CONSULTATION SECTION
Cataract Surgical Problem Edited by Rupert M. Menapace, MD
An 80-year-old man sustained blunt contusional trauma to the right eye when he was manipulating a war explosive at the age of 12 years. He immediately lost vision in this eye. Vision partly recovered during the following months and deteriorated again to perception of light and hand movements. More recently, the patient has been increasingly bothered by photophobia. Almost 70 years after the trauma, the patient presents because of increasing photophobia in the injured eye. Findings are as follows: a very dense nuclear cataract, a large iridodialysis and zonular defect along 3 clock hours temporally, and circumscribed vitreous prolapse into the coloboma (Figures 1 and 2). Through the pseudopupil thus created, a normal retina and macula can be seen, indicating good visual potential. The crystalline lens appears slightly shrunken, with a thin and brittle lens capsule (Figure 2) and an undulating exposed equatorial contour (Figure 3). Tapping on the limbus does not cause the lens to move or tremble. The endothelial cell count (ECC) is within normal limits, the intraocular pressure (IOP) is 14 mm Hg, and the corneal astigmatism is +2.00 @ 90. The left eye has +3.00 diopters (D) of hyperopia with normal corrected distance visual acuity. The patient reports significant impairment and strongly desires surgery that would relieve the increasing photophobia, which was obviously caused by the slow secondary extension of the coloboma along with the progressive shrinkage of the cataractous lens. With this very hard nuclear cataract, large temporal iridodialysis and zonular dehiscence, circumscribed
Figure 1. Overview showing cataract and iridodialysis.
1930
Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
vitreous prolapse, and good visual potential and with photophobia being the patient’s primary complaint, what approach would you consider and prefer?
- I would begin by staining the vitreous with dilute triamcinolone. I would first attempt to push back the prolapsed vitreous with a cohesive ophthalmic viscosurgical device (OVD). If this were unsuccessful, I would proceed with a limited anterior vitrectomy. The zonular gap is large enough that one could direct the vitrector through the defect, making sure to be posterior to the lens equator to pull the vitreous from the anterior chamber. However, I would favor a pars plana approach, taking only enough to remove the vitreous from the anterior chamber. A vitrectomy that is too aggressive could make the lens more mobile and deepen the anterior chamber, making later maneuvers more difficult. Once the vitreous is removed, I would stain the anterior capsule. The lack of phacodonesis and the blunt shape of the lens indicate that the remaining zonular fibers are likely intact. It is important to begin the capsulorhexis by pulling toward the area of zonular dialysis, using intact zonular fibers for countertraction. A micrograsping forceps could also be used for countertraction if necessary. Sometimes the anterior capsule becomes fibrotic, which may necessitate cutting with microscissors. If this leaves an irregularity in the capsulotomy, it may preclude the use of a capsular tension
Figure 2. Narrow slit-beam illumination highlights brittle capsule and dense nuclear cataract.
http://dx.doi.org/10.1016/j.jcrs.2014.09.004 0886-3350
CONSULTATION SECTION
1931
target would have to occur before surgery to decide between mild hyperopia to avoid anisometropia or emmetropia with the plan of correction in the fellow eye in the near future. David A. Crandall, MD Detroit, Michigan, USA
REFERENCES
Figure 3. Close-up view of the coloboma and undulated contour of lens equator.
ring (CTR) or capsular tension segment (CTS). Given the good dilation, I would consider femtosecond laser creation of the capsulotomy, although there is debate over the strength compared with a manual capsulorhexis.1,2 I would use viscodissection to free the lens and expand the capsule, especially in the temporal area, creating a pseudo-CTR. The lens in this area can be very adherent to the capsule, so it may take multiple attempts to free it completely. I would plan on chopping, avoiding maneuvers that would put further strain on the zonular fibers near the dialysis. During cortex removal, I would pull toward the zonular defect and tangentially, rather than centrally. Once the lens is removed, a CTR can be placed. Zonular dialysis in these cases is often more than what can be seen clinically, so I would expect more than 3 clock hours of extension. However, there may be enough support that the lens is stable and well centered without further support. If not, an Ahmed CTS sutured to the sclera under a flap with 8-0 polytetrafluoroethylene (Gore-Tex) would stabilize and center the lens.3 I would close the iridodialysis to reduce glare and prevent diplopia from polycoria. I would use an ab interno approach with 10-0 polypropylene sutures; 3 sutures would likely be required for a defect this size.4 The external knots would be buried under a scleral flap. Alternatively, CTS suturing and iridodialysis repair could be performed through a Hoffman pocket.5 Assuming the case has gone as planned, a toric intraocular lens would be my choice for correcting the astigmatism. A discussion about the refractive
1. Abell RG, Davies PEJ, Phelan D, Goemann K, McPherson ZE, Vote BJ. Anterior capsulotomy integrity after femtosecond laser-assisted cataract surgery. Ophthalmology 2014; 121:17–24 2. Friedman NJ, Palanker DV, Schuele G, Anderson D, Marcellino G, Seibel BS, Battle J, Feliz R, Talamo JH, Blumenkranz MS, Culbertson WW. Femtosecond laser capsulotomy. J Cataract Refract Surg 2011; 37:1189–1198; erratum, 1742 3. Slade DS, Hater MA, Cionni RJ, Crandall AS. Ab externo scleral fixation of intraocular lens. J Cataract Refract Surg 2012; 38:1316–1321 4. Snyder ME, Lindsell LB. Nonappositional repair of iridodialysis. J Cataract Refract Surg 2011; 37:625–628 5. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg 2006; 32:1907–1912. Available at: http://www.finemd.com/reprints/Scleral%20Fix ation%20Without%20Conjunctival%20Dissection.pdf. Accessed August 30, 2014
- Before proceeding with surgical rehabilitation of this eye, the patient should be warned of the possibility of limited visual recovery, diplopia, and persistent photophobia as a result of removal of this dense cataract and restoration of vision. The patient and surgeon will be most comfortable with surgery performed under a peribulbar or retrobulbar block. Repair of the iridodialysis should be performed first. A paracentesis placed at the inferonasal limbus will allow a dispersive OVD to be used to help reposition the prolapsed vitreous behind the lens equator. This would be preferable to a limited limbal or pars plana vitrectomy because the removal of vitreous would eliminate some of the posterior support for the lens and potentially encourage further zonular dialysis during phacoemulsification. If the vitreous cannot be pushed back, a limited bimanual vitrectomy will be required before the iridodialysis is repaired. The dialysis can be easily repaired by creating a temporal corneoscleral pocket from a 350 mm deep temporal grooved incision. A double-armed 10-0 polypropylene suture on a long curved needle can be passed through the inferonasal paracentesis, passed through the iris root of the iridodialysis, and then passed out through the full thickness of the globe corresponding to the dissected scleral pocket (2.0 mm posterior to the limbus). Passing the 2 sutures through the iris edge so that each pass trisects the dialysis will allow it to close
J CATARACT REFRACT SURG - VOL 40, NOVEMBER 2014
Cataract Surgical Problem Edited by Rupert M. Menapace, MD
An 80-year-old man sustained blunt contusional trauma to the right eye when he was manipulating a war explosive at the age of 12 years. He immediately lost vision in this eye. Vision partly recovered during the following months and deteriorated again to perception of light and hand movements. More recently, the patient has been increasingly bothered by photophobia. Almost 70 years after the trauma, the patient presents because of increasing photophobia in the injured eye. Findings are as follows: a very dense nuclear cataract, a large iridodialysis and zonular defect along 3 clock hours temporally, and circumscribed vitreous prolapse into the coloboma (Figures 1 and 2). Through the pseudopupil thus created, a normal retina and macula can be seen, indicating good visual potential. The crystalline lens appears slightly shrunken, with a thin and brittle lens capsule (Figure 2) and an undulating exposed equatorial contour (Figure 3). Tapping on the limbus does not cause the lens to move or tremble. The endothelial cell count (ECC) is within normal limits, the intraocular pressure (IOP) is 14 mm Hg, and the corneal astigmatism is +2.00 @ 90. The left eye has +3.00 diopters (D) of hyperopia with normal corrected distance visual acuity. The patient reports significant impairment and strongly desires surgery that would relieve the increasing photophobia, which was obviously caused by the slow secondary extension of the coloboma along with the progressive shrinkage of the cataractous lens. With this very hard nuclear cataract, large temporal iridodialysis and zonular dehiscence, circumscribed
Figure 1. Overview showing cataract and iridodialysis.
1930
Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
vitreous prolapse, and good visual potential and with photophobia being the patient’s primary complaint, what approach would you consider and prefer?
- I would begin by staining the vitreous with dilute triamcinolone. I would first attempt to push back the prolapsed vitreous with a cohesive ophthalmic viscosurgical device (OVD). If this were unsuccessful, I would proceed with a limited anterior vitrectomy. The zonular gap is large enough that one could direct the vitrector through the defect, making sure to be posterior to the lens equator to pull the vitreous from the anterior chamber. However, I would favor a pars plana approach, taking only enough to remove the vitreous from the anterior chamber. A vitrectomy that is too aggressive could make the lens more mobile and deepen the anterior chamber, making later maneuvers more difficult. Once the vitreous is removed, I would stain the anterior capsule. The lack of phacodonesis and the blunt shape of the lens indicate that the remaining zonular fibers are likely intact. It is important to begin the capsulorhexis by pulling toward the area of zonular dialysis, using intact zonular fibers for countertraction. A micrograsping forceps could also be used for countertraction if necessary. Sometimes the anterior capsule becomes fibrotic, which may necessitate cutting with microscissors. If this leaves an irregularity in the capsulotomy, it may preclude the use of a capsular tension
Figure 2. Narrow slit-beam illumination highlights brittle capsule and dense nuclear cataract.
http://dx.doi.org/10.1016/j.jcrs.2014.09.004 0886-3350
CONSULTATION SECTION
1931
target would have to occur before surgery to decide between mild hyperopia to avoid anisometropia or emmetropia with the plan of correction in the fellow eye in the near future. David A. Crandall, MD Detroit, Michigan, USA
REFERENCES
Figure 3. Close-up view of the coloboma and undulated contour of lens equator.
ring (CTR) or capsular tension segment (CTS). Given the good dilation, I would consider femtosecond laser creation of the capsulotomy, although there is debate over the strength compared with a manual capsulorhexis.1,2 I would use viscodissection to free the lens and expand the capsule, especially in the temporal area, creating a pseudo-CTR. The lens in this area can be very adherent to the capsule, so it may take multiple attempts to free it completely. I would plan on chopping, avoiding maneuvers that would put further strain on the zonular fibers near the dialysis. During cortex removal, I would pull toward the zonular defect and tangentially, rather than centrally. Once the lens is removed, a CTR can be placed. Zonular dialysis in these cases is often more than what can be seen clinically, so I would expect more than 3 clock hours of extension. However, there may be enough support that the lens is stable and well centered without further support. If not, an Ahmed CTS sutured to the sclera under a flap with 8-0 polytetrafluoroethylene (Gore-Tex) would stabilize and center the lens.3 I would close the iridodialysis to reduce glare and prevent diplopia from polycoria. I would use an ab interno approach with 10-0 polypropylene sutures; 3 sutures would likely be required for a defect this size.4 The external knots would be buried under a scleral flap. Alternatively, CTS suturing and iridodialysis repair could be performed through a Hoffman pocket.5 Assuming the case has gone as planned, a toric intraocular lens would be my choice for correcting the astigmatism. A discussion about the refractive
1. Abell RG, Davies PEJ, Phelan D, Goemann K, McPherson ZE, Vote BJ. Anterior capsulotomy integrity after femtosecond laser-assisted cataract surgery. Ophthalmology 2014; 121:17–24 2. Friedman NJ, Palanker DV, Schuele G, Anderson D, Marcellino G, Seibel BS, Battle J, Feliz R, Talamo JH, Blumenkranz MS, Culbertson WW. Femtosecond laser capsulotomy. J Cataract Refract Surg 2011; 37:1189–1198; erratum, 1742 3. Slade DS, Hater MA, Cionni RJ, Crandall AS. Ab externo scleral fixation of intraocular lens. J Cataract Refract Surg 2012; 38:1316–1321 4. Snyder ME, Lindsell LB. Nonappositional repair of iridodialysis. J Cataract Refract Surg 2011; 37:625–628 5. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg 2006; 32:1907–1912. Available at: http://www.finemd.com/reprints/Scleral%20Fix ation%20Without%20Conjunctival%20Dissection.pdf. Accessed August 30, 2014
- Before proceeding with surgical rehabilitation of this eye, the patient should be warned of the possibility of limited visual recovery, diplopia, and persistent photophobia as a result of removal of this dense cataract and restoration of vision. The patient and surgeon will be most comfortable with surgery performed under a peribulbar or retrobulbar block. Repair of the iridodialysis should be performed first. A paracentesis placed at the inferonasal limbus will allow a dispersive OVD to be used to help reposition the prolapsed vitreous behind the lens equator. This would be preferable to a limited limbal or pars plana vitrectomy because the removal of vitreous would eliminate some of the posterior support for the lens and potentially encourage further zonular dialysis during phacoemulsification. If the vitreous cannot be pushed back, a limited bimanual vitrectomy will be required before the iridodialysis is repaired. The dialysis can be easily repaired by creating a temporal corneoscleral pocket from a 350 mm deep temporal grooved incision. A double-armed 10-0 polypropylene suture on a long curved needle can be passed through the inferonasal paracentesis, passed through the iris root of the iridodialysis, and then passed out through the full thickness of the globe corresponding to the dissected scleral pocket (2.0 mm posterior to the limbus). Passing the 2 sutures through the iris edge so that each pass trisects the dialysis will allow it to close
J CATARACT REFRACT SURG - VOL 40, NOVEMBER 2014
