ASCRS News
September 2021

The Ophthalmology Quicksand Chronicles podcast, hosted by Elizabeth Yeu, MD, and Nicole Fram, MD, has featured some interesting guests over the past couple of months. These experts shared their “quicksand moments” in the OR, lessons learned from those moments, and how these vulnerable situations ultimately helped them evolve as surgeons. 

“The Mature Intumescent Lens: Eye Cried For Me, Argentina!”

Drs. Yeu and Fram welcomed Rosa Braga-Mele, MD, to share a case of a white cataract and the Argentinian flag sign. Dr. Braga-Mele said it was meant to teach a resident how to handle a white cataract. She stained the lens with trypan blue, noting that when she stains with this, she will put in a little viscoelastic, about half of the anterior chamber, then paint the trypan blue across. She refills with viscoelastic, and the trypan blue gets pushed to the side (about 0.1 cc will go into eye).

Using a 27-gauge needle and overfilling the chamber with dispersive viscoelastic, Dr. Braga- Mele began decompressing the cortex. She was trying to avoid the chance of the Argentinian flag sign, but it happened, and she said she knew the exact reason why. As she was decompressing, the patient coughed. Dr. Braga-Mele said she uses “verbal anesthesia,” warning the patient when she’s going in with the needle and possibly sedating the patient a bit more.

In this case, Dr. Braga-Mele decided to put in dispersive viscoelastic underneath the flaps, overfilled the chamber with viscoelastic, and impaled the lens to bring it up and out over the iris. She noted that she was removing the lens without chopping it because she wanted to be careful not to have any nuclear fragments floating around in case the posterior capsule was not intact.

“The eye will always humble you,” she said, adding that it’s all about how you react to it. The key in situations like this is to not panic and to react appropriately, she said, recommending maintaining the chamber all the time to minimize the amount of damage.

Dr. Braga-Mele put in the lens, which she let unfold in the anterior chamber to get it into place.

Dr. Yeu pointed out that a three-piece lens may not be a good choice in this situation because there is too much positive pressure, and Dr. Braga-Mele agreed that she would use a single-piece lens. 

After the lens was in the bag, she hydrated the incisions, noting that it’s important to decrease the amount of decompression and use gentle, low-flow removal of viscoelastic. The patient ended up with a good outcome postop.

“Humbling Hurdles of IOL Fixation”

Brandon Ayres, MD, shared a case where he was asked to consult and perform surgery on a fellow eyecare professional whose multifocal IOL dislocated when he was hit with a ricocheted golf ball. The patient loved the multifocal and wanted to keep it. 

The patient flew up from Florida and bought his own biometry and IOLs with him. At the slit lamp the day before surgery, the lens was clearly dislocated in the capsular bag.

The plan was to do a pars plana vitrectomy no matter what. Dr. Ayres put in a trocar to ensure he had access to the chamber, and the case generally went well. His main concern was to get the implant centered. 

The real issue came several days later when Dr. Ayres received a follow-up text from his patient saying: “I was doing great over the weekend but this morning my vision has changed.” The text was accompanied by what looked like a slit lamp picture from a smartphone with the IOL sideways. 

Dr. Ayres immediately found a time on his next OR day for the patient to come back, but he admitted that he was puzzled by this outcome and to this day doesn’t know what happened.

He noted that if the patient was not an eyecare professional, he wouldn’t have kept the multifocal IOL in.

When the patient came back for a follow-up procedure, the lens looked twisted, and the haptic was completely upside down. Dr. Ayres ended up explanting the lens and replacing it with another multifocal IOL that the patient had brought with him.

Despite a successful surgery, Dr. Ayres wasn’t 100% happy with the outcome because of the multifocal platform that was used, but he said the patient was happy postop and was 20/30 uncorrected on postop day 1.

To watch/listen to the full episodes, go to ascrs.org/clinical-education/podcasts-qc.