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Migration of retained broken chopper tip after phacoemulsification
CASE REPORT
Migration of retained broken chopper tip after phacoemulsification Devesh K. Varma, MD, Vaquas M. Shaikh, Tim R. Hillson, MD, Iqbal Ike K. Ahmed, MD
We report removal of a retained broken chopper tip after phacoemulsification. Although the foreign body was thought to be stable in the ciliary sulcus 2 months postoperatively, it dislocated into the anterior chamber 8 months later. It was removed with a microforceps under gonioscopic visualization. Although previous reports suggest that retained metallic fragments after phacoemulsification can be left in place if they are difficult to access and appear stationary, our case highlights the potential for long-term instability. We therefore recommend consideration of surgical removal with the use of gonioscopic, endoscopic, or posterior segment visualization systems, as required. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2010; 36:857–860 Q 2010 ASCRS and ESCRS Online Video
The presence of retained intraocular metallic fragments after phacoemulsification is well documented.1,2 The fragments can arise from the phaco needle or from a second instrument. Small phaco needle fragments can be chipped off by vibration and wear against the irrigation sleeve, although this is rare with modern fabrication techniques.1–3 Fragments can be released from second instruments when they come in contact with the phaco tip, and metal fatigue can lead to complete fracture, usually at the tip, resulting in an intraocular foreign body.4 One third of cataract surgeons experience intraoperative fracture of the tip of the second instrument during their career.4 Visualization and removal of intraocular foreign bodies located in the anterior chamber can be achieved with intraoperative gonioscopy, and those located in the vitreous cavity can be removed by vitrectomy using posterior segment viewing systems. In these cases, removal is the preferred management.5,6
Submitted: November 20, 2009. Accepted: November 23, 2009. From the University of Toronto (Varma, Ahmed), Toronto, and McMaster University (Shaikh, Hillson), Hamilton, Ontario, Canada; University of Utah (Ahmed), Salt Lake City, Utah, USA. Corresponding author: Iqbal Ike K. Ahmed, MD, Credit Valley EyeCare, 3200 Erin Mills Parkway, Unit 1, Mississauga, Ontario L5L 1W8, Canada. E-mail: [email protected]. Q 2010 ASCRS and ESCRS Published by Elsevier Inc.
However, intraocular foreign bodies in the ciliary sulcus may be harder to remove due to difficulties with visualization. Sulcus intraocular foreign bodies can remain stationary, particularly if they are lodged in the ciliary processes. Furthermore, they tend to be inert, which is why some have argued against their removal (D.A. John, MD, et al., ‘‘Management of Intraocular Foreign Bodies,’’ EyeNet, September 2009, pages 31–32).7 We report a case of a broken chopper tip in the ciliary sulcus discovered after phacoemulsification. The broken tip initially appeared to be stable but ultimately dislodged into the anterior chamber, requiring removal. CASE REPORT A 66-year-old man had phacoemulsification and intraocular lens implantation in the left eye. After phacoemulsification, the tip of the Rosen chopper was missing. It was not visualized in the eye. The surgery was completed, and plain films followed by computed tomography (CT) scans of the orbits were taken to rule out a retained intraocular foreign body. The images revealed a 2.0 mm metallic foreign body located temporally in the ciliary sulcus (Figure 1). The patient was taken back to the operating room the same day; however, the fragment could not be retrieved. The postoperative course was uneventful, and the patient achieved a corrected distance visual acuity of 20/25 with normal intraocular pressures and a quiet anterior chamber. Two months postoperatively, the chopper tip could still not be visualized on examination; however, ultrasound biomicroscopy (UBM) scans confirmed that the fragment 0886-3350/10/$dsee front matter doi:10.1016/j.jcrs.2009.11.031
857
858
CASE REPORT: RETAINED BROKEN CHOPPER TIP MIGRATION
Figure 2. Ultrasound biomicroscopy image taken 2 months postoperatively shows a foreign body in the ciliary sulcus
instilled to further constrict the pupil and reduce the risk for posterior migration of the intraocular foreign body. Sodium hyaluronate 1.0% (Provisc) was injected to maintain the anterior chamber. The foreign body was removed under direct visualization using Ahmed micrograspers (MicroSurgical Technology) (Figures 4 and 5). The ophthalmic viscosurgical device was then removed using a dry aspiration technique. The patient did well postoperatively, maintaining 20/25 visual acuity.
DISCUSSION Studies in which metallic intraocular foreign bodies after cataract surgery were not removed show that they are well tolerated.1,2,7 However, the studies were not designed to specifically evaluate the long-term effects of the foreign bodies. Loose intraocular foreign bodies can cause trauma to the corneal endothelium, angle structures, and even the posterior lens capsule intraoperatively if contact with a vibrating phacoemulsification needle pushes them posteriorly at high velocity. Stable retained metallic intraocular foreign bodies can cause chronic recalcitrant postoperative inflammation that Figure 1. A: Axial noncontrast CT scan taken on the day of surgery confirms a retained metallic foreign body. B: Coronal noncontrast CT scan taken on the day of surgery confirms retained metallic foreign body inferotemporally. C: Sagittal noncontrast CT scan taken on the day of surgery confirms a retained metallic foreign body in the ciliary sulcus
remained stationary (Figure 2). Thus, a reasonable argument could be made to leave it in place. However, the patient was referred to a center equipped with endoscopic visualization equipment for additional evaluation and possible removal of the fragment from the ciliary sulcus. By 8 months after the initial cataract surgery, the fragment had migrated into the anterior chamber and was sitting in the inferior angle (Figure 3). The patient was prescribed pilocarpine and advised to sleep with his head elevated to prevent posterior migration of the fragment. Intraoperatively, the chopper tip was visualized in the inferior angle using an Osher surgical gonioscopy posterior pole lens (Ocular Instruments) (Video available at www. jcrsjournal.org). Intracameral acetylcholine chloride was
Figure 3. Digital retinal camera photograph taken 8 months postoperatively shows that the chopper tip has migrated into the anterior chamber angle.
J CATARACT REFRACT SURG - VOL 36, MAY 2010
CASE REPORT: RETAINED BROKEN CHOPPER TIP MIGRATION
Figure 4. Removal under gonioscopic visualization with a micrograsping forceps.
can lead to cystoid macular edema and macular epiretinal membrane formation.8 Furthermore, there is a theoretical risk for siderosis bulbi caused by ionizable iron, which is present in some alloys used to fabricate second instruments. To evaluate this, we
859
contacted Bausch & Lomb, Rhein-Tec, and American Surgical Instruments Corp. Bausch & Lomb reported trace amounts of iron in the steel/titanium alloy used to fabricate Rosen choppers (personal communication, R. Khanna, October 2009). Rhein Medical, Inc. (personal communication, J. Bee, October 2009) and American Surgical Instruments Corp. (personal communication, S. Ghotavadekar) reported no use of iron in the fabrication of their choppers. Siderosis bulbi can result chronic iron deposition in corneal stroma, iris, lens, and retina, leading to iris heterochromia, uveitis, secondary glaucoma, and retinal degeneration. Computed tomography and UBM can be helpful in localizing intraocular foreign bodies that cannot be visualized clinically, as is the case with intraocular foreign bodies in the ciliary sulcus. Although intraocular foreign bodies in this location can remain stable, our case shows that even those that appear stable may dislodge in the late postoperative course. A loose intraocular foreign body can be asymptomatic at first but then traumatize various intraocular structures including, but not limited to, the corneal endothelium. We therefore recommend strong consideration of removal of metallic intraocular foreign bodies after cataract surgery. Intraoperative gonioscopy and a micrograsping forceps enabled removal of the retained intraocular foreign body in the angle in this case. Should the intraocular foreign body have remained or moved into the ciliary sulcus, endoscopic-guided removal would be our preferred approach. As a general rule, if the intraocular foreign body is easily accessible, removal is the best option. When the intraocular foreign body is difficult to visualize or access, despite apparent stability and inertness, we recommend strong consideration of removal. In some cases, this may necessitate referral to a vitreoretinal surgeon or a center equipped with endoscopic equipment.
REFERENCES
Figure 5. Top: Retrieved chopper tip. Bottom: Original Rosen chopper handle with missing tip.
1. Braunstein RE, Cotliar AM, Wirostko BM, Gorman BD. Intraocular metallic-appearing foreign bodies after phacoemulsification. J Cataract Refract Surg 1996; 22:1247–1250 2. Dunbar CM, Goble RR, Gregory DW, Church WC. Intraocular deposition of metallic fragments during phacoemulsification: possible causes and effects. Eye 1995; 9:434–436 3. Martı´nez-Toldos JJ, Elvira JC, Hueso JR, Ariola A, Mengual E, Barcelo´ A, Garcia J, Martı´nez-Reina MJ. Metallic fragment deposits during phacoemulsification. J Cataract Refract Surg 1998; 24:1256–1260 4. Nazemi F, Odorcic S, Braga-Mele R, Wong D. Second instrument tip breaks during phacoemulsification. Can J Ophthalmol 2008; 43:702–706. Available at: http://article.pubs.nrc-cnrc.gc.ca/ RPAS/rpv?hmZHInit&calyLangZeng&journalZcjo&volumeZ43 &afpfZi08-148.pdf Accessed January 16, 2010
J CATARACT REFRACT SURG - VOL 36, MAY 2010
860
CASE REPORT: RETAINED BROKEN CHOPPER TIP MIGRATION
5. Pelosini L, Richardson EC, Goel R, Hugkulstone CE. Intraoperative breakage of the mushroom manipulator tip during phacoemulsification [letter]. Eye 2006; 20:1451–1452 6. Manjunatha NP, Deshmukh RR, Kayarkar VV. Large metallic fragment found in the angle of anterior chamber after phacoemulsification, and its removal [letter]. Eye 2007; 21:295–296 7. Arbisser LB. Origin of intraocular metallic foreign bodies during phacoemulsification. J Cataract Refract Surg 2005; 31:2423–2424 8. Stangos AN, Pournaras CJ, Petropoulos IK. Occult anteriorchamber metallic fragment post-phacoemulsification masquerading
as chronic recalcitrant postoperative inflammation. Am J Ophthalmol 2005; 139:541–542
J CATARACT REFRACT SURG - VOL 36, MAY 2010
First Author: Devesh K. Varma, MD University of Toronto, Toronto, Ontario, Canada
Migration of retained broken chopper tip after phacoemulsification Devesh K. Varma, MD, Vaquas M. Shaikh, Tim R. Hillson, MD, Iqbal Ike K. Ahmed, MD
We report removal of a retained broken chopper tip after phacoemulsification. Although the foreign body was thought to be stable in the ciliary sulcus 2 months postoperatively, it dislocated into the anterior chamber 8 months later. It was removed with a microforceps under gonioscopic visualization. Although previous reports suggest that retained metallic fragments after phacoemulsification can be left in place if they are difficult to access and appear stationary, our case highlights the potential for long-term instability. We therefore recommend consideration of surgical removal with the use of gonioscopic, endoscopic, or posterior segment visualization systems, as required. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2010; 36:857–860 Q 2010 ASCRS and ESCRS Online Video
The presence of retained intraocular metallic fragments after phacoemulsification is well documented.1,2 The fragments can arise from the phaco needle or from a second instrument. Small phaco needle fragments can be chipped off by vibration and wear against the irrigation sleeve, although this is rare with modern fabrication techniques.1–3 Fragments can be released from second instruments when they come in contact with the phaco tip, and metal fatigue can lead to complete fracture, usually at the tip, resulting in an intraocular foreign body.4 One third of cataract surgeons experience intraoperative fracture of the tip of the second instrument during their career.4 Visualization and removal of intraocular foreign bodies located in the anterior chamber can be achieved with intraoperative gonioscopy, and those located in the vitreous cavity can be removed by vitrectomy using posterior segment viewing systems. In these cases, removal is the preferred management.5,6
Submitted: November 20, 2009. Accepted: November 23, 2009. From the University of Toronto (Varma, Ahmed), Toronto, and McMaster University (Shaikh, Hillson), Hamilton, Ontario, Canada; University of Utah (Ahmed), Salt Lake City, Utah, USA. Corresponding author: Iqbal Ike K. Ahmed, MD, Credit Valley EyeCare, 3200 Erin Mills Parkway, Unit 1, Mississauga, Ontario L5L 1W8, Canada. E-mail: [email protected]. Q 2010 ASCRS and ESCRS Published by Elsevier Inc.
However, intraocular foreign bodies in the ciliary sulcus may be harder to remove due to difficulties with visualization. Sulcus intraocular foreign bodies can remain stationary, particularly if they are lodged in the ciliary processes. Furthermore, they tend to be inert, which is why some have argued against their removal (D.A. John, MD, et al., ‘‘Management of Intraocular Foreign Bodies,’’ EyeNet, September 2009, pages 31–32).7 We report a case of a broken chopper tip in the ciliary sulcus discovered after phacoemulsification. The broken tip initially appeared to be stable but ultimately dislodged into the anterior chamber, requiring removal. CASE REPORT A 66-year-old man had phacoemulsification and intraocular lens implantation in the left eye. After phacoemulsification, the tip of the Rosen chopper was missing. It was not visualized in the eye. The surgery was completed, and plain films followed by computed tomography (CT) scans of the orbits were taken to rule out a retained intraocular foreign body. The images revealed a 2.0 mm metallic foreign body located temporally in the ciliary sulcus (Figure 1). The patient was taken back to the operating room the same day; however, the fragment could not be retrieved. The postoperative course was uneventful, and the patient achieved a corrected distance visual acuity of 20/25 with normal intraocular pressures and a quiet anterior chamber. Two months postoperatively, the chopper tip could still not be visualized on examination; however, ultrasound biomicroscopy (UBM) scans confirmed that the fragment 0886-3350/10/$dsee front matter doi:10.1016/j.jcrs.2009.11.031
857
858
CASE REPORT: RETAINED BROKEN CHOPPER TIP MIGRATION
Figure 2. Ultrasound biomicroscopy image taken 2 months postoperatively shows a foreign body in the ciliary sulcus
instilled to further constrict the pupil and reduce the risk for posterior migration of the intraocular foreign body. Sodium hyaluronate 1.0% (Provisc) was injected to maintain the anterior chamber. The foreign body was removed under direct visualization using Ahmed micrograspers (MicroSurgical Technology) (Figures 4 and 5). The ophthalmic viscosurgical device was then removed using a dry aspiration technique. The patient did well postoperatively, maintaining 20/25 visual acuity.
DISCUSSION Studies in which metallic intraocular foreign bodies after cataract surgery were not removed show that they are well tolerated.1,2,7 However, the studies were not designed to specifically evaluate the long-term effects of the foreign bodies. Loose intraocular foreign bodies can cause trauma to the corneal endothelium, angle structures, and even the posterior lens capsule intraoperatively if contact with a vibrating phacoemulsification needle pushes them posteriorly at high velocity. Stable retained metallic intraocular foreign bodies can cause chronic recalcitrant postoperative inflammation that Figure 1. A: Axial noncontrast CT scan taken on the day of surgery confirms a retained metallic foreign body. B: Coronal noncontrast CT scan taken on the day of surgery confirms retained metallic foreign body inferotemporally. C: Sagittal noncontrast CT scan taken on the day of surgery confirms a retained metallic foreign body in the ciliary sulcus
remained stationary (Figure 2). Thus, a reasonable argument could be made to leave it in place. However, the patient was referred to a center equipped with endoscopic visualization equipment for additional evaluation and possible removal of the fragment from the ciliary sulcus. By 8 months after the initial cataract surgery, the fragment had migrated into the anterior chamber and was sitting in the inferior angle (Figure 3). The patient was prescribed pilocarpine and advised to sleep with his head elevated to prevent posterior migration of the fragment. Intraoperatively, the chopper tip was visualized in the inferior angle using an Osher surgical gonioscopy posterior pole lens (Ocular Instruments) (Video available at www. jcrsjournal.org). Intracameral acetylcholine chloride was
Figure 3. Digital retinal camera photograph taken 8 months postoperatively shows that the chopper tip has migrated into the anterior chamber angle.
J CATARACT REFRACT SURG - VOL 36, MAY 2010
CASE REPORT: RETAINED BROKEN CHOPPER TIP MIGRATION
Figure 4. Removal under gonioscopic visualization with a micrograsping forceps.
can lead to cystoid macular edema and macular epiretinal membrane formation.8 Furthermore, there is a theoretical risk for siderosis bulbi caused by ionizable iron, which is present in some alloys used to fabricate second instruments. To evaluate this, we
859
contacted Bausch & Lomb, Rhein-Tec, and American Surgical Instruments Corp. Bausch & Lomb reported trace amounts of iron in the steel/titanium alloy used to fabricate Rosen choppers (personal communication, R. Khanna, October 2009). Rhein Medical, Inc. (personal communication, J. Bee, October 2009) and American Surgical Instruments Corp. (personal communication, S. Ghotavadekar) reported no use of iron in the fabrication of their choppers. Siderosis bulbi can result chronic iron deposition in corneal stroma, iris, lens, and retina, leading to iris heterochromia, uveitis, secondary glaucoma, and retinal degeneration. Computed tomography and UBM can be helpful in localizing intraocular foreign bodies that cannot be visualized clinically, as is the case with intraocular foreign bodies in the ciliary sulcus. Although intraocular foreign bodies in this location can remain stable, our case shows that even those that appear stable may dislodge in the late postoperative course. A loose intraocular foreign body can be asymptomatic at first but then traumatize various intraocular structures including, but not limited to, the corneal endothelium. We therefore recommend strong consideration of removal of metallic intraocular foreign bodies after cataract surgery. Intraoperative gonioscopy and a micrograsping forceps enabled removal of the retained intraocular foreign body in the angle in this case. Should the intraocular foreign body have remained or moved into the ciliary sulcus, endoscopic-guided removal would be our preferred approach. As a general rule, if the intraocular foreign body is easily accessible, removal is the best option. When the intraocular foreign body is difficult to visualize or access, despite apparent stability and inertness, we recommend strong consideration of removal. In some cases, this may necessitate referral to a vitreoretinal surgeon or a center equipped with endoscopic equipment.
REFERENCES
Figure 5. Top: Retrieved chopper tip. Bottom: Original Rosen chopper handle with missing tip.
1. Braunstein RE, Cotliar AM, Wirostko BM, Gorman BD. Intraocular metallic-appearing foreign bodies after phacoemulsification. J Cataract Refract Surg 1996; 22:1247–1250 2. Dunbar CM, Goble RR, Gregory DW, Church WC. Intraocular deposition of metallic fragments during phacoemulsification: possible causes and effects. Eye 1995; 9:434–436 3. Martı´nez-Toldos JJ, Elvira JC, Hueso JR, Ariola A, Mengual E, Barcelo´ A, Garcia J, Martı´nez-Reina MJ. Metallic fragment deposits during phacoemulsification. J Cataract Refract Surg 1998; 24:1256–1260 4. Nazemi F, Odorcic S, Braga-Mele R, Wong D. Second instrument tip breaks during phacoemulsification. Can J Ophthalmol 2008; 43:702–706. Available at: http://article.pubs.nrc-cnrc.gc.ca/ RPAS/rpv?hmZHInit&calyLangZeng&journalZcjo&volumeZ43 &afpfZi08-148.pdf Accessed January 16, 2010
J CATARACT REFRACT SURG - VOL 36, MAY 2010
860
CASE REPORT: RETAINED BROKEN CHOPPER TIP MIGRATION
5. Pelosini L, Richardson EC, Goel R, Hugkulstone CE. Intraoperative breakage of the mushroom manipulator tip during phacoemulsification [letter]. Eye 2006; 20:1451–1452 6. Manjunatha NP, Deshmukh RR, Kayarkar VV. Large metallic fragment found in the angle of anterior chamber after phacoemulsification, and its removal [letter]. Eye 2007; 21:295–296 7. Arbisser LB. Origin of intraocular metallic foreign bodies during phacoemulsification. J Cataract Refract Surg 2005; 31:2423–2424 8. Stangos AN, Pournaras CJ, Petropoulos IK. Occult anteriorchamber metallic fragment post-phacoemulsification masquerading
as chronic recalcitrant postoperative inflammation. Am J Ophthalmol 2005; 139:541–542
J CATARACT REFRACT SURG - VOL 36, MAY 2010
First Author: Devesh K. Varma, MD University of Toronto, Toronto, Ontario, Canada