Challenging Anterior Segment Surgical Cases

Discussing strategies helps us all improve.

BY UDAY DEVGAN, MD, FACS, FRCS

AS SURGEONS, WE ALL EXPERIENCE COMPLICATIONS and encounter our share of challenging cases, some more nerve-wracking than others. Perhaps from the following descriptions of three cases from my practice you can take away some pearls.

IOL Sinking into the Vitreous

I noticed nothing out of the ordinary during this seemingly routine cataract surgery, except a bit of subincisional cortex that I planned to remove at the end of the case. As I was inserting the single-piece acrylic IOL, I realized it was sinking into the vitreous. I couldn’t see a reason why it would, so I assumed I must have torn the capsular bag during lens insertion. (It turned out that a sharp edge on the IOL ripped the capsule.) No matter the reason, I had to decide what to do. Let it go and send the patient to a retina specialist? Perform the Kelman-Chang posterior assisted levitation (PAL) technique? I opted to use my chopper and ophthalmic viscosurgical device (OVD) to retrieve the IOL. By putting the chopper behind the lens and adding OVD there, I was able to bring it up to the sulcus.

Now what? Even though I had a good anterior capsulorhexis, securing the IOL in the sulcus wasn’t an option because of the risk of causing uveitis-glaucoma-hyphema (UGH) syndrome or other problems by implanting a single-piece acrylic IOL in the sulcus. I decided to remove the IOL and replace it with a three-piece lens. I did this by cutting the IOL mostly in half. Once I enlarged the incision and used additional OVD to keep the iris out of the way, I was able to grab the lens and bring it out of the eye.

I then performed a 23-gauge bimanual anterior vitrectomy, rather than a coaxial vitrectomy, to take advantage of the more favorable fluidics and enhanced control. Implantation of the three-piece IOL in the sulcus was uneventful, and the patient did well postoperatively. In a case like this, where a broken capsule and vitreous loss increase the risk of CME, it makes sense to suture the wound, use NSAIDs for a prolonged period and check the retina carefully.

Decentered Multifocal IOL Exchange

As we know, there are many reasons we might elect to remove an IOL. In this case, it took some sleuthing to determine whether exchanging a multifocal IOL that had been implanted 3 months prior was the right course of action. When a patient presented with the chief complaint of ghosting and doubling of his vision, his uncorrected visual acuity in the operated eye was 20/40-, and correctable to 20/30- (mild cataract and low myopia in the fellow eye, correctable to 20/20.) The IOL appeared decentered, which would lead us to believe it was the cause of the problems he was experiencing, but perhaps he could adapt in time. We certainly can’t assume though, so a closer look was in order. OCT was normal, no CME, but a dilated exam revealed much more than the shifted lens was going on. The capsular bag was partially open and some vitreous had prolapsed inferiorly at 6 o’clock. Some pigment was visible in the vitreous tongue, and the posterior capsule was wrinkled in the middle. Interestingly, the fundus photo taken through the decentered lens showed ghosting of the optic nerve and vessels. Faced with these issues, I performed an anterior vitrectomy, removed the decentered multifocal IOL, cutting it part way down the middle and rotating it out, and replaced it with a three-piece, silicone, monofocal aspheric lens in the sulcus. Results were quite good.

It’s important to mention that IOL exchange patients should be fully educated on the risks these procedures entail. I have a special consent form for higher-risk surgeries and try to impress upon patients that they are less predictable and, frankly, stressful for me.

Airbag Injury Iris Defect

In some cases, knowing what not to do is just as important as knowing what to do. For example, I recently had a young phakic patient with an iris defect from an airbag injury (Figure 1). Attempting to repair it could have led to trouble, notably, nicking the capsular bag and instantly creating a total cataract. While her vision was correctable to 20/20, she was beginning to develop a slight traumatic cataract. Here, it’s best to wait until she needs cataract surgery and repair the iris at that time. In the meantime — she’s a low myope — she is wearing blue cosmetic contact lenses, which create a sufficient block.

FIGURE 1. The risks of repairing the iris injury in this young phakic patient outweighed the potential benefits.

So, if you remember only one thing from these cases, it’s think before you act. Have a backup plan and take your time.