OCT 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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66 EW FEATURE February 2011 Challenging cataract cases October 2012 Mental challenges, intumescent cataracts by Vanessa Caceres EyeWorld Contributing Writer AT A GLANCE • Performing bilateral same-day cataract surgery was an effective option for a 60-year-old mentally handicapped adult • The patient had brunescent cataracts in both eyes • The surgeon performed a posterior capsulorhexis with an optic capture, to avoid a YAG capsulotomy • The surgeon provided a near correction How would you handle this challenging case? L isa Arbisser, M.D., adjunct clinical associate professor, John A. Moran Eye Center, University of Utah, Salt Lake City, and in private practice, Eye Surgeons Associates, Iowa and Illinois Quad Cities, re- cently treated a 60-year-old severely mentally handicapped female. The patient started to bump into walls and had trouble finding her food. "Her caretakers brought her in, and she had total cataracts in both eyes, both hypermature and brunescent," Dr. Arbisser said. Because of the patient's mental condition, Dr. Arbisser knew she could never undergo subsequent YAG laser capsulotomy if needed in the future and that her post-op care would be challenging. With POA consent she opted to recommend exam under anesthesia and bilateral sequential same-day cataract surgery with planned posterior capsu- lorhexis and optic capture into Berger's space. "My typical modus operandi (M.O.) for people who can- not sit for a YAG, at any age, is to plan a posterior capsulorhexis with an optic capture, termed a button- hole procedure by Dr. Menapace," she said. "This is something that I do in all children as well. It's the only way to reduce the YAG rate to zero even in children. The goal is to leave the anterior hyaloid intact so as not to disturb the vitreous body by defin- ing Berger's space with OVD placed through a controlled opening in the posterior capsule, and once the con- tinuous rhexis is completed to then place a three-piece lens in the bag and capture the optic into Berger's space through the posterior capsule opening. " Navigating surgery Dr. Arbisser decided to operate first on the right eye, which was the more challenging cataract and was suspected to be amblyopic as she appeared to have a right exotropia on initial exam by Hirschberg reflex. "That eye was probably poor forever, and she had been using the other eye to function. I presume that when the second eye became hyper- mature, the patient experienced the sudden and profound decrease in function," she said. Dr. Arbisser follows guidelines from the International Society of Bilateral Cataract Surgeons regarding bilateral same-day surgery treating each eye separately. During surgery, Dr. Arbisser was surprised to find the first eye was "the most pressurized intumescent cataract I've ever seen." To prevent an Argentine flag sign, "I like to give a ¼ gram of mannitol per kilogram via an IV push 15 minutes prior to cutting and then use Healon GV [Abbott Medical Optics, AMO, Santa Ana, Calif.] as part of the soft shell technique, with dispersive Viscoat [Alcon, Fort Worth, Texas] and try- pan blue for visualization," she said. In the patient's first eye, Dr. Arbisser was able to complete a suitable capsulorhexis followed by a posterior capsulorhexis after remov- ing the cataract. "Since I was able to achieve the anterior rhexis at a size that could capture if needed, I was free to proceed with the posterior rhexis knowing I had a backup plan for a stable implant. I did the poste- rior rhexis, placed a three-piece lens, and captured the optic into Berger's space as planned," she said. After complete change of instru- ments and pre-op preparation for the second eye, she then proceeded with the second surgery. "This eye proved to have quite a fibrotic poste- rior capsule after removing the very dense nucleus," she said. "I decided to go ahead and attempt the poste- rior rhexis, but because of fibrosis that extended from central to peripheral, it was impossible to rely on its continuous nature so I didn't want to depend on capturing the optic into Berger's space for fear that the forces required might rupture the 4-6 micron membrane. I instead sulcus implanted and captured through the anterior rhexis." A three-piece implant is always used for either of these two capturing maneuvers. Dr. Arbisser also noted that her refractive correction for this pa- tient—and patients with similar mental challenges—was slightly myopic, as that tends to be most functional for these patients' needs without spectacles. Dr. Arbisser's goal for this patient was lens stability and rapid and permanent visual rehabilitation by reducing posterior capsule opaci- fication (PCO). The chance of PCO in the right eye was zero; there was only a 2% risk in the left eye, although this would be higher in a child due to formed vitreous, Dr. Arbisser said. Upon awaking, the patient behaved completely differently, indicating that the surgeries were a success, Dr. Arbisser said. "She picked chocolate chips out of pancakes the next morning, so her caretakers knew she had better vision," Dr. Arbisser said. She had a perfect red reflex, round pupils, and formed chambers the next morning. The patient's post-op course has been normal and successful. Dr. Arbisser was curious to find out how other surgeons who have experience with the various tech- niques she used would handle a similar case. Here, they weigh in. "What I would do …" Overall, the surgeons praised how Dr. Arbisser handled the case. "She did extremely well," said Steve A. Arshinoff, M.D., clinical instructor of ophthalmology, University of Toronto. "She fixed everything in the same sitting in the OR, which is definitely beneficial in this mentally handicapped patient. I would have done the same thing, perhaps with slight changes in technique, which are personal preferences, but not substantially different." Dr. Arshinoff is president of the International Society of Bilateral Cataract Surgeons. "I agree with the surgical approach chosen here," said Rupert Menapace, M.D., Intraocular Lens Service, Medical University of Vienna, Department of Ophthalmol- ogy, Vienna General Hospital, Vienna. "Single-session cataract sur- Egress of lens milk upon perforation of anterior capsule Controlling capsule dome with Healon GV Densely brunescent vertical chop circumferential disassembly Centripetal vector for posterior capsulorhexis

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