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Eyes Before Cataract Surgery

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Eyes Before Cataract Surgery HIGH-RISK EYES Recognising ‘high-risk’ eyes before cataract surgery Parikshit Gogate Mark Wood Head, Department of Paediatric Ophthalmology, Community Consultant Ophthalmologist, CCBRT Hospital, Eye Care, HV Desai Eye Hospital, Pune 411028, India. Box 23310, Dar es Salaam, Tanzania. Email: [email protected] Email: [email protected] Certain eyes are at a higher risk of compli- Conjunctivitis should be treated with cation during cataract surgery. Operations topical antibiotics prior to intraocular on such ‘high-risk’ eyes are also more likely surgery. to yield a poor visual outcome (defined as Noble Bruce best corrected vision less than 6/60 after Potential visualisation surgery).1 Learning to recognise when eyes are at problems during surgery greater risk, and acting accordingly, will help Corneal opacity you to avoid complications. Even so, before Leucoma-grade opacity will make your task the operation takes place, it is good practice Conjunctivitis extremely difficult. You will find it difficult to to explain to such patients that a poor see details, in particular the capsulotomy. outcome is a possibility. This makes these There may be residual lens matter • Measuring intraocular pressure. It is patients’ expectations more realistic and remaining in the bag, which will be difficult important to measure intraocular pressure improves postoperative compliance and to see. It will also be challenging to place in all patients, for example to identify follow-up. In most cases, patients who are the intraocular lens (IOL) in the posterior glaucoma. blind with complicated cataract will be chamber with both haptics under the iris. • A fundus examination. The fundus can happy with even a modest improvement of be seen through all but the densest Patients suffering from trachoma with their vision. cataracts. You can do a B-scan if the pannus, corneal dystrophy, degeneration, It is also important to have available all medium is not clear. and band-shaped keratopathy, have hazy the equipment you may need to manage a corneas. Raised intraocular pressure may possible complication, for example a Your examination should be able to identify cause epithelial oedema. Phenylephrine vitrectomy machine in the case of capsular problems or signs which indicate that the dilating drops, if used too frequently, may rupture and vitreous loss. operation may not be straightforward. cause epithelial haze. Even minimal corneal Depending on where you are in the During the examination, you will need to handling during surgery may decrease world, certain ‘high-risk’ eyes will be more pay attention to the following areas, which corneal clarity. common: for example, pseudoexfoliation in are discussed in this article: Older patients, and those with Fuchs’ Somalia and India, onchocerciasis in • infection dystrophy, uveitis, or glaucoma, may have a Sudan, and angle-closure glaucoma in Asia. • potential visualisation problems compromised endothelium; their corneas You will get to know your local problems as • anatomy of the anterior segment may decompensate after surgery. The use of you perform more operations. • crystalline lens profiles high-viscosity viscoelastics, such as Healon • other health conditions. GV (sodium hyaluronate), and minimal Before you operate anterior chamber manipulations may help preserve the endothelium.2,3 It may be Get an accurate patient history. In particular, Infection advisable to perform extracapsular cataract obtain information on trauma, previous Any infection in or around the eye could lead extraction (ECCE), rather than phacoemulsi- operations, diabetes, dry eye, amblyopia, to endophthalmitis; infections should fication or manual small incision cataract and congenital abnormalities. If the patient therefore be treated before surgery. surgery (SICS).4 has only one eye, it is necessary to find out If there is a central corneal scar obscuring A blocked and infected lacrimal sac may what caused the loss of the other eye. the pupil, an optical sector iridectomy may cause endophthalmitis. It is extremely Perform a thorough eye examination. be helpful. This should include: important to check the sac patency before surgery. If the sac has mucoid regurgitation, A small pupil • Measuring best corrected visual instil local antibiotic drops and postpone A small, rigid pupil poses a problem in both acuity. This will determine whether a surgery. A dacryocystectomy (DCT) or dacryo- ECCE and SICS. Any unnecessary manipu- potentially risky operation should be cystorhinostomy (DCR) may be done if lation of the iris can result in a small pupil. attempted or avoided. If the patient only antibiotics do not resolve the condition This will make it difficult to see residual lens has one eye, is the patient content with before surgery is to take place. his or her present vision? Be aware that matter, the position of the IOL, and the you could make it worse. Entropion, ectropion, and lagoph- • A slit lamp examination with dilated thalmos: these eyes may have corneal pupil. Many potential problems become exposure before and after surgery. visible when the pupil is dilated. A slit lamp Eyelashes rubbing on the eye are a source examination will identify most problems of infection. In such eyes, the postoperative you are liable to face during surgery, such use of steroids may precipitate a corneal Hogeweg Margreet as subluxated lenses. Check the maturity ulcer. In addition, lack of a proper lid closure of the lens, the condition of the capsule, mechanism will not allow the eye drops and whether the cataract really is the instilled to stay in the conjunctival sac. cause of the patient’s poor vision, before These three conditions need to be corrected deciding to perform a potentially risky by surgery before you can contemplate a Small pupil operation. cataract extraction. Copyright © 2008 Parikshit Gogate and Mark Wood. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. anterior capsule for capsulotomy. However, the nucleus can be very large and Traumatic cataracts can give nasty A small pupil can be dealt with in the the chamber deep. A deep anterior chamber surprises. The following steps may help you following ways: may be caused by a ‘reverse pupil block’. In deal with them: this situation, the iris should be raised from • Intracameral phenylephrine can be tried • Do an ultrasound B-scan before surgery. the capsule to even out the pressure; the first. • There may be corneal or iris tears that chamber depth will then return to normal.5 • A Sinskey hook or Y-shaped IOL dialler can need to be repaired. Make a small incision Viscoelastics help to maintain anterior be used to stretch the pupillary sphincter. at the 12 o’clock position and use air or chamber depth where necessary and to The instruments are placed 180° apart viscoelastic to form the anterior chamber ease the insertion of instruments. The entry and the pupil stretched right out to the before suturing the cornea. and exit of instruments should be kept to a limbus for ten seconds. • The anterior capsule may be broken or minimum. • If the pupil is still too small, a sphincter- torn. The tear can be extended as a CCC ectomy (three small radial cuts on the or an ‘envelope’ capsulotomy. sphincter pupillae, 120° apart) can be done Crystalline lens profiles • Keep the hydrodissection minimal, as there to facilitate nucleus delivery (Figure 1). The cataracts mentioned below will test a may be a posterior capsular tear. • Finally, iris hooks may be used to dilate surgeon’s skill, experience, and patience. In • If there is a posterior capsular tear, perform the pupil. ECCE, a capsular tension ring (CTR) can be dry aspiration under cover of viscoelastic. inserted after doing a continuous (complete) • Anterior vitrectomy is necessary if the If the surgeon is fastidious about having a circular capsulo rhexis (CCC) to stabilise the posterior capsule is torn. Try and preserve round pupil postoperatively, a small bag.6 Note that it is more important that the as much of the capsule as possible. peripheral iridectomy can be made and the CCC be ‘complete’ than it be ‘circular’, We normally do not put an IOL in at this cut extended to the pupillary margin (radial because an intact capsular margin ensures stage, but rather do this as a secondary iridotomy). The iridotomy can be sutured that the zonular tension is equally divided all procedure. later using 10-0 Prolene interrupted sutures around. Keep hydrodissection to a (Figure 2); this procedure demands consid- Membranous cataract occurs when the minimum. If you are using phacoemulsifi- erable skill and patience. However, this is lens matter has been absorbed and the cation, do it ‘in the bag’. If you are using not often required. anterior and posterior capsules fuse. ECCE or SICS, gently rotate the nucleus into A capsulotomy, possibly followed by an the anterior chamber (do not tumble) and Figure 1: Figure 2: Radial anterior vitrectomy, should clear the opacity. then deliver it outside the incision. All are Sphincterotomy for iridotomy Leave enough capsule to support an IOL. difficult procedures. It may be easier to a small, rigid pupil: sutured with This IOL will have to be placed in the sulcus. three cuts made 10.0 interrupted remove the lens (possible intracapsular 120° apart sutures extraction with vectis loop or lensectomy) and implant an anterior chamber lens. • Hard, dense nuclei are difficult to remove with phacoemulsification or SICS. You may prefer to do a routine extracap- sular extraction.4 • Hypermature cataracts have a small nucleus and a wrinkled capsule. Anterior (http://drsobol.com) Sobol Aaron capsulotomy may be difficult. • Milky cataract (Morganian): when Uveitis Anatomy of the anterior making the capsulotomy, the ‘milk’ from the cataract fills the anterior chamber, Uveitis causes synechiae and cataract. segment obscuring the surgeon’s view. The anterior Posterior synechiae can be gently separated Narrow anterior chambers capsulotomy may not be complete.
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