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EW FEATURE 40 Challenging cases • July 2018 by Vanessa Caceres EyeWorld Contributing Writer posed to be an Argentinian flag sign became one," she said. If this happens during surgery, don't panic, Dr. Braga-Mele advised. Also, do not let the eye decompress. She put more OVD on top of the capsule and behind the white cata- ract to provide a bed of viscoelastic material. "At this point, I didn't know if the rupture was 360 degrees all around. I tried to put visco behind to make the capsule more taut or if it had run, to prevent the nucleus from dropping, and hopefully it would lift up to the anterior cham- ber," Dr. Braga-Mele said. She went in using high vacuum and embedded the phaco tip into the nucleus and scaffolded the nu- cleus on top of the iris. "I used the viscoelastic as a second instrument and eat that whole nucleus piece in what I call Pacman style, nibbling around the edge in a controlled fashion," Dr. Braga-Mele said. She kept the bag height at a moderate level. She then used her multiple vials of dispersive OVD to maintain the anterior chamber and bag pressure before pulling out of the eye. She also saw at this point that the posterior capsule had remained intact. The OVD was used to viscodissect the cortex off the capsule, making it easier to remove. She then went in with a gentle irri- gation/aspiration tip. Dr. Braga-Mele chose a soft, foldable, and stickier IOL and put the haptics where the two flaps were; she also put the optic in the center. "At this point, I gingerly took out visco with the second instrument to hold the lens posteri- orly against the capsular bag. I only removed about 70% of the visco. I didn't want to go underneath the IOL," she said. She also put in a stitch to maintain the integrity of the eye and to make sure it did not decompress. At 5 days postoperatively, the patient was 20/20. Even when you have the best- laid surgical plans, consider what could go wrong and prepare accord- ingly, Dr. Braga-Mele advised. She also said that using a little "verbal anesthesia" to talk to the patient be- fore going in for the capsulorhexis would have been helpful. She could have asked the patient not to move Problems can occur when you least expect it E ven the most seasoned cat- aract surgeons can and will experience challenging cas- es from time to time. Three cataract surgeons shared with EyeWorld how they managed difficult cases, both in the moment and over the long term. Take a page from their playbook for better surgi- cal preparedness. The best-laid plans Rosa Braga-Mele, MD, professor of ophthalmology, University of To- ronto, Canada, had a resident with her when she was about to perform surgery in a 55-year-old woman with bilateral cataracts, including a right eye with a white cataract. The patient had no history of ocular trauma. Dr. Braga-Mele's goal was to teach the resident what to do to avoid the Argentinian flag sign. Of course, things don't always work out as planned. Dr. Braga-Mele performed proper wound construction to avoid chamber shallowing and put in a dispersive ophthalmic viscosurgi- cal device (OVD). She painted the capsule with trypan blue and then put in more dispersive OVD to flatten out the front. "I could see the capsule dimpling as I compressed it," she said. She used a 27G needle to decompress the cortical fluff and relieve any posterior pressure on the anterior capsule. "I then put in more visco, and I went in with my cysto- tome and started the capsulorhexis, and it just ruptures," she said. When Dr. Braga-Mele went in with the cystotome, the patient had coughed. "A case that wasn't sup- at that point or she could have told the anesthesiologist to give a bit more sedation. "I learned my lesson," she said. Avoiding methylene blue When cataract surgeons present challenging cases, there tends to be a lot of focus on how they handle them in the moment. What's shared less often is the long-term manage- ment. That led Kevin M. Miller, MD, Kolokotrones Chair in Oph- thalmology, David Geffen School of Medicine at UCLA, Los Angeles, to present the management of a wom- an in her 50s who experienced toxic anterior segment syndrome (TASS) and macular edema in the left eye after the intraoperative use of meth- ylene blue in the eye in December 2010, as performed by another surgeon. The patient's management continues to the present time. "Methylene blue is toxic to the inside of the eye. It's a fairly easy mistake to make in the OR, espe- cially with nurses floating between rooms," Dr. Miller said. "If a surgeon doesn't check, he or she could end up with problems." Surgeons should make sure trypan blue is used in- stead for intraocular surgery. Dr. Miller began to see the patient in March 2011. During his various appointments with her, he was able to track her TASS and mac- ular edema. The patient eventually underwent a Descemet's stripping endothelial keratoplasty (DSEK), although there was a brief rejection episode when a retina specialist withheld topical corticosteroids fol- lowing an intravitreal corticosteroid injection, he said. Various problems encoun- tered by the patient in addition to TASS and macular edema included a slightly higher IOP, abnormal central corneal thickness, and an abnormal endothelial cell count. At her last exam in May 2018, the patient's vision was 20/30–2, compared with nonfunctional vi- sion when she was first seen. "She's not 20/20, and she may never be," he said. "For now she's doing OK, but that may change down the road. She may end up with graft failure and another DSEK at some point." It's hard to reassure a patient with acute insults at the initial consultation because you do not know what their final outcome will be, Dr. Miller said. He recommended any surgeon managing a difficult sit- uation be honest but upbeat and to encourage the patient to collaborate with the physician. The take-home message of Dr. Miller's case is that some issues will continue for a prolonged time period. "There's the acute insult, but then they deal with complications for the rest of their life," he said. AT A GLANCE • Always have a back-up plan for things that could go wrong, even during the best-planned surgeries. • Provide "verbal anesthesia" before more challenging steps of cataract surgery to encourage patients not to move. • Be honest but upbeat when manag- ing patients with long-term prob- lems after cataract surgery. Three cataract cases highlight challenges and pearls continued on page 42 Argentinian flag sign after trypan blue and attempted capsulotomy Source: Rosa Braga-Mele, MD

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