September 2008

 

CATARACT/ IOL

 

Traumatic cataract has long-term vulnerability


by Lisa Arbisser, M.D.

 

Lisa Arbisser, M.D., is a spectacular cataract surgeon who has established an internationally renowned, high volume surgery center with multiple branch offices in Iowa. She is a welcome presence in meetings all over the world and has taught in many places. She has performed live surgery in a variety of foreign countries. The case she is presenting this month reminds us that traumatic cataracts stemming from injuries can present with a myriad of complications that are, perhaps, more prone to re-injury and exacerbation of already compromised anatomy. This is an interesting case and a great lesson for all of us.

I. Howard Fine, MD, Column Editor

 

Re-injury leaves capsular bag hanging into the vitreous and suspended by a single zonules

Pre-op sublux aniridia ring

Aniridia rings, scleral fixation day 1 Source for both: Lisa Arbisser, M.D.

The patient had limited zonular damage without vitreous prolapse and I was able to implant aniridia rings (Morcher GmbH, Stuttgart, Germany) on a compassionate use request basis with IRB approval. The procedure left him with solid visual outcomes.

However, the patient re-injured the eye recently and began to notice inconsistent vision. An examination revealed that the capsular bag was nasally subluxated, yet the aniridia rings and the IOL remained solidly centered and stable within it. A knuckle of vitreous protruded around the missing zonules temporally. When the patient returned a week later to receive a peribulbar injection, I found “his bag was hanging into the vitreous suspended by what looked like a single zonules.” Removal of the bag-lens complex would require a large incision and leave him without an iris diaphragm and an uncovered IOL edge, so I consulted with Michael E. Snyder, M.D., Cincinnati Eye Institute, on the best approach.

The first step of my treatment was to lasso the bag by placing one end of a 9-0 prolene suture above and one arm through the bag in the only gap in the interdigitated dual aniridia ring complex. Then, I secured it to the sulcus with an ab-externo approach to prevent its descent entirely into the vitreous and raised the complex through a pars plana approach and placed a 27-gauge needle across from pars to pars behind it to keep it in position for further fixation.

The second scleral fixation suture traversed the peripheral optic of the one piece acrylic IOL and looped loosely around the equator of the bag so I could fixate it to the sulcus—as the needle cannot pierce the black PMMA material.

The prolapsed vitreous—now about 180 degrees around the temporal bag—was then particulate-identified with washed Kenalog (Bristol-Myers Squibb, New York) and removed through the pars plana incision, which was secured with a scleral plug.

“At this point the bag remained a little tilted. With no iris diaphragm to hold it back it required sulcus fixation at a third point.”

I performed all the sulcus fixation sutures through a reverse scleral pocket, a technique I learned about through a video presentation by Rich Hoffmann, M.D., [clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland] at the 2008 ASCRS Annual Meeting and Symposium. The technique detailed fashioning a 350-micron groove at the limbus and creating a pocket with a crescent knife back into the sclera. The ab-externo needle was placed through the conjunctiva, the roof and floor of the pocket and into the sulcus. The double armed prolene needle was passed through a paracentesis 180 degrees away and docked into the needle. The needles were then removed and the sutures retrieved from under the scleral pocket through the limbal groove so that the knot could be buried under the scleral pocket without a need for peritomy, cautery or creation of a scleral flap.

I then sutured the pars plana incision with a 8-0 Vicryl. “A pars plana approach to vitrectomy is most efficient and reduces traction and makes it the least likely that the vitreous will represent as you leave the lowest pressure in the posterior segment instead of the low pressure in the anterior segment. Since vitreous follows a gradient from high to low pressure that means that during other manipulations the vitreous is less likely to represent and end up at the incision.”

Although a small amount of bleeding from the ciliary body remained from the slightly anterior one-needle pass, the case concluded with a well-centered bag, no vitreous in the anterior segment and sutureless paracentesis, as well as a sutured and covered pars plana sclerotomy. The patient was still in the early post-op period when this article went to press but had an anatomically perfect appearance and an attached retina. I noted that the dispersed vitreous hemorrhage was likely to delay visual recovery.

Pearls for complications Surgical pearls gleaned from such cases include the use of half marcaine (various manufacturers) and half lidocaine (various manufacturers) in such extended cases. I switch to this combination from my normal peribulbar combination of lidocaine with epinerphin (various manufacturers) because that does not last as long as the other combination.

In addition, if surgeons secure the lens with a needle across the eye from pars to pars, that will keep it in position while they are suturing.

Lastly, in cases of interdigitated aniridia rings that include an area where there is a gap, surgeons can place the suture through the peripheral optic of the lens.

“That’s unique about this” surgical situation.

Editors’ note: Dr. Arbisser has financial interests with Alcon (Fort Worth, Texas).

Contact information
Arbisser: 563-323-2020, drlisa@arbisser.com

Traumatic cataract has long-term vulnerability Traumatic cataract has long-term vulnerability
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