Cases that made us stop and think

Call them challenging, difficult, puzzling. Some cases test skills and summon creativity.

While cataract surgery has long since become routine, with good results reliable, today’s cataract surgeons still have their wits tested here and there. Challenging cases may walk through the practice door at any time, requiring surgeons to think creatively to come up with a solution. Here are three who rose to the challenge.

Creativity is critical

BY AMIN ASHRAFZADEH, MD

I inherited Mr. Bubbles (fictitious name), a former high myope with history of LASIK OU followed years later by multifocal intraocular lenses (IOLs). He was very unhappy dealing with his glare and halos and requested an IOL exchange. I performed the procedure with an AMO ZA9003 monofocal lens in the left eye.

Figure 1. The IOL haptic in the AC with associated corneal edema. In the pupil, the reflex off the bottom of the bubble can be seen superiorly.

The complication presents

Two years later, he presented with a retinal detachment for which he had an urgent repair, including placement of a gas bubble in the left eye. A few days later, he presented distressed, saying that his IOL dislocated into the anterior chamber.

On exam, I found the superior haptic in the anterior chamber touching the endothelium with resultant 2+ edema and 2+ Descemet folds. The inferior haptic was in the sulcus. A bubble filled one-third of the vitreous cavity. This presented a problem because the patient could not lie flat — the bubble would migrate into the anterior chamber.

Inspiration strikes

I chose to take Mr. Bubbles to the OR and put him in a seated position, while turning my OPMI VISU160 microscope (Zeiss) to full horizontal position. I turned his face fully to the side of the bed toward me. Without any sedation, the patient was completely cooperative. We cleansed and draped the eye in sterile fashion and placed the lid speculum. Then, I made a sideport entry of 1.1 mm. My attempts with Sinskey hook were not successful. I switched to a Dietz IOL manipulator, and the superior haptic was dunked under the iris with perfect lens centration.

I completed the case in five minutes with excellent results — even if it did take 30 minutes to figure out how I was going to do the surgery. Next time you and I come across a difficult case and need to think outside the box, hopefully we will have a new trick up our sleeves.

Amin Ashrafzadeh, MD is a cataract, cornea and refractive surgeon in private practice at Modesto Eye Center in Modesto, Calif.

The spontaneously dislocating lens

BY CYNTHIA MATOSSIAN, MD

The patient was a 65-year-old male with high myopia and a history of a retinal detachment in his left eye with a scleral buckle repair performed approximately 30 years ago. He presented with very advanced cataracts in both eyes.

The challenge

The patient delayed cataract surgery until he became intolerant of his contact lenses. His topography revealed minimal anterior corneal astigmatism. His Cassini revealed minimal posterior corneal astigmatism.

The patient’s prescription:

OD: -14.00 sph

OS: -17.75 sph

UCDVA OD: CF

UCDVA OS: CF

BCDVA with spectacles:

OD: 20/80; OS: 20/200

He had a 4+ brunescent cataract in each eye.

Axial length measure with IOL Master, which was confirmed with immersion biometry was:

OD: 29.04 mm with a SNR = 53.8

OS: 31.53 mm with a SNR = 54.6

The patient was consented for a possible vitrectomy due to his extremely dense cataracts and his history of a previous retinal detachment with scleral buckle repair.

A surgical surprise

After an uneventful manual capsulorhexis of approximately 5.5mm and gentle hydrodissection, I hydroprolapsed the nucleus out of the capsular bag for a supracapsular cataract disassembly technique. I used my nondominant hand to block the microscope light while I reached for my next instrument. When I looked back into the microscope, the lens was gone. The entire lens had sunk into the vitreous. (See Figures 2-4.)

BEFORE
Figure 2. Intact capsulorhexis with Vision Blue stain.

AFTER
Figure 3. Hydro-prolapsed cataract for supra-capsular disassembly lens technique through intact capsulorhexis.

Figure 4. Sudden dislocation of entire lens into vitreous before phaco was started.

I proceeded with the planned anterior vitrectomy and left the patient aphakic since his calculated IOL power was +0.50D to 0.00D. I immediately referred him to a retina specialist who proceeded with a pars plana lensectomy and vitrectomy, hoping the probe would be long enough to reach the lens sitting on the retina.

The results

One month after surgery, the patient’s vision was:

BCVA OD: -14.00 sph 20/80-1

BCVA OS (operated eye): plano 20/25-2.

The patient is delighted with his surgical outcome. He cannot recall ever seeing this well with his left eye.

I checked with our corneal specialist to see whether a sutured plano posterior chamber IOL would be recommended. Since the patient experienced a vitrectomy during his retinal detachment repair years ago, there was no risk of any vitreous prolapsing through the pupil. Therefore, we decided an additional procedure would be warranted. The patient is very happy and is scheduled to undergo cataract surgery in his right eye in the near future.

Reflection

Causes of spontaneous lens dislocation after uncomplicated capsulorhexis can include an undetected small defect in the posterior lens capsule from previous retinal surgery, which may have extended during hydrodissection. At times, a small tear in the posterior capsule in the setting of a very dense mature cataract may not show up on imaging, or the surgeon may not detect it.

In this case, I performed an OCT of his macula and then our retina specialist saw the patient for a consultation before surgery. I bypassed anterior segment OCT since there was no reason for me to proceed with that imaging test. However, anterior segment OCT may have detected a small tear in the posterior capsule, which probably extended to let the entire cataract drop into the vitreous before phacoemulsification was even started.

Cynthia Matossian, MD, FACS, is founder of Matossian Eye Associates. Her email is cmatossian@matossianeye.com

When DED patients need cataract surgery

BY KARL G. STONECIPHER, MD

Patients present with dry eye disease (DED) — either aqueous deficient or evaporative DED — for cataract surgery every day. According to a recent study by Trattler et al., roughly one in five patients will present with a previous diagnosis of DED, and 80.7% of the patients we routinely see for cataract surgery will have an International Task Force grading (ITF) of level 2 or higher.^1,2

So what should we do differently for these patients? What follows are conclusions drawn from my own experiences.

Treat before surgery

First, we must treat the DED aggressively. Poor tear film can alter preoperative biometry and the keratometry associated with the measurements can fluctuate with tear film instability. Typically, patients with ITF level two or higher are recommended to start cyclosporine eye drops, but other measures can be instituted if that treatment fails.^3,4 Low-dose topical steroids can reduce the inflammation of DED. It also is an effective alternative when topical cyclosporine fails or it can be used in conjunction with cyclosporine.

Figure 5. Sjogren’s patients often have very dense lenses and tend to present later in life. I like to use a cylinder chop method to break up the lens.

Once you have managed the inflammation, lacrimal duct closure with punctal plugs or thermal cautery may be an option.

Perioperative precautions

Options at the perioperative stage include pretreatment of the tear film with the surgeon’s typical regimen starting three days prior to surgery with the addition of doxycycline orally when the patient has concomitant meibomian gland disease. Take extra care in the operative suite and monitor topical anesthesia closely. You can use viscoelastic topically throughout the case and at the end to maintain ocular surface integrity.

So what did I learn from this challenging dry eye disease patient? Use of viscoelastic agents prior to surgery topically, as well as during and immediately after the procedure helped with visualization and intraoperative aberrometry during the case. Perioperative and postoperative drops may be complicated with certain drops that contain additional mucoadhesives. Intuitively we would think they help, but with the patient’s inability to produce tears, they can inhibit the patient’s ability to blink.

Remember, with cataract surgery we produce ocular surface issues and in this patient population, we have no room for error. So when we encounter the severe dry eye patient such as that with Sjogren’s, always pretreat any issues you can resolve before surgery. Repeat preoperative testing to reduce error as needed and use intraoperative confirmation when you can.

Communicate your concerns with the patient and engage her to participate in the plan preoperatively and postoperatively. Inform these patients that their case will not be routine because they will compare their rehabilitation to other patients and be concerned if their recovery is different. Finally, support the patient throughout the process and you both will benefit. OM

REFERENCES

Karl G. Stonecipher, MD, is Clinical Associate Professor of Opthalmology at the University of North Carolina and Medical Director for Laser Defined Vision.

Feel like you can go one, two or even three better than these stories? Prove it: Send your story to Rene Luthe, senior editor, at rene.luthe@pentavisionmedia.com.