary, and similarly any irido capsular adhe- sions should be lysed. Then a wide capsulorhexis should be made that, if possible, is peripheral to the known anterior capsular rent to create a large rhexis that can be as- sured to be continuous (as opposed to the traumatic capsular rent) and to allow a facilitated removal of the lens contents. The lens is careful- ly hydrodelineated, cleaving the nucleus from the epinucleus, leaving a shell of epinucleus and cortex to the very end, in a manner similar to that used to remove a posterior polar cataract. The removal of the delin- eated nucleus can be accomplished by gently phacoemulsifying it in situ, or by carefully lifting it into the anterior chamber, using an air Perforated cataract post penetrating trauma Figure 1. White arrow delineates vitreous strand to cornea Figure 2. Blue arrow points to suspected posterior capsule defect T his is a 20-year-old male who had a penetrating nail injury to the cornea of the right eye about 8 months earlier. The eye had good vision prior to this incident and he never wore glasses. The nail punctured his lens and there is an opening in the anterior capsule with vitreous adherent to the cornea (Figure 1). The anterior capsule and iris are fused on the temporal side of this right eye. With dilation it appears that there may be an opening in the posterior capsule as well (Figure 2). The patient has 3.5 D of with-the- rule cornea astigmatism in this eye that is mostly remarkably regular, although there is some very slight irregularity due to his cornea injury. He is referred for complex cataract surgery. He has no APD and his B-scan is normal. He has no inflammation and the IOP is normal. Steven Safran, MD, ASGR editor

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