CONSULTATION SECTION
anterior vitreous face if there is zonular loss. This can result in a significantly reduced red reflex, making visualization more difficult once the liquid cortex is removed. (2) Make sure the anterior chamber is well pressurized with additional OVD because some invariably leaks out during trypan blue staining. (3) Puncture the anterior capsule centrally with a 25-gauge needle, bevel-down, attached to a 3 cc syringe with the needle passed through a paracentesis.2 Withdraw some liquid cortex by pulling on the plunger of the syringe, staying anterior to the nucleus. (4) Once the bag is decompressed, create a capsulorhexis with a forceps. Aim for a slightly smaller capsulorhexis (4.0 mm) so that if radialization occurs, recovery can be achieved. (5) Perform phacoemulsification with a vertical chopping technique. Horizontal chopping should probably be avoided because there is no solid cortex protecting the posterior capsule. A dispersive OVD could be injected behind the nucleus to protect the posterior capsule during phacoemulsification. (6) After IOL insertion, perform very complete irrigation/aspiration (I/A) to remove all OVD and as much residual lens protein and cellular debris as possible. Brock K. Bakewell, MD Tucson, Arizona, USA REFERENCES 1. American Academy of Ophthalmology. Basic and Clinical Science Course. Lens and Cataract, Section 11, 2008–2009. San Francisco, CA, American Academy of Ophthalmology, 2008 2. Figueiredo CG, Figueiredo J, Figueiredo GB. Brazilian technique for prevention of the Argentine flag sign in white cataract. J Cataract Refract Surg 2012; 38:1531–1536
OTHER CITED MATERIAL A. Alan S. Crandall, MD and Robert J. Cionni, MD, personal communication, November 2013 and February 2014, respectively
- This patient presents with elevated IOP and an anterior chamber reaction in the setting of a hypermature cataract. Although other processes, such as phacomorphic or uveitic glaucoma, should be considered, this presentation is most consistent with a diagnosis of phacolytic glaucoma. In phacolytic glaucoma, highmolecular-weight lens proteins from a hypermature cataract leak through an intact lens capsule, inciting an anterior chamber reaction through the recruitment of a large number of macrophages. The lens protein and engorged macrophages subsequently obstruct conventional outflow through the trabecular meshwork, resulting in markedly elevated IOP and glaucomatous damage to the optic nerve. The definitive treatment for this type of glaucoma is removal of the lens. Preoperatively, keratometry, an A-scan ultrasound, and a complete ophthalmic examination should be performed with close attention to any amount of
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phacodonesis. Because no view of the posterior segment can likely be obtained with ophthalmoscopy, we would also perform a B-scan ultrasound to rule out gross pathology, such as retinal detachment or an intraocular mass. The presence of severe optic nerve cupping may also be noted on B-scan and would provide some means of estimating the severity of glaucoma and visual potential of the eye. We would try to obtain old records to help define the patient’s history and determine the visual prognosis. We would also initiate topical aqueous suppressants and aggressive topical corticosteroids to reduce the IOP and calm the anterior chamber inflammation. Surgically, we would anticipate poor zonular stability and a fragile, potentially pressurized capsule. We would choose retrobulbar, rather than topical, anesthesia in preparation for a more complex case. To aide with visualization of the capsulorhexis, we would stain the capsule with trypan blue. We would then completely fill the anterior chamber with a cohesive OVD to flatten the anterior capsule as much as possible and minimize radial tension in the region of the planned capsulorhexis. A 27-gauge needle on a syringe would then be used to puncture the capsule centrally and depressurize the bag via controlled suction of liquefied cortex. These steps would likely decrease the risk for sudden splitting of a pressurized capsule with posterior tear extension. After capsulorhexis creation, the liquefied cortical material would likely be easily aspirated, leaving little, if any, cortex and the extremely dense nucleus in the capsular bag. We would reapply a dispersive OVD to protect the endothelium and capsular bag before phacoemulsification. If zonular integrity were in question, a capsular tension ring (CTR) would be placed. We would proceed with manual disassembly of the nucleus with horizontal chop maneuvers to minimize the amount of phacoemulsification used inside the eye. If the nucleus were too dense to disassemble safely inside the eye, we would convert to a small-incision ECCE technique. We would then place a posterior chamber IOL. At the conclusion of such a case, we would administer a subconjunctival–sub-Tenon steroid and plan for a prolonged course of topical steroids postoperatively, with close monitoring of the IOP. Zachary Zavodni, MD Sherman Reeves, MD, MPH Minneapolis, Minnesota, USA - This patient has typical findings of phacolytic glaucoma in an eye with a Morgagnian cataract. Liquefied lens proteins are leaking through the intact lens capsule and causing the IOP to rise. These proteins,
J CATARACT REFRACT SURG - VOL 40, JULY 2014
anterior vitreous face if there is zonular loss. This can result in a significantly reduced red reflex, making visualization more difficult once the liquid cortex is removed. (2) Make sure the anterior chamber is well pressurized with additional OVD because some invariably leaks out during trypan blue staining. (3) Puncture the anterior capsule centrally with a 25-gauge needle, bevel-down, attached to a 3 cc syringe with the needle passed through a paracentesis.2 Withdraw some liquid cortex by pulling on the plunger of the syringe, staying anterior to the nucleus. (4) Once the bag is decompressed, create a capsulorhexis with a forceps. Aim for a slightly smaller capsulorhexis (4.0 mm) so that if radialization occurs, recovery can be achieved. (5) Perform phacoemulsification with a vertical chopping technique. Horizontal chopping should probably be avoided because there is no solid cortex protecting the posterior capsule. A dispersive OVD could be injected behind the nucleus to protect the posterior capsule during phacoemulsification. (6) After IOL insertion, perform very complete irrigation/aspiration (I/A) to remove all OVD and as much residual lens protein and cellular debris as possible. Brock K. Bakewell, MD Tucson, Arizona, USA REFERENCES 1. American Academy of Ophthalmology. Basic and Clinical Science Course. Lens and Cataract, Section 11, 2008–2009. San Francisco, CA, American Academy of Ophthalmology, 2008 2. Figueiredo CG, Figueiredo J, Figueiredo GB. Brazilian technique for prevention of the Argentine flag sign in white cataract. J Cataract Refract Surg 2012; 38:1531–1536
OTHER CITED MATERIAL A. Alan S. Crandall, MD and Robert J. Cionni, MD, personal communication, November 2013 and February 2014, respectively
- This patient presents with elevated IOP and an anterior chamber reaction in the setting of a hypermature cataract. Although other processes, such as phacomorphic or uveitic glaucoma, should be considered, this presentation is most consistent with a diagnosis of phacolytic glaucoma. In phacolytic glaucoma, highmolecular-weight lens proteins from a hypermature cataract leak through an intact lens capsule, inciting an anterior chamber reaction through the recruitment of a large number of macrophages. The lens protein and engorged macrophages subsequently obstruct conventional outflow through the trabecular meshwork, resulting in markedly elevated IOP and glaucomatous damage to the optic nerve. The definitive treatment for this type of glaucoma is removal of the lens. Preoperatively, keratometry, an A-scan ultrasound, and a complete ophthalmic examination should be performed with close attention to any amount of
1243
phacodonesis. Because no view of the posterior segment can likely be obtained with ophthalmoscopy, we would also perform a B-scan ultrasound to rule out gross pathology, such as retinal detachment or an intraocular mass. The presence of severe optic nerve cupping may also be noted on B-scan and would provide some means of estimating the severity of glaucoma and visual potential of the eye. We would try to obtain old records to help define the patient’s history and determine the visual prognosis. We would also initiate topical aqueous suppressants and aggressive topical corticosteroids to reduce the IOP and calm the anterior chamber inflammation. Surgically, we would anticipate poor zonular stability and a fragile, potentially pressurized capsule. We would choose retrobulbar, rather than topical, anesthesia in preparation for a more complex case. To aide with visualization of the capsulorhexis, we would stain the capsule with trypan blue. We would then completely fill the anterior chamber with a cohesive OVD to flatten the anterior capsule as much as possible and minimize radial tension in the region of the planned capsulorhexis. A 27-gauge needle on a syringe would then be used to puncture the capsule centrally and depressurize the bag via controlled suction of liquefied cortex. These steps would likely decrease the risk for sudden splitting of a pressurized capsule with posterior tear extension. After capsulorhexis creation, the liquefied cortical material would likely be easily aspirated, leaving little, if any, cortex and the extremely dense nucleus in the capsular bag. We would reapply a dispersive OVD to protect the endothelium and capsular bag before phacoemulsification. If zonular integrity were in question, a capsular tension ring (CTR) would be placed. We would proceed with manual disassembly of the nucleus with horizontal chop maneuvers to minimize the amount of phacoemulsification used inside the eye. If the nucleus were too dense to disassemble safely inside the eye, we would convert to a small-incision ECCE technique. We would then place a posterior chamber IOL. At the conclusion of such a case, we would administer a subconjunctival–sub-Tenon steroid and plan for a prolonged course of topical steroids postoperatively, with close monitoring of the IOP. Zachary Zavodni, MD Sherman Reeves, MD, MPH Minneapolis, Minnesota, USA - This patient has typical findings of phacolytic glaucoma in an eye with a Morgagnian cataract. Liquefied lens proteins are leaking through the intact lens capsule and causing the IOP to rise. These proteins,
J CATARACT REFRACT SURG - VOL 40, JULY 2014
