Coming to a cataract surgery theater near you?

Methods for handling unusual cataract challenges

By Jeffrey S. Eisenberg

A 52-year-old male rancher presented to Samuel Masket, MD, with a history of three separate ocular injuries. First, a dynamite explosion led to shrapnel and puncture wounds to his eyes, however leaving useful vision. Another time, a direct kick to the right eye from a horse induced a ruptured globe that resulted in loss of all vision and phthisis in that eye. Finally, a tire explosion to the left eye resulted in marked retinal damage and an inferiorly subluxated traumatic progressive cataract. The challenge now was how to best manage the cataract in the presence of zonulysis.

A Malyugin ring is one of the easiest ways to keep the pupil dilated in IFIS cases.

Admittedly, this patient’s situation is extreme. But it shows one of several challenges that might test the skills of the best cataract surgeon. Here, we look at several situations that make cataract surgery anything but routine.

SPECIAL CASES

Trauma

Let’s go back to the rancher. Dr. Masket, a clinical professor at University of California-Los Angeles and in private practice at Advanced Vision Care, Century City, Calif., had another concern. “Eyes associated with trauma have greater likelihood of retinal detachment and supra-choroidal hemorrhage; they need to be followed carefully during and after surgery,” he says.

First, he used the femtosecond laser to create the anterior capsulotomy. “With subluxated cataract and weakened zonular fibers, the laser can create a more predictable capsulotomy regarding size, shape, and positioning,” Dr. Masket explains.

Next, Dr. Masket used MST capsule support hooks (Microsurgical Technology, Redmond, Wash.) to hold the capsular bag in place while he completed phacoemulsification and cortical clean up. He noted no further worsening of the zonule, with about 3 clock hours of disinsertion as prior to surgery. He elected to place a larger standard capsule tension ring in the capsule bag and noted perfect stability and centration of the bag; he subsequently implanted a single-piece acrylic standard IOL. As the bag/IOL complex was centered and stable, there was no need to suture fixate any device to the scleral wall.

Too mature

The femtosecond laser also offers specific advantages in cases such as this subluxated cataract, as well as eyes with endothelial damage or shallow anterior chamber. For example, less phaco energy is needed, providing greater protection to the corneal endothelium.

“In addition to cases with zonulysis and compromised endothelium, I find it also helpful in eyes with advanced cataracts, mature cataracts, and in certain case types where anterior capsulorrhexis is particularly challenging,” Dr. Masket says, citing aniridia, anterior polar cataracts, anterior lenticonus and fibrotic anterior capsules as examples. “I have used femtosecond laser successfully in all of those case types. While the femtosecond laser may be more predictable, in the routine cases, varying with the skill of the surgeon, the advantages of the laser are less obvious. But they’re very obvious to me in very distinct cases.”

The femtosecond laser aided Dr. Masket in treating another extreme case: a patient with Morgagnian cataract in whom manual capsulotomy techniques alone might have been complicated.

In Morgagnian cataract, the lens become hyper mature so that the cortex, rather than being solid, becomes liquefied, and a dense nucleus floats inside this liquid mass.

“The surgical challenge of the Morgagnian cataract is the capsule is extremely friable, so managing it in the traditional way often fails to create a typical capsulorrhexis,” Dr. Masket explains. “Then, it’s really easy to lose the nucleus into the posterior segment and [lead to] other complications associated with capsule rupture.”

Dr. Masket used the femtosecond laser to create a partial anterior capsulotomy. Once the laser to opened the capsule, he then manually completed what the laser initiated. “However, I felt that it was safer to remove the very dense and enlarged nucleus in the technique of manual small incision surgery, spooning the nucleus out under viscoelastic protection, and via a large temporal frown shaped incision” he says.

The rest of the surgery was uncomplicated. He implanted a three-piece silicone lens in the capsular bag, and the patient did extremely well.

IFIS

Dilating the pupil

Intraoperative floppy iris syndrome (IFIS) is especially challenging for several reasons. The easiest way of dealing with it is to keep the pupil dilated with a pupil expansion ring or iris hooks (Figure).

“What makes the surgery challenging is the pupils don’t dilate very well,” says Richard S. Hoffman, MD, Clinical Associate Professor of Ophthalmology at Casey Eye Institute, part of the Oregon Health and Science University. Flaccidity to the iris is a further problem. “The iris starts to billow and the pupil tends to decrease in size, making the surgery more challenging. And the iris will start to prolapse out of the phacoemulsification incision or sideport incisions.”

The result, Dr. Hoffman says, is a higher incidence of broken capsules and iris deformities in patients who have IFIS.

Rosa M. Braga-Mele, MD, a professor at the University of Toronto and an Alcon consultant, says her approach depends, in part, on pupil size. Suppose, for example, the pupil still dilates to 5 mm or more. In that event, she does not change her protocol. “It’s going to probably stay dilated,” says Dr. Braga-Mele.

Two methods

What Dr. Braga-Mele will do is use intracameral phenylephrine to ensure that the pupil does not come down and possibly Healon 5 (Abbott Medical Optics, Santa Ana, Calif.) halfway through the case. (Realize that even if you use unpreserved phenylephrine 2.5%, there may still be some bisulfate, so you need to dilate it 1 to 4 with BSS or a lidocaine cocktail.)

“If there’s room in the anterior chamber, I always try to flip the nucleus out of the capsular bag because I think that’s a great way to deal with it and negate the iris,” she adds.

But, suppose the pupil is less than 4 mm, even when dilated. “Something is going to happen; the pupil is inevitably going to come down,” she says. In this case, Dr. Braga-Mele injects Healon 5 in a donut configuration on the iris and uses dispersive viscoelastic in the center of the pupil (a technique initially described by Steven Arshinoff, MD and Robert Osher, MD).

Dr. Hoffman typically uses a bimanual or biaxial technique, placing the phacoemulsification needle and irrigation system in two separate incisions rather than using them as one combined unit through a single incision. “This allows you to keep the irrigation that’s going into the eye above the plane of the iris. So there’s less fluid behind the iris, which can cause the iris to billow.”

He also suggests doing most of the phacoemulsification of the lens in the anterior chamber rather than behind the iris within the capsular bag. “[You will] have less fluid that you’re irrigating behind the iris, you’re less likely to get the pupil constricting and less likely to have the iris prolapsing out of your incisions,” he says.

Another tip Dr. Hoffman suggests injecting epi-Shugarcaine, (a combination of 9 cc BSS Plus (Alcon), 3 cc 4% preservative-free lidocaine (Hospira) and 4 cc 1:1000 preservative-free, bisulfite-free epinephrine) at the beginning of the procedure to help stiffen the iris to keep the pupil dilated. He does this at the beginning of the procedure, and inserts a Malyugin ring (Microsurgical Technology) if he has any suspicion of IFIS, such as the patient having taken prostate medications.

Tools of the Trade

“The key is to be prepared with an armamentarium of techniques or technology just in case,” Dr. Braga-Mele says. That armamentarium includes:

■ Healon 5. Understand, though, that if you layer Healon 5 on top of the iris, the iris may come down in between. At this point, you can insert a Malyugin ring, keep adding Healon 5 (this will lengthen the procedure), or inject intracameral phenylephrine or epinephrine.

■ Malyugin ring. When inserting the Malyugin ring, Dr. Braga-Mele applies viscoelastic over and under the iris. Then, she lifts the iris and, starting with the distal end, twists slightly to one side in order to insert the other loop, and then gently twists her hand to the other side to finish inserting the ring. “At this point, the ring sometimes gets caught there and you can’t always release it,” Dr. Braga-Mele says.

Should this occur and you are unable to get the inserter off of it, she recommends using a second instrument. “It’s the easiest option,” she says. “You can use a Sweeney or a Sinskey hook through your sideport incision and hold onto it and then leave it in the eye. And then I like to gently go in and place it on the proximal iris. The key point here is you need to center it.”

When removing the Malyugin ring, Dr. Braga-Mele says, first remove the more proximal end. “I actually go in and disinsert the two side ends, leaving just the distal end in,” she says. “And then I’ll go in with the reinserter and capture that proximal end.”

Be careful to remove all three hoops lest you inadvertently remove part of the iris.

One extra tip: If Dr. Braga-Mele anticipates needing a Malyugin ring, especially after a capsulorrhexis, she stains the capsule with VisionBlue (Dorc, Zuidland, The Netherlands) in order to see the edges and not risk rupturing the capsulorrhexis with the edges of the Malyugin ring.

■ Iris hooks. Although using iris hooks adds to the length of the procedure, they do offer a distinct advantage. “The reason I like hooks is that you can control how much expansion of the pupil you’re doing,” Dr. Braga-Mele says.

When using iris hooks, be sure to gently manipulate any posterior adhesions. Take care not to over-manipulate, lest you develop a situation similar to IFIS, Dr. Braga-Mele adds.

With these tools, you should be well prepared for the sort of stressful situations described in these pages. Cynthia Matossian, MD, of Doylestown, Pa., though, has one more piece of critical advice: “Stay cool and collected, don’t panic, take a deep breath and approach the situation after you’ve analyzed it thoroughly.” OM