September 2009




In the nick of time: saving the best for last

by I. Howard Fine, M.D.


For my last column as editor of Perspectives of Lens in IOL Surgery, I was asked to write about some of the complicated cases that I thought I had managed unusually successfully; my so-called greatest saves. I hope you will find it interesting. I would like to offer my grateful thanks to the editors and journalists with whom I have worked for many years on this column and that have allowed it to remain for me a labor of love. I also want to thank the many surgeons who have taken the time and trouble to contribute to the column and the many readers who have communicated with me regarding the column. My successor as editor of this column is my partner Richard Hoffman, M.D., whose modesty and easy-going demeanor hides brilliance, his enormous surgical skill and his surprising wit. I am sure readers will enjoy his contributions in the coming years.

I. Howard Fine, M.D., Column Editor


Given the lack of advanced technology at the time, Dr. Fine offers up renderings of his cases Source: I. Howard Fine, M.D.

It happened without warning—back in the days of intracapsular cataract extractions I was administering an anesthesia injection in the superior part of the orbit, when I realized that something wasn’t quite right. If I moved the needle the eye moved with it, which I knew meant that I was probably facing a perforation. Worse yet, this patient was already effectively blind in his other eye as the result of a retinal detachment. What to do next? As I reflect back over my career, it is cases like this one I find myself revisiting. We all have them – the ones where we have to put all of our ingenuity and surgical skill to the test to keep our patient’s sight intact. Whether you are dancing on the grid iron, out on the baseball field, or tucked in a surgical suite these are the ones for the ages—our best saves.

In this case, I drew on my background as an engineer, and as is customary in that field “eye-balled” the problem. I had somebody put an indirect ophthalmoscope on my head. When I looked in I could see that the needle had gone completely through the vitreous cavity, with an exit perforation temporal to the macular. If I removed the needle it would likely result in a retinal detachment. In this pre-vitrectomy era, we would treat impending detachments by freezing the sclera over the hole, creating an adhesive choroiditis.

So, as I stood there with the syringe in my hand, I ask for a cold probe. I then simply touched the probe to the hub of the needle, allowing the conductivity of the metal to do the rest. I watched as ice balls formed at both the entry and exit perforation sites. I waited for the ice balls to melt and then took the needle out. I then went ahead and removed the cataract without further incident.

The patient here developed scars at both perforation sites and had an organized band of vitreous between them. I followed him for the rest of his life and he saw very well and never had any trouble. When I think back on this it seems to me that I averted the worst potential disaster of my career.

On shaky ground with floppy iris

Another case that I consider to be a great save involved an early floppy iris patient. I was managing the case proficiently enough and then it came time to implant the IOL. My technique in such cases had been to place the IOL cartridge in the eye bevel up, then to rotate it bevel down before implanting lens, and then finally to rotate it bevel up again so that the trailing portion of the cartridge acted like a shoe horn to keep the iris in the eye.

This time all went fine until the last step. After injecting the IOL in the eye I neglected to rotate the cartridge bevel up. As I withdrew it the iris prolapsed into the cartridge tearing the root of the iris for a full 90 degrees. The question was what to do. In this case, I was able to reposit the iris by going through a side-port incision and sweeping it back in, while adding a little viscoelastic just above. I found that, after doing this I saw that the pupil was still flatted temporally, was positioned more centrally than it should be and that there was a big triangular shaped dialysis in the subincisional area.

I tried burping the wound just a little bit and found that the root of the iris came halfway into the temporal clear corneal incision. Then I added a suture in the cornea tangential to the limbus. With that single stitch I sutured the incision closed. Since there was no iris left protruding, this virtually closed the exposed portion of the eye. I found that this brought the root of the iris back almost up to its original position. The pupil was once again round and normal and the patient never had a complaint.

Testing my mettle

In another case which I faced in a hospital setting, I had a patient who had a perforating injury in which an intraocular foreign body went through the edge of the capsule nasally. The foreign body had created a cataract and was sitting in the center of the lens with a lot of surrounding opacification but was by no means adherent to the lens. In this case, which occurred, pre-viscoelastics, my concern was how to remove the cataract without losing the metallic, potentially poisonous object, inside of the eye. To help resolve this case I made a very small paracentisis and then brought the giant hospital magnet to the table. I then took a very thin Bowman probe and placed this through the paracentisis up against the foreign body. Next, I touched the giant magnet to the edge of the Bowman probe. Happily, the magnetism was transferred to the Bowman probe and I was able to pull this out with the intraocular foreign body still attached. Then I was able to remove the cataract and put an implant in and the patient ultimately did very well.

Foreign body flap

A final case, in which I really had to think outside the box, involved a central deeply penetrating corneal metallic foreign body. The patient was once again almost entirely dependent upon this eye since he had strabismus and amblyopia in the other eye. In the operating room I made a paracentisis and filled the eye with viscoelastic and then I dug out the foreign body. Unfortunately, the central penetrating wound was now perforating and beginning to leak. The problem was that I knew that suturing it was going to create an enormous amount of astigmatism and perhaps a bigger scar than I would like. So, instead I dissected the conjunctiva at the limbus temporally from nearly the 12:30 to the 5:30 mark. Then I made another similar incision 2 to 3 mm external to that creating a bipedal conjunctival flap. I sutured that flap very tightly across the center of the cornea, using two stitches superiorly near the limbus and two inferiorly. This created enough tension so that the leaking stopped and the chamber completely reformed.

After leaving this in place for a significant period, I finally took the four sutures out and stripped the conjunctival flap off the cornea, with the epithelium also in tow. I then placed in a soft lens. After the epithelium re-healed I removed this lens and the patient had a very small central corneal scar but saw perfectly.

When I look back on these four great saves, I hope that others will take from it the need to always be prepared for the unexpected. You must be willing to reach with your imagination. Be open to anything that could potentially solve the problem – an ice inducing probe, a giant magnet, incarcerating the iris, a conjunctival flap or something entirely your own. With some skill and some serendipity hopefully your outcomes will be as fortuitous as mine in these four cases which help to punctuate a career which for me can only be described as wonderful. I don’t think anyone has had more fun in ophthalmology than I have.

In the nick of time: saving the best for last In the nick of time: saving the best for last
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