Cataract surgical crises
A Sunday afternoon session focused on cataract surgical crises. It was moderated by David F. Chang, MD, and Surendra Basti, MD.
Nick Mamalis, MD, shared a case of a 70-year-old male on tamsulosin. During the case, he noted that he had no Omidria (ketorolac and phenylephrine, Rayner) or Malyugin rings (MicroSurgical Technology) available. There was good pupil dilation at the beginning of the case, and Dr. Mamalis proceeded with surgery, noting that he was working with a resident on this case.
The pupil was looking fine, and a good rhexis was created. The pre-chop technique was used, but Dr. Mamalis noted that it didn’t quite get deep enough, so a second instrument was used to make sure the chop went all the way through. Then, iris prolapse occurred.
Dr. Chang questioned panelist Boris Malyugin, MD, PhD, when it would be too late to put in a Malyugin ring.
Dr. Malyugin didn’t think it was too late in this case, and he said he would be considering a mechanical pupil strategy but noted that you have to be cautious because the capsulorhexis had been done, and it’s easy to catch the edge of it with the ring or an iris hook.
Panelist Sonia Yoo, MD, said when you have a capsulorhexis, it might be beneficial to use elective pupil hooks, rather than a ring, in order to ensure you don’t capture the edge of the capsulorhexis and create a tear.
Proceeding with the case, Dr. Mamalis noted that he and his resident didn’t do that. They tried to crack the nucleus to chop it a bit and were bringing up the pieces carefully, and he started to see some red reflex. They then encountered PCR.
Dr. Yoo noted the importance of injecting dispersive viscoelastic into a second sideport to tamponade any vitreous, before you withdraw the instrument.
Dr. Mamalis put OVD in, and he thought the hyaloid face was intact. They lifted the nucleus up partially in front of the iris, and he told the resident to get a grip on the nucleus and bring it forward slowly. As the last piece was coming out slowly, he realized that the hyaloid face was not completely intact. They came out of the eye again, and he had the resident put in a second port, avoiding the surgical wound to try to keep the chamber formed. They had to clear it out to see if they could get all the strands out. They came in from the sideport and put in OVD first this time, so it didn’t extend.
Dr. Mamalis said you have to be careful because you don’t want the haptic to go into the bag. You can put it into the ciliary sulcus but not in the bag. Once the haptics were in, Dr. Mamalis said they could perform optic capture because the capsulotomy was still intact.
Offering tips when putting in iris retractors, Dr. Yoo recommended dilating at the beginning of the case. You know the pupil will come down during the case, and the denser the cataract, the longer the case will take, she said.
Mitchell Weikert, MD, presented a case of “globe warming,” sharing about his 84-year-old male patient who had a dense cataract and small pupil. Dr. Weikert used iris retractors to expand, stained the capsule, and did the capsulorhexis. As he proceeded with doing phaco on the nucleus, he got wound burn.
So, what are the next steps? Dr. Malyugin said he would assess the integrity of the wound to see if it’s possible to continue with phaco without losing too much irrigation fluid. You might think about making a new incision, he said.
Dr. Weikert used the same incision in his case because he got a good seal with the phaco. The reason this happened was because there was too much dispersive OVD when he started. With dense lenses, it can be difficult to chop. Each time he goes in and out, he fills with more OVD. With dense lenses, once you separate the pieces, it’s not too bad, Dr. Weikert said.
Dr. Yoo commented on options for closing the incision, saying that a mattress suture could potentially be used.
Dr. Weikert sutured the incision using interrupted sutures. He noted that he was not trying to close the incision completely with the first suture. He wanted to titrate the tension, so he didn’t stress one suture too much. The main incision seemed to be sealed, but he was having issues with the suture track and ended up using sealant.
Dr. Weikert said he waited a long time to take these sutures out—6 weeks or more, and he didn’t take them all out at once. The patient had a moderate amount of astigmatism and responded to a corneal relaxing incision on the opposite side of the cornea.
Douglas Koch, MD, shared his case of “Why is the chamber shallow?” He first discussed how to manage a shallow anterior chamber, noting that there are tools to handle this at the beginning of surgery, like mannitol, acetazolamide, etc. You can even use a pars plana vitrectomy.
But what about in the middle of the case? The case involved a 65-year-old patient, where his resident was operating, and Dr. Koch was guiding the case. The patient had sudden intense pressure in the middle of surgery. Dr. Koch tried using regular OVD then viscoadaptive, but nothing was staying in the eye.
Dr. Chang questioned panelists and the audience about what to do when you see a suddenly firm eye. Steven Safran, MD, said he would ask the patient if they’re having pain, which could be an indication of choroidal hemorrhage. He also suggested giving mannitol and waiting to see if things get better before proceeding.
Dr. Koch used indirect ophthalmoscope, and he said everything looked fine. They massaged the eye and saw no choroidal hemorrhage. They got the eye soft enough to proceed.
Dr. Koch and his resident were able to get the instruments in and do bimanual I/A. They removed the first half of the cortex, and the second half was being removed when they got PCR. Dr. Koch noted that he wasn’t sure how it happened. Because of the PCR, anterior vitrectomy was performed, and Dr. Koch said the case was progressing fine. They were preparing to put in a 3-piece lens, but suddenly there was choroidal hemorrhage when the lens was part of the way into the eye.
Dr. Koch offered several lessons from this case: assume that large mid-surgical pressure rise is effusion or hemorrhage, and stop and come back another day.
Editors’ note: Drs. Mamalis, Weikert, and Koch have no relevant financial interests.
‘The Zoster Eye Disease Randomized Clinical Trial’
Bennie Jeng, MD, gave an update during a cornea symposium on Sunday on zoster eye disease, sharing results from a large clinical trial. He noted that two papers were published on this earlier this year as well.
Herpes zoster is caused by reactivation of the varicella zoster virus, and there are approximately 1.2 million new cases of zoster in the U.S. annually. The problem is that over time, we’ve seen an increase in incidence of zoster, he said. Additionally, the age at presentation has also been dropping. It’s alarming to see that those who present younger than age 50 has almost doubled. Dr. Jeng added that around two-thirds of individuals have some sort of ocular manifestation. In those with ocular manifestations, recurrence is a real thing. On top of that, we worry about vision loss that can occur, he added.
Dr. Jeng described the double-masked, multicenter, randomized controlled trial. Immunocompetent adults ≥18 years of age were included, with a history of typical unilateral rash. Those included had an episode in their medical record within the year prior to enrollment of keratitis or iritis. The trial was randomized at a 1:1 ratio to suppressive valacyclovir 1,000 mg daily or placebo for 1 year of treatment and 18 months of follow-up, with study visits every 3 months. The study participants were randomized in four strata: age of onset of zoster (less than 60 years versus ≥60 years) and time since onset at enrollment (less than 6 months versus ≥6 months).
The first aim of the study was to evaluate whether or not 12 months of suppressive valacyclovir treatment, compared with placebo, delays the time to the first occurrence by 12 months of new or worsening of specific disease manifestations of HZO. The secondary endpoint was to evaluate whether there was a persistent treatment benefit at 18 months, 6 months after the cessation of treatment.
There were 95 centers participating in the study. Ultimately, 527 participants were randomized.
There are no significant treatment benefits in reducing new or worsening dendriform epithelial keratitis, stromal keratitis, endothelial keratitis, or iritis at the primary endpoint of 12 months of treatment, but there was a significant benefit for the secondary endpoint at 18 months.
Dr. Jeng also explained the Bayesian analysis that was done, which he said produces results that are more clinically meaningful by expressing findings as a “posterior” distribution of benefit and credible intervals. This allows clinicians to make decisions based on the likelihood that an intervention produces a specified effect size. Post-study or posterior probabilities provide a direct estimate of the probability that a hypothesis is true.
Dr. Jeng concluded by offering Zoster Eye Disease Study guidance for evidence-based clinical practice. He said that evidence supports suppressive valacyclovir treatment 1,000 mg daily for 1 year to reduce new or worsening keratitis or iritis in immunocompetent non-pregnant adults with good renal function. There is a significant benefit at 18 months, and those with recent onset within 6 months are more likely to benefit than in chronic herpes zoster.
Editors’ note: Dr. Jeng has no relevant financial interests.
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