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DENSE, DISLOCATED, BRUNESCENT CATARACT Approaching Cataract Surgery in a Monocular Patient

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DENSE, DISLOCATED, BRUNESCENT CATARACT Approaching Cataract Surgery in a Monocular Patient CATARACT SURGERY CASE FILES s DENSE, DISLOCATED, BRUNESCENT CATARACT Approaching cataract surgery in a monocular patient. BY ASHVIN AGARWAL, MS; MARJAN FARID, MD; P. DEE G. STEPHENSON, MD, FACS; AND AUDREY R. TALLEY ROSTOV, MD CASE PRESENTATION An 84-year-old Russian woman presents for a cataract surgery evaluation. The patient has a history of a failed graft, retinal detachment, and glaucoma in her right eye. Visual acuity is light perception in her right eye and count- ing fingers in her left. A slit-lamp examination of the patient’s left eye finds a dense cataract, an inferiorly dislocated lens, loose zonules, and phacodonesis (Figure). The cornea is clear, and endothelial cell density is normal. B-scan ultrasonography shows no retinal detachment. The IOP measures 15 mm Hg. Examination reveals no other significant findings. How would you proceed? What form of anesthesia would you use? What would your preferences be in terms of surgical technique and IOL? —Case prepared by Audrey R. Talley Rostov, MD Figure. Examination of the patient’s left eye shows a dense cataract and loose zonules. I would begin by making a conjuncti- were well tucked into the Scharioth val peritomy at the 3 and 9 clock hours tunnels, I would seal them with glue. I and two partial-thickness scleral flaps would end the case with pupilloplasty located 180º apart. I would also create to optimize the outcome. the SICS tunnel but leave it unopened. ASHVIN AGARWAL, MS After performing continuous curvilinear capsulorhexis, in order to ensure that Because the patient is almost blind the zonules were manipulated as little as and her right eye has undergone mul- possible, I would pull the lens into the tiple surgeries, I would first attempt to anterior chamber. Next, I would open restore some vision in her left eye. It the SICS wound and extract the lens MARJAN FARID, MD has a diseased bag-lens complex and using a viscoexpulsion technique, which, a progressive condition that threatens in my experience, minimizes stress on A controlled plan of action would the longevity of the bag-IOL complex. the zonules. Examination with iris hooks be extremely important in this My procedures of choice would be might then be warranted. case. The first steps would be to set manual small-incision cataract surgery I would use the space under each realistic expectations for the patient (SICS) to explant the cataractous lens, scleral flap to make a sclerotomy, and to select the correct approach followed by intrascleral haptic fixation which I would then use to perform to anesthesia. I would explain to the of an IOL (glued IOL technique) under anterior vitrectomy and externalize the patient the severity of her situation and peribulbar anesthesia. haptics. After ensuring that the haptics make sure she understood that a second OCTOBER 2018 | CATARACT & REFRACTIVE SURGERY TODAY 27 s CATARACT SURGERY CASE FILES surgery with a team of retina doctors will longer than usual, and I would be pre- be necessary if the cataract cannot be pared for supplemental anesthesia to be safely removed via an anterior approach. necessary. Having retina colleagues available on The patient is at increased risk of WHAT I DID: AUDREY R. standby would be a good idea. complications, additional surgery may TALLEY ROSTOV, MD The degree of zonular laxity and loss be needed, and her recovery time will ultimately determine the overall and use of medication are likely to be Owing to some medical issues, the success of this case through an anterior longer than usual. It will be important patient waited 4 months before schedul- approach. I would use a femtosecond to explain all of these things to the ing cataract surgery. At that point, the laser to create a capsulotomy centered patient before proceeding. lens nucleus had dropped entirely into on the lens and to perform nuclear The maturity of the lens will require the vitreous. Based on the medical com- fragmentation. I would employ capsular a larger capsulotomy (5.5–6 mm) plexity of the case (eg, cardiac issues and hooks to help center the lens-capsule than I typically create. The Zepto concerns about general anesthesia), the complex and maintain its centration Capsulotomy System (Mynosys Cellular retina specialist decided to observe cata- and stability. I would perform nuclear Devices) could be useful in this case. My ract surgery rather than schedule a joint disassembly with a slow and deliberate preference, however, would be to use a procedure. I selected an anterior cham- chopping technique, being careful femtosecond laser (Lensar Laser System, ber IOL, which was also the preference to minimize stress on the remaining Lensar) for the capsulotomy because it of the retina surgeon. My choice of IOL zonules. A capsular tension ring can be customized to the density of the reflects my concern that potential future might help to stabilize localized areas cataract. I would check that the capsule retinal surgery could disturb the implant. of zonular weakness, but I prefer to was free-floating; if I was unsure, I would Cataract surgery was uneventful, insert the device as late as possible to stain it with trypan blue dye. and the patient had 20/40 UCVA minimize trapping of cortical material I would perform gentle hydrodis- postoperatively. n around the capsular equator, which section. Because this type of cataract can then be difficult to remove with tends to be fibrous or leathery at irrigation and aspiration. the posterior portion of the lens, SECTION EDITOR AUDREY R. TALLEY ROSTOV, MD If I was able to safely remove the the miLoop (IanTech) might help to n Private practice, Northwest Eye Surgeons, Seattle nucleus in its entirety through an cleave the lens into pieces. Care must n Medical advisory board, SightLife, Seattle anterior approach, I would then use be taken not to press down with this n Member, CRST Editorial Advisory Board an Ahmed Capsular Tension Segment device and thus damage the zonules. n [email protected] (CTS, Morcher, US distributor FCI I would protect the endothelium n Financial disclosure: Consultant (Alcon, Bausch + Lomb) Ophthalmics) with scleral fixation to with a dispersive OVD and monitor ASHVIN AGARWAL, MS stabilize the intact capsule. In some the zonules as cataract surgery pro- n Executive Director and Chief of Clinical Services, cases, two or even three CTSs may gressed. I would have at the ready iris Dr. Agarwal’s Eye Hospital, Chennai, India be needed to create 360º stability of hooks, capsular tension rings, CTSs, n [email protected] the capsule complex. My preference and pupil expanders. I would also n Financial disclosure: None would be a three-piece IOL because its have more than one type of IOL avail- spring-like haptics would provide some able in anticipation of various pos- MARJAN FARID, MD tension within the capsule. A three- sible circumstances (eg, sulcus fixation n Director of Cornea, Cataract, and Refractive piece IOL would also allow scleral or with optic capture, scleral fixation Surgery; Vice-Chair of Ophthalmic Faculty; Director iris fixation if needed. of the IOL, or use of an anterior of the Cornea Fellowship Program; and Associate chamber IOL). Professor of Ophthalmology, Gavin Herbert Eye If all had gone well to this point, I Institute, University of California, Irvine would exercise caution during cortical n [email protected] removal so as to protect the posterior n Financial disclosure: Consultant (Allergan, Bio- capsule. If the bag and zonules were Tissue, CorneaGen, Johnson & Johnson Vision, Kala stable, I would place the IOL in the Pharmaceuticals, Shire) bag or perform reverse optic capture. P. DEE G. STEPHENSON, MD, FACS If the nucleus precipitated posteriorly, P. DEE G. STEPHENSON, MD, FACS I would insert an appropriately sized n Founder, Stephenson Eye Associates, Venice, Florida I would have more than one surgical and powered anterior chamber IOL n Member, CRST Editorial Advisory Board plan ready. No matter the technique, I and leave the rest of the case for a n [email protected] n would expect its execution to require retina specialist. Financial disclosure: None 28 CATARACT & REFRACTIVE SURGERY TODAY | OCTOBER 2018.
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