April 2016




Cataract editors corner of the world

What caused a complication that cataract surgeons fear most?

by Liz Hillman EyeWorld Staff Writer


Rosa Braga-Mele, MDAs the saying goes, Interesting things happen to interesting people. Or is it, Bad things happen to good people? Regardless, something truly astounding happened to Kevin Miller, MD, which he describes in this article; really it could have happened to any of us. It was an unfortunate occurrence, but luckily, early diagnosis and effective management led to a great patient outcome.

But we must always pose the question: Why did this happen? This article has some experts theorizing what the mechanism of a well-known but feared complication was in this small incision cataract surgery. All are plausible theories, and I will let you decide which one you think is the ultimate reason. We may never know, but it is always important to reassess the situation, question new technology, decide what might have been done differently (which may be nothing at all), and try to learn from the situation. It is also very important to share our challenges with our colleagues so we may all learn from one another how to prevent or manage these complications.

Kudos to Dr. Miller for sharing and teaching. It is amazing how the eye can humble us. I learned a lot from this case.

Rosa Braga-Mele, MD, MEd, FRCSC, cataract editor


A suprachoroidal hemorrhage

A suprachoroidal hemorrhage (black wedge) on top of optic nerve, pictured a week after initial surgery Source: Kevin M. Miller, MD

Physician wonders if multiple docking attempts to femtosecond laser caused suprachoroidal hemorrhage

In late December 2015, Kevin M. Miller, MD, chief of the cataract and refractive surgery division, David Geffen School of Medicine, University of California, Los Angeles, was set to perform a routine cataract surgery using a femtosecond laser to create a capsulorhexis, perform the lens segmentation, and make the incisions. He docked the 67-year-old female patient once and found air bubbles in the laser-patient interface that would obscure the lasers ability to create a complete capsulorhexis. He undocked the patients eye from the LenSx laser (Alcon, Fort Worth, Texas), wet her cornea, and redocked her to the laser. Again, air bubbles were in the way. Repeating the process once more, Dr. Miller found that the third time was a charm, and he proceeded with the surgery. It wasnt until he tried to get a multifocal IOL into the capsule that he learned something was wrong. In fact, it was an issue he called the single worst intraoperative complication that a cataract surgeon can have: a suprachoroidal hemorrhage. I got the lens in and as I was trying to contain it in the capsule, everything was shallowing on me, he said. The lens wouldnt stay in the capsule. I was getting posterior pressure. I kept working, trying to get the entire opticnot just part of itto stay inside the capsule, when it dawned on me, this is not normal. Dr. Miller knew it was most likely aqueous misdirection or suprachoroidal hemorrhage. He put a suture in the incision, leaving the lens half in and half out of the capsule and pressed up against the patients cornea. The eye was hard and the anterior chamber non-existent. Indirect ophthalmoscopy confirmed it was a suprachoroidal hemorrhage. I didnt know how it was going to play out, he said, explaining that he sent the patient to the recovery room for an hour, hoping that her eye would soften up and her anterior chamber would deepen. I didnt need it to deepen much. I just needed to get the lens inside the capsule. If it was still rock hard and everything was shallow, I was going to see her in the office the next day and make plans to bring her back in a day, a week, or 2 weeks, whatever it took. Fortunately, the womans eye softened and Dr. Miller was able to go back through a side port, place the IOL correctly, inject some balanced salt solution, and close up the eye. The next day, her vision was better than Dr. Miller expected (2/25-1), considering the trauma and the fact that her cornea was a bit damaged with the lens sitting against it for a time. A week after surgery, the patients vision was about the same as 1-day postop, but her cornea had healed further.

Overall, Dr. Miller called it a great outcome for a potentially bad complication. But what caused the suprachoroidal hemorrhage in the first place? Dr. Miller speculates that repeated undocking from the femtosecond laser caused several sudden depressurizations of the eye that could have created a small hole in a vessel in the choroid, thus leading to the hemorrhage. In light of that hypothesis, he wonders if suprachoroidal hemorrhage is a previously unreported complication associated with this technology.

I bet its a more common scenario than anyone recognizes. Not that were seeing huge numbers of cases reported, but small hemorrhages may be occurring that we are not seeing, he said. This complication was more severe prior to the advent of small incision cataract surgery.1 As Dr. Miller put it, the pressure buildup due to the hemorrhage can result in the iris, lens, and even the retina being pushed out of the eye, something that is more likely if a larger incision is used. [The patient goes] blind very quickly, basically on the table, he said. So we fear this one more than anything else. While weve made suprachoroidal hemorrhage almost a non-issue with small incision cataract surgery, I think this may be the next problem in the saga of cataract surgery, he said, adding that he thinks doctors using femtosecond lasers should be aware of the potential for this.

Jonathan Talamo, MD, Massachusetts Eye and Ear, Waltham, Massachusetts, does not think the docking attempts were to blame in this case. I do not think that the degree of IOP elevation or fluctuations with the femtosecond laser docking systems I am most familiar with (the LenSx and Catalys [Abbott Medical Optics, Abbott Park, Illinois]) would put a patient at increased risk for a suprachoroidal hemorrhage. I dont think the IOP changes incurred by docking are any more dramatic than the brief elevations that occur in some instances during draping, speculum placement, instrument insertion, or simply pushing on the globe with a gloved finger, and likely less than those incurred by Honan balloon placement or OVD injection. Where I do think one needs to be careful is during air/fluid release from the anterior chamber if the IOP is elevated significantly when the eye is entered, since rapid decompression of the globe can be very dramatic under such circumstances, he said.

This can occur if a patient is treated with the femtosecond laser and then left waiting for a long period of time before entering the eye. I think that significant elevations have been reported after 2 hours. It would be interesting to know in this case what the time interval was between laser treatment and the rest of surgery, and it will certainly be important to report events such as occurred during Dr. Millers case as experience continues to grow with image-guided femtosecond laser systems. Samuel Masket, MD, clinical professor, University of California, Los Angeles, and Advanced Vision Care, Los Angeles, said he is unaware of any prior reports of suspected suprachoroidal hemorrhages associated with the procedure. Nevertheless, its interesting to speculate whether the multiple docking attempts could be responsible because when the docking is done, the intraocular pressure is elevated, varying with the laser and that does have an effect on the choroidal vasculature, Dr. Masket said.

Dr. Masket later added that proving what caused this complication one way or the other is impossible, but its good to make other surgeons aware of this case, and well see if others have noted it. Fortunately, an experienced surgeon in this case recognized the condition and made the correct management decisions. As for prevention, if the docking attempts were the cause of a pressure rise and fall and this issue, Dr. Miller said one just has to roll with the punches. Of course a physician would prefer to dock a patient just once to a femtosecond laser, but Dr. Miller said going forward with the surgery in the presence of air bubbles would result in a worse outcome. You have to deal with the air bubbles, you cant ignore them, he said. The only way to avoid this particular issue, if in fact the femtosecond laser caused the problem, would be not to do the femto laser, and Im not sure thats the solution.


1. Stein JD, et al. Severe adverse events following cataract surgery among Medicare beneficiaries. Ophthalmology. 2011; 118(9):17161723.

Contact information
Masket: sammasket@aol.com
Miller: miller@jsei.ucla.edu
Talamo: jht@jhtmdpc.com

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