July 2018

COVER FEATURE

Challenging cases
Three cataract cases highlight challenges and pearls


by Vanessa Caceres EyeWorld Contributing Writer


Argentinian flag sign after trypan blue and attempted capsulotomy
Source: Rosa Braga-Mele, MD





Appearance of Dr. Miller’s patient’s left cornea 3 months after cataract surgery, which was complicated by TASS from exposure to methylene blue. She had finger counting VA at presentation.



Endothelial keratoplasty solved the corneal failure. She requires glaucoma medications for IOP control.


A toxic posterior segment syndrome and severe cystoid macular edema developed from the methylene blue exposure.


After many years of topical and intravitreal treatment, she still suffers from low-grade CME. Her VA has improved to 20/30 –2.
Source: Kevin M. Miller, MD

Problems can occur when you least expect it

Even the most seasoned cataract surgeons can and will experience challenging cases from time to time. Three cataract surgeons shared with EyeWorld how they managed difficult cases, both in the moment and over the long term. Take a page from their playbook for better surgical preparedness.

The best-laid plans

Rosa Braga-Mele, MD, professor of ophthalmology, University of Toronto, Canada, had a resident with her when she was about to perform surgery in a 55-year-old woman with bilateral cataracts, including a right eye with a white cataract. The patient had no history of ocular trauma. Dr. Braga-Mele’s goal was to teach the resident what to do to avoid the Argentinian flag sign.
Of course, things don’t always work out as planned.
Dr. Braga-Mele performed proper wound construction to avoid chamber shallowing and put in a dispersive ophthalmic viscosurgical device (OVD). She painted the capsule with trypan blue and then put in more dispersive OVD to flatten out the front. “I could see the capsule dimpling as I compressed it,” she said. She used a 27G needle to decompress the cortical fluff and relieve any posterior pressure on the anterior capsule. “I then put in more visco, and I went in with my cystotome and started the capsulorhexis, and it just ruptures,” she said.
When Dr. Braga-Mele went in with the cystotome, the patient had coughed. “A case that wasn’t supposed to be an Argentinian flag sign became one,” she said.
If this happens during surgery, don’t panic, Dr. Braga-Mele advised. Also, do not let the eye decompress. She put more OVD on top of the capsule and behind the white cataract to provide a bed of viscoelastic material.
“At this point, I didn’t know if the rupture was 360 degrees all around. I tried to put visco behind to make the capsule more taut or if it had run, to prevent the nucleus from dropping, and hopefully it would lift up to the anterior chamber,” Dr. Braga-Mele said.
She went in using high vacuum and embedded the phaco tip into the nucleus and scaffolded the nucleus on top of the iris. “I used the viscoelastic as a second instrument and eat that whole nucleus piece in what I call Pacman style, nibbling around the edge in a controlled fashion,” Dr. Braga-Mele said.
She kept the bag height at a moderate level. She then used her multiple vials of dispersive OVD to maintain the anterior chamber and bag pressure before pulling out of the eye. She also saw at this point that the posterior capsule had remained intact. The OVD was used to viscodissect the cortex off the capsule, making it easier to remove. She then went in with a gentle irrigation/aspiration tip.
Dr. Braga-Mele chose a soft, foldable, and stickier IOL and put the haptics where the two flaps were; she also put the optic in the center. “At this point, I gingerly took out visco with the second instrument to hold the lens posteriorly against the capsular bag. I only removed about 70% of the visco. I didn’t want to go underneath the IOL,” she said. She also put in a stitch to maintain the integrity of the eye and to make sure it did not decompress.
At 5 days postoperatively, the patient was 20/20.
Even when you have the best-laid surgical plans, consider what could go wrong and prepare accordingly, Dr. Braga-Mele advised. She also said that using a little “verbal anesthesia” to talk to the patient before going in for the capsulorhexis would have been helpful. She could have asked the patient not to move at that point or she could have told the anesthesiologist to give a bit more sedation.
“I learned my lesson,” she said.

Avoiding methylene blue

When cataract surgeons present challenging cases, there tends to be a lot of focus on how they handle them in the moment. What’s shared less often is the long-term management. That led Kevin M. Miller, MD, Kolokotrones Chair in Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, to present the management of a woman in her 50s who experienced toxic anterior segment syndrome (TASS) and macular edema in the left eye after the intraoperative use of methylene blue in the eye in December 2010, as performed by another surgeon. The patient’s management continues to the present time.
“Methylene blue is toxic to the inside of the eye. It’s a fairly easy mistake to make in the OR, especially with nurses floating between rooms,” Dr. Miller said. “If a surgeon doesn’t check, he or she could end up with problems.” Surgeons should make sure trypan blue is used instead for intraocular surgery.
Dr. Miller began to see the patient in March 2011. During his various appointments with her, he was able to track her TASS and macular edema. The patient eventually underwent a Descemet’s stripping endothelial keratoplasty (DSEK), although there was a brief rejection episode when a retina specialist withheld topical corticosteroids following an intravitreal corticosteroid injection, he said.
Various problems encountered by the patient in addition to TASS and macular edema included a slightly higher IOP, abnormal central corneal thickness, and an abnormal endothelial cell count.
At her last exam in May 2018, the patient’s vision was 20/30–2, compared with nonfunctional vision when she was first seen. “She’s not 20/20, and she may never be,” he said. “For now she’s doing OK, but that may change down the road. She may end up with graft failure and another DSEK at some point.”
It’s hard to reassure a patient with acute insults at the initial consultation because you do not know what their final outcome will be, Dr. Miller said. He recommended any surgeon managing a difficult situation be honest but upbeat and to encourage the patient to collaborate with the physician.
The take-home message of Dr. Miller’s case is that some issues will continue for a prolonged time period. “There’s the acute insult, but then they deal with complications for the rest of their life,” he said.

Horizontal approach to laser capsulotomy

Richard Tipperman, MD, attending surgeon, Wills Eye Hospital, Philadelphia, treated a 3-year-old girl with bilateral retinoblastoma who was enucleated in one eye. She had multiple treatments for the other eye to try and salvage it. “These children all get cataracts, and there is always an issue of whether to open the posterior capsule with a primary posterior capsulorhexis,” he said.
“Although primary posterior capsulorhexis does obviate the need for a future laser capsulotomy, this needs to be balanced with the increased risk of endophthalmitis associated with opening the posterior capsule, as well as the potential for taking a straightforward routine cataract case with assured IOL fixation and turning it into a more complex case,” Dr. Tipperman said.
After pediatric patients with retinoblastoma are treated by ocular oncologists Carol Shields, MD, and Jerry Shields, MD, both of Wills Oncology Service, Philadelphia, cataract formation is common. This can make clinical observation of tumor regression difficult. “Although by the time these children develop cataracts, the retinoblastoma is usually regressed and quiescent, there is the potential in an active tumor for cells to seed the anterior segment,” Dr. Tipperman said. Because he has opted not to perform a primary posterior capsulorhexis, he must use another technique to manage the capsule when it opacifies. Dr. Tipperman has a technique to use a YAG laser under anesthesia and shares his approach to help other surgeons working with a very young or uncooperative patient.
“In most laser slit lamps, the bars for the head and chin rest can be removed, allowing the laser to be brought right up to the side of the surgical stretcher, and the capsulotomy is performed with the child turned on his or her side,” Dr. Tipperman said. “If the surgical table and laser is constructed so that the laser cannot be brought close enough to the surgical stretcher, a backer board like those found on crash carts for cardiac suppression can be placed to extend the head of the bed, providing a thin but firm support for the patient’s head and shoulders. This allows the laser capsulotomy to be performed horizontally.”
This approach to perform laser capsulotomy was used successfully on the 3-year-old girl with retinoblastoma, but it also could be used on adults with severe orthopedic deformities such as kyphosis, which might otherwise preclude performing a laser capsulotomy in a seated position, Dr. Tipperman said.

Editors’ note: The physicians have no financial interests related to their comments.

Contact information

Braga-Mele: rbragamele@rogers.com
Miller: kmiller@ucla.edu
Tipperman: rtipperman@mindspring.com

Three cataract cases highlight challenges and pearls Three cataract cases highlight challenges and pearls
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