- Email: [email protected]
August consultation #10
CONSULTATION SECTION
planned. Corneal thinning, posterior synechiae, a small pupil, no red reflex, a rock-hard lens, zonular weakness, and other factors are possible complications. The technique would include a 2.0 to 2.2 mm CCI and 1 paracentesis for my left hand, filling the anterior chamber with highly cohesive hyaluronic acid 2.3%, synechialysis, and pupillary stretching. Next, the OVD is removed and the anterior chamber filled with air to allow sufficient capsule staining with trypan blue. Refilling the anterior chamber with the highly cohesive OVD and taking advantage of its viscoadaptive characteristics should result in a sufficient minimum pupil size (3.0 mm). If this were not achieved, I would use a Malyugin ring to enlarge the pupil. Iris retractors would require additional corneal incisions in this already affected cornea. Capsulorhexis is performed through the main incision with an endoforceps, with the help of a push–pull instrument, if needed. Hydrodissection and phacoemulsification are performed. Because of the small pupil and anticipated lens nucleus hardness, I would use a 45-degree Kelman tip and torsional phaco with longitudinal phaco bursts during occlusion. To increase safety and efficiency, the Fukasaku snap-and-split technique would be used.3 This technique uses simultaneous vector forces for nucleus cracking and is useful in small-pupil cases because all maneuvers are performed in the safe capsulorhexis zone. It works well with a Sinskey hook and does not require a sharp chopper or manipulations under the iris. The residual cortex is cleared from the capsular bag and a 1-piece hydrophobic IOL implanted in the bag. If these devices were not available or affordable, I would consider performing ECCE through a CCI to reduce intraoperative pressure spikes because of the extremely weakened sclera. Nucleus cracking could be performed with the help of an irrigating vectis to keep the incision smaller. Gabor B. Scharioth, MD Recklinghausen, Germany Szeged, Hungary
REFERENCES 1. Talbot EM, Murdoch JR, Keating D. The Purkinje vascular entoptic test: a halogen light gives better results. Eye 1992; 6:322–325
1567
2. Nguyen QD, Foster CS. Scleral patch graft in the management of necrotizing scleritis. Int Ophthalmol Clin 1999; 39(1):109–131 3. Fukasaku H. The snap and split phacoemulsification. Tech Ophthalmol 2004; 2:135–136
- In this case of Wegener granulomatosis, the figure shows additional information that must be taken into account; that is, circular vascularization close to the limbus, but not going centrally, and thinning of the peripheral cornea superiorly. My concept would be to work on the only healthyappearing structures without touching the severely diseased tissue. The eye must be exposed to the least elevated pressure possible. Ultrasound should only be used with the phaco tip far from the endothelium. Given these prerequisites, I would mark the cornea with an 8-bar redial keratotomy marker and perform a 7.0 mm corneal trephination with the Guided-Trephine System or Hanna system to avoid elevating the pressure when trephining. Next, the pupil would be dilated and kept so with a pupil-stretching iris ring to a 7.0 mm width. Then, I would perform a capsulorhexis after staining the capsule and would aspirate the loose cortex as much as possible. The next step is to mobilize the nucleus. First would be hydrodissection with a round-headed cannula with horizontal holes to avoid downward pressure. Then, the nucleus would be luxated upward and removed by the phaco tip suction. If not, I would be prepared to use a cryo tip to freeze the nucleus and bring it out. Irrigation/aspiration of remaining cortex and IOL implantation in the bag if the capsulorhexis is intact are the following steps. The rest of the operation, including an iridectomy, would be the same as a corneal triple procedure except that it is the patient's own cornea (kept in corneal storage medium during surgery) that is resutured with a double-running antitorque suture under keratoscopic control. The endothelium of the trephined corneal button, being the only healthy part of the cornea, would not have suffered. I think this procedure is the safest way to avoid ultrasound damage and elevated IOP during cataract removal by phacoemulsification. At the same time, the endothelium is protected, the procedure can be planned, and every step is under full control.
J CATARACT REFRACT SURG - VOL 37, AUGUST 2011
J€ org Krumeich, MD Bochum, Germany
planned. Corneal thinning, posterior synechiae, a small pupil, no red reflex, a rock-hard lens, zonular weakness, and other factors are possible complications. The technique would include a 2.0 to 2.2 mm CCI and 1 paracentesis for my left hand, filling the anterior chamber with highly cohesive hyaluronic acid 2.3%, synechialysis, and pupillary stretching. Next, the OVD is removed and the anterior chamber filled with air to allow sufficient capsule staining with trypan blue. Refilling the anterior chamber with the highly cohesive OVD and taking advantage of its viscoadaptive characteristics should result in a sufficient minimum pupil size (3.0 mm). If this were not achieved, I would use a Malyugin ring to enlarge the pupil. Iris retractors would require additional corneal incisions in this already affected cornea. Capsulorhexis is performed through the main incision with an endoforceps, with the help of a push–pull instrument, if needed. Hydrodissection and phacoemulsification are performed. Because of the small pupil and anticipated lens nucleus hardness, I would use a 45-degree Kelman tip and torsional phaco with longitudinal phaco bursts during occlusion. To increase safety and efficiency, the Fukasaku snap-and-split technique would be used.3 This technique uses simultaneous vector forces for nucleus cracking and is useful in small-pupil cases because all maneuvers are performed in the safe capsulorhexis zone. It works well with a Sinskey hook and does not require a sharp chopper or manipulations under the iris. The residual cortex is cleared from the capsular bag and a 1-piece hydrophobic IOL implanted in the bag. If these devices were not available or affordable, I would consider performing ECCE through a CCI to reduce intraoperative pressure spikes because of the extremely weakened sclera. Nucleus cracking could be performed with the help of an irrigating vectis to keep the incision smaller. Gabor B. Scharioth, MD Recklinghausen, Germany Szeged, Hungary
REFERENCES 1. Talbot EM, Murdoch JR, Keating D. The Purkinje vascular entoptic test: a halogen light gives better results. Eye 1992; 6:322–325
1567
2. Nguyen QD, Foster CS. Scleral patch graft in the management of necrotizing scleritis. Int Ophthalmol Clin 1999; 39(1):109–131 3. Fukasaku H. The snap and split phacoemulsification. Tech Ophthalmol 2004; 2:135–136
- In this case of Wegener granulomatosis, the figure shows additional information that must be taken into account; that is, circular vascularization close to the limbus, but not going centrally, and thinning of the peripheral cornea superiorly. My concept would be to work on the only healthyappearing structures without touching the severely diseased tissue. The eye must be exposed to the least elevated pressure possible. Ultrasound should only be used with the phaco tip far from the endothelium. Given these prerequisites, I would mark the cornea with an 8-bar redial keratotomy marker and perform a 7.0 mm corneal trephination with the Guided-Trephine System or Hanna system to avoid elevating the pressure when trephining. Next, the pupil would be dilated and kept so with a pupil-stretching iris ring to a 7.0 mm width. Then, I would perform a capsulorhexis after staining the capsule and would aspirate the loose cortex as much as possible. The next step is to mobilize the nucleus. First would be hydrodissection with a round-headed cannula with horizontal holes to avoid downward pressure. Then, the nucleus would be luxated upward and removed by the phaco tip suction. If not, I would be prepared to use a cryo tip to freeze the nucleus and bring it out. Irrigation/aspiration of remaining cortex and IOL implantation in the bag if the capsulorhexis is intact are the following steps. The rest of the operation, including an iridectomy, would be the same as a corneal triple procedure except that it is the patient's own cornea (kept in corneal storage medium during surgery) that is resutured with a double-running antitorque suture under keratoscopic control. The endothelium of the trephined corneal button, being the only healthy part of the cornea, would not have suffered. I think this procedure is the safest way to avoid ultrasound damage and elevated IOP during cataract removal by phacoemulsification. At the same time, the endothelium is protected, the procedure can be planned, and every step is under full control.
J CATARACT REFRACT SURG - VOL 37, AUGUST 2011
J€ org Krumeich, MD Bochum, Germany