- Presentations on capsular issues
- Cases of loose zonules
- Handling wound burn
- Zonular loss after a car accident
- Kelman Lecture
Presentations on capsular issues
Monday morning at the AAO Annual Meeting featured a 4-hour symposium on complications in cataract surgery. Moderator David Chang, MD, said 18 faculty members were asked to share not their surgical triumphs but their cases that didn’t go so well where there were lessons learned.
The first presentations addressed capsular complications. Jeff Pettey, MD, shared a case where he was showing a resident a grooving technique. As he was narrating to the resident, he emphasized how it’s important to not have an oily tear film, to have a clean view, then he saw “a nice red opening.” At this point, however, Dr. Pettey said he didn’t think it was a posterior capsule rent (PCR); there was not shallowing of the anterior chamber that could indicate this.
Dr. Pettey said he treated it as a “fire drill” for a PCR, putting in viscoelastic and approaching the case with a slower technique and epinuclear setting to remove the fragments without rotation. He used a bowl and fold technique.
Later in the case it became obvious that there was a PCR. Dr. Pettey injected dispersive OVD, which ended up extending the rent. Fortunately, the epinucleus was far enough away from the rent that it could be safely phacoed with lower settings.
After the cataract was removed, Dr. Pettey made an alternate paracentesis, put in the vitrector, keeping the chamber full as he used a low level of aspiration to clear out the cortex. He didn’t see any vitreous. He removed the Malyugin ring he had used and inserted an IOL into the sulcus, using reverse optic capture.
He still had viscoelastic in the anterior chamber, but before removing, he closed the wound with a suture, prehydrated his wounds, and used diffuse hydration across the wounds while removing viscoelastic. This, he said, ensures that the chamber stays full. Immediately as he exited the eye, he hydrated the paracentesis. The case ended well with a 20/20 result.
Soosan Jacob, MD, took a look at a case that had an issue at the anterior capsule. The case involved a patient who had previous therapeutic PK and presented for cataract surgery and PDEK needed for graft decompensation. Dr. Jacob showed how she went in with a needle and touched the anterior capsule, resulting in a puncture.
From there she tried to initiate the rhexis from the other side to encircle the punch. She tried to take it around the tear, but the rhexis joined up with the tear and began to extend to the periphery—a “runaway rhexis.”
Dr. Jacob made a new incision and continued the rhexis with microscissors, taking it around and joining with the other point. She performed gentle hydrodissection, didn’t rotate, and was able to bring the nucleus out with a supracapsular chop phaco technique and the epinucleus with an I/A approach.
At this point, Dr. Jacob said to look at the edges of the tear. She noted that they were flapping outward. The edges of the tear being everted is a sign that the tear has not extended and that you could continue phaco with caution.
This is called the flap motility sign. If there is a wraparound tear, the hypothesis is that the flaps will go downward, while everted fluttering flaps suggest the tear does not extend around. To check this sign, Dr. Jacob said to place the phaco probe within the anterior chamber, not the capsular bag. Dr. Jacob also noted that more studies are needed to confirm the utility of the flap motility sign.
Dr. Jacob concluded with a few tips for cases with a rhexis tear, including avoid intracapsular maneuvers, avoid capsular stretch, use slow motion phaco, avoid chamber fluctuations, look for the flap motility sign, and make sure the IOL haptics are placed perpendicular to the tear. She said that 24–52% of anterior capsule tears result in posterior extensions and those who are unsure or unexperienced should consider converting to ECCE.
Editors’ note: Dr. Pettey and Dr. Jacob have no financial interests related to their comments.
Cases of loose zonules
The cataract symposium on Monday morning continued with several cases that addressed complications with loose zonules.
Mitchell Weikert, MD, presented a case that involved a white cataract with a prior pars plana vitrectomy. Dr. Weikert said the lens was dense and the anterior chamber was very deep. This might make you think there was a capsule violation, so that was in his mind going forward.
Trying to chop across, Dr. Weikert said that the resident he was working with was having trouble getting the lens to disassemble. The lens was not behaving as if it became white due to a prior capsule violation, so Dr. Weikert said the resident gently rotated and was able to groove and crack the lens into two. Half of the lens was removed, and it was going well, but then there was 4–5 clock hours of zonular dialysis.
Dr. Weikert said they tried to put in MST hooks but found it hard to engage and support the capsule because it was so deep. They filled with OVD and used that to support taking the rest of the lens out with delicate chopping, refilling multiple times with OVD.
After the nucleus was out, Dr. Weikert said they put in a CTR but had trouble getting it into the right place; at one point it was half in the bag and half out. Dr. Weikert took over the case at this point but said he couldn’t get it into the bag.
He tried to dilate it out, but the CTR got stuck in the anterior chamber.
“I don’t do MIGS, but I thought, let’s break out the gonio lens,” Dr. Weikert said.
After several attempts at trying to retrieve it, Dr. Weikert was able to successfully grab the CTR with microforceps and hook the eyelet with a Sinskey and dial it out. From there, he filled the bag but left the anterior chamber shallow and put in a 3-piece IOL.
Dr. Weikert’s take-home points were use a dispersive viscoelastic that can bolster limited areas of zonular loss for nuclear removal; fill the capsule and not too much of the anterior chamber for CTR insertion; and intraoperative gonioscopy is not just for MIGS.
Thomas Oetting, MD, also had a case of a dense lens and loose zonules. He put in retractors and after struggling with phaco, decided to use the miLOOP (Carl Zeiss Meditec). The miLOOP “skimmed the surface” and still left a dense nuclear core. So, Dr. Oetting went around with the filament again. At this point, the miLOOP got caught in one of the capsule retractors.
“We have a real problem now. Not only did it catch, but we also tore the anterior capsule with this process,” he said.
Dr. Oetting ended up converting to an ECCE and said the case turned out reasonably well with a 3-piece lens put in the sulcus.
“If you do this combination [miLOOP and capsule retractors], be really careful,” he said, noting that he has done this combination before without any trouble.
Editors’ note: Dr. Weikert and Dr. Oetting have no financial interests related to their comments.
Handling wound burn
Lisa Arbisser, MD, shared a case where she experienced wound burn. The case was initially going well, and Dr. Arbisser was using her usual vertical chop technique. She noted that she usually doesn’t chop through the posterior plate in a brunescent lens, but rather she looks for anterior break, which allows her to open the lens like a clam shell. Dr. Arbisser was able to finish her case but had noticed before finishing that something was going on at the wound, and it turned out that she had wound burn, which needed to be closed.
Panelist Richard Lindstrom, MD, noted that he didn’t initially see much wound burn in Dr. Arbisser’s video, but he noticed it when she took out the phaco tip. To handle this, he said to use a horizontal mattress suture, which will generally seal it quite well.
Dr. Arbisser was having a tough time closing the wound burn. She tried to use multiple sutures, but it was still leaking. She tried a deeper suture and described it as an “experiment in frustration.”
Though she did put in a horizontal mattress suture, she put it in the presence of three sutures that were trying to keep the lips together, so it didn’t work. Dr. Arbisser already had the lips approximated, but some tissue had shrunken away, so she had to take out the original mattress suture to start over. She decided to do a mattress suture after making a fornix-based flap that she would cover the incision with. She finally got it sealed and added that she also roughed up the tissue a bit so the flap would stick; she sutured down the flap and that allowed it to be very secure. Dr. Arbisser noted that since 2007, she has also used intracameral moxifloxacin off label for every case.
Audience members were polled about how often they have experienced wound burn, with 32% noting that they have never experienced wound burn, 45% saying 1–2 times, 13% 3–4 times, and 10% who had experienced wound burn more than 4 times.
At the end of the case, Dr. Arbisser suggested a few tips for burn prevention. She said to use an appropriate-sized incision. She also mentioned vigilance for occlusion. If wound burn does occur, early recognition is key.
Editors’ note: Dr. Arbisser has no related financial interests.
Zonular loss after a car accident
Uday Devgan, MD, though not present at the meeting, shared a case via video narration. His case featured zonular loss and a shallow anterior chamber.
Dr. Devgan noted that this was the second eye for the patient. He got a 5-mm rhexis done, and the cataract was not too dense; he was using the phaco probe to chop at the iris plane to get it out.
In the first eye, the patient had an extended depth of focus (EDOF) lens implanted, and the patient wanted the same in this eye. However, Dr. Devgan noted that the patient had been in a bad car accident and had been hit in the face with the airbag, causing an orbital fracture. As a result, there was zonular loss.
The tough part of the case, he said, was getting the cortex out because of zonular laxity. The anterior chamber was shallow and capsular bag was shallowing. There was fluid around the area of zonular loss, and the bag was super shallow.
Panelist Soon Phaik Chee, MD, said that, if she was proceeding in this case, her next action would depend on how shallow the chamber is and if she could still do viscodissection to release the cortex. She said she would use viscoelastic to cleave out the cortex and would put in a capsular hook at the area of zonular dialysis. She would then inject a CTR and would reassess to see if the chamber was deep enough to inject the lens into the capsular bag.
As Dr. Devgan proceeded with his case, he used a CTR. He put the IOL into the capsular bag and used cohesive viscoelastic to keep the bag open. Dr. Devgan noted in his video that he was worried that if he didn’t get the lens in at this point, it would be hard to get it into position later.
Then he began to remove the lens cortex but noted that it was difficult to remove. The amount of cortex left over looked reasonable.
But he switched to a disposable bimanual I/A set to have better access. The tips are nice and fine, so it’s easier to get in and clean up lens cortex, he said, adding that he ended with a beautifully centered EDOF lens and put in triamcinolone to make sure there was not any vitreous prolapse.
Editors’ note: Dr. Devgan and Dr. Chee have financial interests with several ophthalmic companies.
Kelman Lecture
Liliana Werner, MD, PhD, gave the Kelman Lecture titled “25 Years Evaluating New IOL Technology and Complications.” She was the first female recipient of this award.
She highlighted various studies, technologies, and other research areas she has focused on in her career. She noted how she has used rabbit models in evaluation of new IOL designs, materials, and technology. She also noted that she has been evaluating biocompatibility of interesting materials.
Dr. Werner discussed IOL designs and said that the square optic edge plays a prominent role in PCO prevention. In Germany, she studied the microedge structure of IOLs and said that she was surprised with the variability in this area among lenses that look different but are equally sold in the market as having square edges. She noted six factors to reduce PCO. Surgery-related factors include: hydrodissection-enhanced cortical clean-up, in-the-bag IOL fixation, and a capsulorhexis smaller than the diameter of the IOL optic. IOL-related factors include: a biocompatible IOL to reduce stimulation of cellular proliferation, contact between the IOL optic and the posterior capsule, and an IOL with a square, truncated optic edge.
Dr. Werner mentioned development of a number of different IOL designs, including a dual optic silicone accommodating IOL, a dual optic PMMA IOL with PVDF haptics, open bag IOL designs, and a silicone open bag fluid-filled modular IOL.
You can also prevent PCO by changing the relationship between the IOL and the capsular bag and eliminating contact between the IOL and the inner surface of the bag, like with the bag-in-the-lens concept, Dr. Werner said.
Dr. Werner went on to discuss analysis of explantation of IOLs, noting that this is one of her favorite areas of study. She has been working on the problem of calcification of hydrophilic acrylic IOLs for many years. Calcification of silicone lenses may occur in some eyes.
In-the-bag IOL dislocation is another topic that is studied in Dr. Werner’s lab. This problem is not restricted to one IOL design or material.
At the end of her lecture, Dr. Werner shared three lessons she has learned in her career: 1) we have to keep an open mind, 2) use a thorough scientific process, and 3) have constant vigilance regarding IOL-related complications.
Editors’ note: Dr. Werner has financial interests with a variety of ophthalmic companies, but none related to her lecture.
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