680
CORRESPONDENCE
Figure 2. Reported sources of information about ocular complications of alpha blockers.
the most commonly prescribed a1-antagonist by 44.3%, 35.1%, 12.2%, and 0.8%, respectively (Figure 1). For patients with symptomatic BPH and cataract, 42.8% of respondents reported no preference among the different classes of BPH medications; selective a1-antagonists, nonselective a1-antagonists, or 5-a reductase inhibitors would be the first choice of 19.8%, 17.6%, and 19.9% of respondents, respectively. Only 46 respondents (35.2%) were aware that a1-antagonists can cause cataract surgical complications. The source of information for these 46 respondents was, in descending order of frequency, medical journals (50.0%), ophthalmologists (26.1%), primary care colleagues (15.2%), patients (6.5%), urologists (6.5%), and drug companies (2.2%) (Figure 2). Only half of those aware of IFIS (n Z 23) factored this knowledge into treatment considerations. Disappointingly, 90.1% of respondents do not ask patients about their history of cataract symptoms prior to initiating a1-antagonist treatment and only 31.3% regularly advise patients to inform their ophthalmologist about taking these drugs. An overwhelming number of respondents (96.2%) desired more information on this topic. At the conclusion of the online survey, all respondents received an informational handout on IFIS. The apparent ineffectiveness of previous educational efforts underscores the importance of provider-toprovider education and communication. Instruments such as our survey may be used to educate prescribing doctors. Considering that more than 3 million cataract surgeries are performed annually and a1-antagonists are universally prescribed for symptomatic BPH, it may be time for renewed efforts at educating primary care physicians about IFIS.
REFERENCES 1. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005; 31:664–673 2. Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard RB, Packer M, for the ASCRS Cataract Clinical Committee. ASCRS white paper: clinical review of intraoperative floppy-iris syndrome. J Cataract Refract Surg 2008; 34:2153–2162 3. Bell CM, Hatch WV, Fischer HD, Cernat G, Paterson JM, Gruneir A, Gill SS, Bronskill SE, Anderson GM, Rochon PA. Association between tamsulosin and serious ophthalmic adverse events in older men following cataract surgery. JAMA 2009; 301:1991–1996. Available at: http://jama.jamanetwork.com/ data/Journals/JAMA/4464/joc90038_1991_1996.pdf. Accessed January 7, 2014 4. Nguyen DQ, Sebastian RT, Kyle G. Surgeon’s experiences of the intraoperative floppy iris syndrome in the United Kingdom [letter]. Eye 2007; 21:443–444. Available at: http://www.nature.com/eye/ journal/v21/n3/pdf/6702616a.pdf. Accessed January 7, 2014 5. Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard RB, Packer M, for the ASCRS Cataract Clinical Committee. Clinical experience with intraoperative floppy-iris syndrome; results of the 2008 ASCRS member survey. J Cataract Refract Surg 2008; 34:1201–1209 6. Chang DF. Floppy iris syndrome: why BPH can complicate cataract surgery [editorial]. Am Fam Physician 2009; 79:1051–1056. Available at: http://www.aafp.org/afp/2009/0615/p1051a.html. Accessed January 7, 2014
Incomplete capsulotomy using femtosecond laser with a pupil expansion device Dilraj S. Grewal, MD, Surendra Basti, MD Small pupils make conventional phacoemulsification more challenging for even experienced surgeons and are listed as a contraindication to femtosecond laser–assisted cataract surgery. Pupil expansion
J CATARACT REFRACT SURG - VOL 40, APRIL 2014
CORRESPONDENCE
devices such as the Malyugin ring (Microsurgical Technology) have been inserted surgically prior to the femtosecond laser treatment to mechanically dilate the pupil.1–4 This technique brings in unique surgical considerations and necessitates a change in the order of surgical steps from conventional femtosecond laser–assisted cataract surgery, in which the laser portion is performed prior to entering the eye. An incomplete capsulotomy due to a retained air bubble has been reported following use of a Malyugin ring prior to laser treatment in a patient with a small pupil.1 We report a case that involved an incomplete capsulotomy due to lack of a homogenous ophthalmic viscosurgical device (OVD) fill in the anterior chamber following placement of a Malyugin ring. CASE REPORT A 67-year-old man with a 3.0 mm pupil despite maximal instillation of mydriatics was having femtosecond laser–assisted cataract surgery. A 0.9 mm paracentesis and a 2.4 mm clear corneal incision were created followed by instillation of intracameral balanced salt solution (Epi-Shugarcaine) and OVD (sodium hyaluronate 1.0%, Healon) in the anterior chamber. A 7.0 mm Malyugin ring was placed to expand the pupil. Following successful placement of the ring, the anterior chamber was copiously manually irrigated with balanced salt solution using a 30-gauge cannula; the wounds were hydrated and
681
confirmed to be watertight. Femtosecond laser treatment (Catalys, Optimedica Corp.) was performed, and manual adjustment of the anterior capsule and lens was required due to the slight distortion of the iris from the Malyugin ring (Figure 1). A capsulotomy (diameter 5.0 mm using an energy setting of 7 mJ instead of the standard 4 mJ to achieve better penetration in the event of retained OVD) and lens softening (350 mm grid size) were performed. The anterior chamber was stable during all steps of the femtosecond procedure, and no redocking of the patient interface was required. Under the microscope, numerous small bubbles arranged in a circular fashion corresponding to the capsulotomy were seen. However, careful inspection showed that the capsule was not completely perforated (Figure 2, A). A Utrata forceps was used to complete the capsulotomy, which did not follow the femtosecond laser–generated perforations (Figure 2, B). Although the manual capsulotomy was not circular as intended (shallow anterior chamber in eye with a dense brunescent lens and OVD [sodium hyaluronate 2.3%, Healon 5] did not deepen the chamber), a continuous curvilinear opening was achieved (Figure 2, C and D). The remainder of the case was uneventful.
DISCUSSION In reports describing placement of a Malyugin ring prior to the use of the femtosecond laser, the laser treatment was performed leaving the OVD in place1,2,4 or after OVD was removed and the anterior chamber
Figure 1. A: Intraoperative image showing the Malyugin ring, which achieved adequate pupil dilation to allow creation of a 5.0 mm capsulotomy. B: Intraoperative optical coherence tomography images show the dilated pupil and the Malyugin ring cross-section (white arrows) causing distortion of the pupil.
J CATARACT REFRACT SURG - VOL 40, APRIL 2014
682
CORRESPONDENCE
Figure 2. Intraoperative photograph (A) shows numerous small bubbles arranged in a circular fashion corresponding to the attempted 5.0 mm diameter femtosecond laser capsulotomy and the blob of OVD overlying the anterior capsule along with cavitation bubbles released following lens fragmentation. The anterior capsule was stained and the capsulotomy completed using a forceps (B) but did not tear along the intended course (arrowheads). Intraoperative image following removal of the lens shows the intended incomplete femtosecond capsulotomy (C) and an overlay (D) comparing the actually achieved capsulotomy completed using the forceps (dotted white line) and the intended femtosecond laser capsulotomy (yellow circle).
was refilled with balanced salt solution.3 In our case, we believe that incomplete OVD removal led to an incomplete capsulotomy with areas of inadequate penetration and nonpenetration. Although we had intended complete OVD removal, residual OVD was seen on the lens capsule when we entered the eye after the laser treatment. Meticulous OVD removal is necessary and may have been better achieved using an irrigation/aspiration probe. Residual amounts of OVD on the lens capsule lead to variation in the index of refraction throughout the anterior chamber and could lead to differential focusing of the laser energy, which in turn could lead to incomplete penetration through the anterior capsule.2 Using appropriate energy settings previously reported for laser treatment in the presence or absence of OVD is important.5 Our case highlights intraoperative challenges that can be encountered if there is a mix of OVD and balanced salt solution in the anterior chamber during femtosecond laser–created capsulotomy. In conclusion, when using a pupil expansion device prior to femtosecond laser–assisted cataract surgery, it is important to ensure a homogenous OVD fill (free of
air bubbles) in the anterior chamber or a homogenous fill with balanced salt solution free of OVD, manually confirm the automated outline of the capsule during the femtosecond laser procedure, and carefully inspect the capsulotomy intraoperatively to ensure it is complete. REFERENCES 1. Kankariya VP, Diakonis VF, Yoo SH, Kymionis GD, Culbertson WW. Management of small pupils in femtosecondassisted cataract surgery pretreatment. Ophthalmology 2013; 120:2359–2360.e1 2. Conrad-Hengerer I, Hengerer FH, Schultz T, Dick HB. Femtosecond laser-assisted cataract surgery in eyes with a small pupil. J Cataract Refract Surg 2013; 39:1314–1320 nitz K, Taka cs AI, Gyenes A, Filkorn T, Gergely R, Kova cs I, 3. Kra Nagy ZZ. Femtosecond laser-assisted cataract surgery in management of phacomorphic glaucoma. J Refract Surg 2013; 29:645–648 4. Roberts TV, Lawless M, Hodge C. Laser-assisted cataract surgery following insertion of a pupil expander for management of complex cataract and small irregular pupil. J Cataract Refract Surg 2013; 39:1921–1924 5. Dick HB, Gerste RD, Rivera RP, Schultz T. Femtosecond laserassisted cataract surgery without ophthalmic viscosurgical devices. J Refract Surg 2013; 11:784–787
J CATARACT REFRACT SURG - VOL 40, APRIL 2014
CORRESPONDENCE
Figure 2. Reported sources of information about ocular complications of alpha blockers.
the most commonly prescribed a1-antagonist by 44.3%, 35.1%, 12.2%, and 0.8%, respectively (Figure 1). For patients with symptomatic BPH and cataract, 42.8% of respondents reported no preference among the different classes of BPH medications; selective a1-antagonists, nonselective a1-antagonists, or 5-a reductase inhibitors would be the first choice of 19.8%, 17.6%, and 19.9% of respondents, respectively. Only 46 respondents (35.2%) were aware that a1-antagonists can cause cataract surgical complications. The source of information for these 46 respondents was, in descending order of frequency, medical journals (50.0%), ophthalmologists (26.1%), primary care colleagues (15.2%), patients (6.5%), urologists (6.5%), and drug companies (2.2%) (Figure 2). Only half of those aware of IFIS (n Z 23) factored this knowledge into treatment considerations. Disappointingly, 90.1% of respondents do not ask patients about their history of cataract symptoms prior to initiating a1-antagonist treatment and only 31.3% regularly advise patients to inform their ophthalmologist about taking these drugs. An overwhelming number of respondents (96.2%) desired more information on this topic. At the conclusion of the online survey, all respondents received an informational handout on IFIS. The apparent ineffectiveness of previous educational efforts underscores the importance of provider-toprovider education and communication. Instruments such as our survey may be used to educate prescribing doctors. Considering that more than 3 million cataract surgeries are performed annually and a1-antagonists are universally prescribed for symptomatic BPH, it may be time for renewed efforts at educating primary care physicians about IFIS.
REFERENCES 1. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005; 31:664–673 2. Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard RB, Packer M, for the ASCRS Cataract Clinical Committee. ASCRS white paper: clinical review of intraoperative floppy-iris syndrome. J Cataract Refract Surg 2008; 34:2153–2162 3. Bell CM, Hatch WV, Fischer HD, Cernat G, Paterson JM, Gruneir A, Gill SS, Bronskill SE, Anderson GM, Rochon PA. Association between tamsulosin and serious ophthalmic adverse events in older men following cataract surgery. JAMA 2009; 301:1991–1996. Available at: http://jama.jamanetwork.com/ data/Journals/JAMA/4464/joc90038_1991_1996.pdf. Accessed January 7, 2014 4. Nguyen DQ, Sebastian RT, Kyle G. Surgeon’s experiences of the intraoperative floppy iris syndrome in the United Kingdom [letter]. Eye 2007; 21:443–444. Available at: http://www.nature.com/eye/ journal/v21/n3/pdf/6702616a.pdf. Accessed January 7, 2014 5. Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard RB, Packer M, for the ASCRS Cataract Clinical Committee. Clinical experience with intraoperative floppy-iris syndrome; results of the 2008 ASCRS member survey. J Cataract Refract Surg 2008; 34:1201–1209 6. Chang DF. Floppy iris syndrome: why BPH can complicate cataract surgery [editorial]. Am Fam Physician 2009; 79:1051–1056. Available at: http://www.aafp.org/afp/2009/0615/p1051a.html. Accessed January 7, 2014
Incomplete capsulotomy using femtosecond laser with a pupil expansion device Dilraj S. Grewal, MD, Surendra Basti, MD Small pupils make conventional phacoemulsification more challenging for even experienced surgeons and are listed as a contraindication to femtosecond laser–assisted cataract surgery. Pupil expansion
J CATARACT REFRACT SURG - VOL 40, APRIL 2014
CORRESPONDENCE
devices such as the Malyugin ring (Microsurgical Technology) have been inserted surgically prior to the femtosecond laser treatment to mechanically dilate the pupil.1–4 This technique brings in unique surgical considerations and necessitates a change in the order of surgical steps from conventional femtosecond laser–assisted cataract surgery, in which the laser portion is performed prior to entering the eye. An incomplete capsulotomy due to a retained air bubble has been reported following use of a Malyugin ring prior to laser treatment in a patient with a small pupil.1 We report a case that involved an incomplete capsulotomy due to lack of a homogenous ophthalmic viscosurgical device (OVD) fill in the anterior chamber following placement of a Malyugin ring. CASE REPORT A 67-year-old man with a 3.0 mm pupil despite maximal instillation of mydriatics was having femtosecond laser–assisted cataract surgery. A 0.9 mm paracentesis and a 2.4 mm clear corneal incision were created followed by instillation of intracameral balanced salt solution (Epi-Shugarcaine) and OVD (sodium hyaluronate 1.0%, Healon) in the anterior chamber. A 7.0 mm Malyugin ring was placed to expand the pupil. Following successful placement of the ring, the anterior chamber was copiously manually irrigated with balanced salt solution using a 30-gauge cannula; the wounds were hydrated and
681
confirmed to be watertight. Femtosecond laser treatment (Catalys, Optimedica Corp.) was performed, and manual adjustment of the anterior capsule and lens was required due to the slight distortion of the iris from the Malyugin ring (Figure 1). A capsulotomy (diameter 5.0 mm using an energy setting of 7 mJ instead of the standard 4 mJ to achieve better penetration in the event of retained OVD) and lens softening (350 mm grid size) were performed. The anterior chamber was stable during all steps of the femtosecond procedure, and no redocking of the patient interface was required. Under the microscope, numerous small bubbles arranged in a circular fashion corresponding to the capsulotomy were seen. However, careful inspection showed that the capsule was not completely perforated (Figure 2, A). A Utrata forceps was used to complete the capsulotomy, which did not follow the femtosecond laser–generated perforations (Figure 2, B). Although the manual capsulotomy was not circular as intended (shallow anterior chamber in eye with a dense brunescent lens and OVD [sodium hyaluronate 2.3%, Healon 5] did not deepen the chamber), a continuous curvilinear opening was achieved (Figure 2, C and D). The remainder of the case was uneventful.
DISCUSSION In reports describing placement of a Malyugin ring prior to the use of the femtosecond laser, the laser treatment was performed leaving the OVD in place1,2,4 or after OVD was removed and the anterior chamber
Figure 1. A: Intraoperative image showing the Malyugin ring, which achieved adequate pupil dilation to allow creation of a 5.0 mm capsulotomy. B: Intraoperative optical coherence tomography images show the dilated pupil and the Malyugin ring cross-section (white arrows) causing distortion of the pupil.
J CATARACT REFRACT SURG - VOL 40, APRIL 2014
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CORRESPONDENCE
Figure 2. Intraoperative photograph (A) shows numerous small bubbles arranged in a circular fashion corresponding to the attempted 5.0 mm diameter femtosecond laser capsulotomy and the blob of OVD overlying the anterior capsule along with cavitation bubbles released following lens fragmentation. The anterior capsule was stained and the capsulotomy completed using a forceps (B) but did not tear along the intended course (arrowheads). Intraoperative image following removal of the lens shows the intended incomplete femtosecond capsulotomy (C) and an overlay (D) comparing the actually achieved capsulotomy completed using the forceps (dotted white line) and the intended femtosecond laser capsulotomy (yellow circle).
was refilled with balanced salt solution.3 In our case, we believe that incomplete OVD removal led to an incomplete capsulotomy with areas of inadequate penetration and nonpenetration. Although we had intended complete OVD removal, residual OVD was seen on the lens capsule when we entered the eye after the laser treatment. Meticulous OVD removal is necessary and may have been better achieved using an irrigation/aspiration probe. Residual amounts of OVD on the lens capsule lead to variation in the index of refraction throughout the anterior chamber and could lead to differential focusing of the laser energy, which in turn could lead to incomplete penetration through the anterior capsule.2 Using appropriate energy settings previously reported for laser treatment in the presence or absence of OVD is important.5 Our case highlights intraoperative challenges that can be encountered if there is a mix of OVD and balanced salt solution in the anterior chamber during femtosecond laser–created capsulotomy. In conclusion, when using a pupil expansion device prior to femtosecond laser–assisted cataract surgery, it is important to ensure a homogenous OVD fill (free of
air bubbles) in the anterior chamber or a homogenous fill with balanced salt solution free of OVD, manually confirm the automated outline of the capsule during the femtosecond laser procedure, and carefully inspect the capsulotomy intraoperatively to ensure it is complete. REFERENCES 1. Kankariya VP, Diakonis VF, Yoo SH, Kymionis GD, Culbertson WW. Management of small pupils in femtosecondassisted cataract surgery pretreatment. Ophthalmology 2013; 120:2359–2360.e1 2. Conrad-Hengerer I, Hengerer FH, Schultz T, Dick HB. Femtosecond laser-assisted cataract surgery in eyes with a small pupil. J Cataract Refract Surg 2013; 39:1314–1320 nitz K, Taka cs AI, Gyenes A, Filkorn T, Gergely R, Kova cs I, 3. Kra Nagy ZZ. Femtosecond laser-assisted cataract surgery in management of phacomorphic glaucoma. J Refract Surg 2013; 29:645–648 4. Roberts TV, Lawless M, Hodge C. Laser-assisted cataract surgery following insertion of a pupil expander for management of complex cataract and small irregular pupil. J Cataract Refract Surg 2013; 39:1921–1924 5. Dick HB, Gerste RD, Rivera RP, Schultz T. Femtosecond laserassisted cataract surgery without ophthalmic viscosurgical devices. J Refract Surg 2013; 11:784–787
J CATARACT REFRACT SURG - VOL 40, APRIL 2014
