Eyeworld

EW CATARACT 79 March 2018 detachment, endophthalmitis/TASS, and endothelial decompensation. The case for retinal detachment being a major concern in highly myopic eyes is well documented. According to a study on the risk of retinal detachment in eyes that underwent cataract surgery from the Danish National Patient regis- try, phacoemulsification increased retinal detachment 4.23 times in the cataract population as a whole, including short, normal, and long eyes. 2 If phacoemulsification increases the overall risk of retinal detachment, as this study suggests, it poses a particular risk in long eyes, according to Dr. Badoza. Risk factors for retinal detachment are young age, male gender, and long axial length. A retrospective consecutive interventional study found the in- cidence of retinal detachment after coaxial phacoemulsification in 439 eyes of 274 highly myopic patients to be 2.7%. The mean axial length in the study was 28 mm. The inves- tigators reported a trend toward an increased incidence and risk of reti- nal detachment in patients younger than 50 years. 3 Another retrospec- tive medical chart review of 2,356 eyes in 1,519 consecutive patients with an axial length greater than 27 mm who had phacoemulsification with IOL implantation revealed a postoperative retinal detachment of 1.5–2.2%. 4 However, the absence of control groups matched for age, sex, and myopia preclude these studies from elucidating the exact influence of phacoemulsification as a risk factor for retinal detachment in eyes more than 30 mm in axial length. A study of 453 emmetropic eyes of 453 patients that had phacoemul- sification with IOL implantation showed the occurrence of posterior vitreous detachment (PVD) as asso- ciated with the reduction of volume occupied by the removal of the lens. The study suggested that the onset of postoperative PVD should be con- sidered an important risk factor for the development of retinal detach- ment after cataract surgery, especial- ly in eyes with lattice areas. 5 Prevention "To assure the prevention of pseu- dophakic retinal detachment in very long eyes, it is important to assess the indications for surgery and intraoperative prophylaxis," Dr. Ba- doza said. "Patients up to 55 years of age with a clear lens and satisfactory BCVA are questioned about contact lens tolerance. If they can wear contact lenses, we prefer to defer surgery. If they are contact lens in- tolerant, however, then we consider posterior chamber phakic IOL im- plantation. Preoperatively, it is very important to give patients a detailed explanation about the pros and cons of this indication. Intraoperative- ly, to prevent severe or abrupt AC decompressions that would provoke vitreous traction and PVD, we need to keep the AC stable. To achieve that, we try to decrease the infusion bottle height before introduction or withdrawal of the infusion. We set slow phacodynamic parameters and perform phacoemulsification through the smallest incision our machine is able to work with, a 1.8 mm primary incision. After emul- sifying the nucleus, we inject air or balanced salt solution through the paracentesis while withdrawing the phaco tip to prevent the anterior chamber from flattening. The same care should be taken after cortical cleanup; instead of air, we inject OVD while removing the I/A tip before implantation of the IOL." EW References 1. Cionni RJ, et al. Management of lens-iris diaphragm retropulsion syndrome during phacoemulsification. J Cataract Refract Surg. 2004;30:953–6. 2. Bjerrum SS, et al. Risk of pseudophakic retinal detachment in 202,226 patients using the fellow nonoperated eye as reference. Ophthalmology. 2013;120:2573–9. 3. Alio JL, et al. The risk of retinal detachment in high myopia after small incision coaxial phacoemulsification. Am J Ophthalmol. 2007;144:93–98. 4. Neuhann IM, et al. Retinal detachment after phacoemulsification in high myopia: analysis of 2356 cases. J Cataract Refract Surg. 2008;34:1644–57. 5. Ripandelli G, et al. Posterior vitreous detachment and retinal detachment after cataract surgery. Ophthalmology. 2007;114: 692–7. Editors' note: Dr. Badoza has no finan- cial interests related to his comments. Contact information Badoza: dabadoza@gmail.com

• Blank Page
• Blank Page (1)