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Cataract surgical problem: Reply #6
CONSULTATION SECTION
f The patient has developed a visually significant cat-
f For the cataract in the left eye, I would perform my
aract and desires visual rehabilitation. Intraocular pressure is reasonable at 10 mm Hg without glaucoma medication, and a filtering bleb is present. The axial length is similar between the 2 eyes without profound hypotony. I would favor temporal clear corneal phacoemulsification with posterior chamber IOL implantation. This would be coupled with lysis of posterior synechias and pupillary stretch as necessary to achieve a satisfactory pupil size for phacoemulsification. A small-incision foldable IOL would be implanted through the clear corneal incision. A silicone, acrylic, or a Collamer lens would be satisfactory because there is no history of significant inflammation. The clear corneal incision would be closed with a single buried 10-0 nylon suture. This would permit use of postoperative digital pressure and manipulation of the globe, if required. Postoperative topical prednisolone acetate 1% would be used initially every 2 hours while awake and increased or decreased based on the clinical response. A standard topical antibiotic and topical NSAID would also be given. Supplemental postoperative 5-FU would be administered depending on bleb development and IOP. The frequency of the 5-FU injections would be titrated to the bleb response. A special aspect of this case is malignant glaucoma in the setting of choroidal detachment. Posterior aqueous diversion is uncommon in the setting of choroidals, and the findings described may simply have been related to the choroidal detachment. Choroidal detachments tend to respond to topical cycloplegic and topical corticosteroid administration, as this patient received. If choroidal detachments persist chronically, they often clear with cataract surgery and IOL implantation. A second aspect pertains to IOL power calculations. If the eye were more hypotonous with a shorter axial length, this would have to be taken into consideration for IOL power calculation. In hypotonous eyes with shortened axial lengths, the IOP tends to rise and the axial length tends to increase slightly after cataract surgery with IOL implantation. However, the axial length does not tend to reach the full prehypotonous axial length. These issues are critical for estimating postoperative refraction and IOL choice.
usual clear corneal temporal phacoemulsification procedure with 2 goals in mind: (1) avoiding aqueous misdirection intraoperatively and postoperatively by preventing transient anterior chamber shallowing and keeping the ciliary body and zonules tight; (2) preserving bleb function with 5-FU and steroids. To achieve these goals, I would vary my typical procedure. Preoperatively, I would prescribe atropine 1% and phenylephrine 2.5% 4 times a day for 3 days in the left eye. I would also do an endothelial cell count to determine endothelial status in an eye with previous surgery and a history of a prolonged shallow anterior chamber postoperatively. Intraoperatively, I would use fortified balanced salt solution (BSS Plus威) if the endothelial cell count were low. I would use Healon GV for the capsulorhexis to avoid anterior chamber shallowing. I would place an anterior chamber maintainer during phacoemulsification and irrigation/aspiration (I/A) to help prevent anterior chamber shallowing when the phaco and I/A tips are removed. Next, I would give a 5-FU injection near the bleb in an attempt to preserve the bleb function. I would implant a 6.0 mm or smaller IOL. (Aqueous misdirection has been reported with 7.0 mm IOLs, especially in small eyes.) I would check the IOP at the end of the procedure and aim for the mid-teens. I would do the surgery in the morning and recheck the patient in the afternoon in the office to monitor anterior chamber depth and IOP. If the chamber is shallow, I would consider an anterior chamber sodium hyaluronate 1% (Healon威) injection at the slitlamp. If aqueous misdirection occurs intraoperatively, I would perform a pars plana vitreous tap to remove a pocket of aqueous or a pars plana limited mechanical vitrectomy with anterior chamber infusion to deepen the anterior chamber. Postoperatively, I would continue the atropine and phenylephrine 4 times a day with a 1-month taper and then continue the atropine 1% once a day for 1 year or longer. (Aqueous misdirection has been associated with cessation of cycloplegia in some eyes.) I would increase the postoperative steroids to Pred Forte 8 times a day with a 1-month taper and give additional 5-FU injections over 1 to 2 months, depending on the bleb status and IOP.
BRADFORD J. SHINGLETON, MD Boston, Massachusetts, USA
J CATARACT REFRACT SURG—VOL 28, AUGUST 2002
1315
CONSULTATION SECTION
If aqueous misdirection occurs postoperatively, I would first treat it medically. If this is not successful in breaking the aqueous misdirection in 1 to 3 days, I would use an argon laser to the ciliary processes through the peripheral iridectomy along with an Nd:YAG laser anterior hyaloid face disruption through the peripheral iridectomy or centrally if necessary along with an Nd: YAG capsulotomy through the peripheral iridectomy or centrally. In my experience, one sees a small anterior chamber deepening almost immediately and then a gradual improvement with resolution over 1 to 5 days. If there is no resolution over 1 to 5 days or the IOP threatens optic nerve function, I would refer the patient for a pars plana core vitrectomy and hyaloid face removal to reestablish anterior flow of aqueous humor. STUART A. TERRY, MD San Antonio, Texas, USA
f There are 2 concerns when considering cataract surgery in this eye: intraoperative rupture of the thin-walled bleb as well as a postoperative pressure rise, bleb failure, or both. I would recommend standard cataract surgery under topical anesthesia with a few adjustments. Regarding the incision, conjunctival bleeding must be avoided as it may initiate bleb scarring. Therefore, I would create a temporally located corneal step incision with a precut just inside the limbal vascular arcade and a short corneal tunnel. For the viscoelastic material, I would use hyaluronic acid because in normal eyes, it causes less frequent and less pronounced postoperative pressure rises than dispersive agents such as sodium hyaluronate 3%– chondroitin sulfate 4% (Viscoat威) or hydroxypropyl methylcellulose (OcuCoat威).1,2 Should pupil dilation be unsatisfactory, I would try to avoid iris retractors. These cause considerable iris trauma which can lead to iridocapsular synechias and uveal cell precipitate formation on the optic. After performing synechiolysis, I would make multiple sphincterotomies, if necessary over the whole circumference with retinal scissors passed through the paracentesis openings. If the use of iris retractors cannot be avoided, I would insert only 3, 1 temporally beneath the cataract incision and the other 2 through superotemporal and inferotemporal paracenteses. The resulting triangular pupil distension provides satisfactory access while precluding subincisional iris chafe. Staining the 1316
anterior capsule may enhance control of the capsulorhexis should it be necessary to perform it beneath the iris. I would implant an open-loop IOL with a 6.0 mm optic and a contiguous posterior sharp edge. Should a well-centered 5.0 to 5.5 mm capsulorhexis be attained (primarily or by reshaping with the optic in place), the IOL material of choice would be silicone or hydrophobic acrylic; however, silicone provokes more fibrotic response than acrylic. With a smaller capsulorhexis opening, acrylic would be preferred. In the presence of pseudoexfoliation, silicone would be contraindicated. Effort should be made to completely remove the viscoelastic material after IOL implantation. This includes thorough retrolental aspiration. At the conclusion of surgery, the incision would be secured with a nylon suture through clear corneal tissue as the strength of wound closure may be compromised in case of postoperative hypotony. Also, the bleb should be checked for leakage using fluorescein. Immediate postoperative topical therapy should include a fixed combination of dorzolamide and timolol (Cosopt威) as it has proved effective in preventing postoperative IOP increases.3,4 With hyaluronic acid, IOP spikes are most frequent and pronounced 6 to 8 hours postoperatively3; thus, the IOP should be measured at this point. Medication would be adjusted, including oral acetazolamide if needed. In the case of bleb leakage, a topical antibiotic would be added. In the rare case of concomitant hypotony and choroidal effusion, a cycloplegic would be given. Bleb leaks usually seal off and reepithelialize quickly. If not, a patch or a bandage lens is helpful. In the rare case of permanent pressure decompensation not responding to maximum tolerable medication, I would rather resort to a drainage implant than a repeat trabeculectomy given the diffuse thin-walled bleb described. RUPERT MENAPACE, MD Vienna, Austria
References 1. Rainer G, Menapace R, Findl O, et al. Intraocular pressure rise after small incision cataract surgery; a randomised intraindividual comparison of two dispersive viscoelastic agents. Br J Ophthalmol 2001; 85:139 –142 2. Rainer G, Menapace R, Findl O, et al. Intraocular pressure after small incision cataract surgery with Healon5 and Viscoat. J Cataract Refract Surg 2000; 26:272–276
J CATARACT REFRACT SURG—VOL 28, AUGUST 2002
f The patient has developed a visually significant cat-
f For the cataract in the left eye, I would perform my
aract and desires visual rehabilitation. Intraocular pressure is reasonable at 10 mm Hg without glaucoma medication, and a filtering bleb is present. The axial length is similar between the 2 eyes without profound hypotony. I would favor temporal clear corneal phacoemulsification with posterior chamber IOL implantation. This would be coupled with lysis of posterior synechias and pupillary stretch as necessary to achieve a satisfactory pupil size for phacoemulsification. A small-incision foldable IOL would be implanted through the clear corneal incision. A silicone, acrylic, or a Collamer lens would be satisfactory because there is no history of significant inflammation. The clear corneal incision would be closed with a single buried 10-0 nylon suture. This would permit use of postoperative digital pressure and manipulation of the globe, if required. Postoperative topical prednisolone acetate 1% would be used initially every 2 hours while awake and increased or decreased based on the clinical response. A standard topical antibiotic and topical NSAID would also be given. Supplemental postoperative 5-FU would be administered depending on bleb development and IOP. The frequency of the 5-FU injections would be titrated to the bleb response. A special aspect of this case is malignant glaucoma in the setting of choroidal detachment. Posterior aqueous diversion is uncommon in the setting of choroidals, and the findings described may simply have been related to the choroidal detachment. Choroidal detachments tend to respond to topical cycloplegic and topical corticosteroid administration, as this patient received. If choroidal detachments persist chronically, they often clear with cataract surgery and IOL implantation. A second aspect pertains to IOL power calculations. If the eye were more hypotonous with a shorter axial length, this would have to be taken into consideration for IOL power calculation. In hypotonous eyes with shortened axial lengths, the IOP tends to rise and the axial length tends to increase slightly after cataract surgery with IOL implantation. However, the axial length does not tend to reach the full prehypotonous axial length. These issues are critical for estimating postoperative refraction and IOL choice.
usual clear corneal temporal phacoemulsification procedure with 2 goals in mind: (1) avoiding aqueous misdirection intraoperatively and postoperatively by preventing transient anterior chamber shallowing and keeping the ciliary body and zonules tight; (2) preserving bleb function with 5-FU and steroids. To achieve these goals, I would vary my typical procedure. Preoperatively, I would prescribe atropine 1% and phenylephrine 2.5% 4 times a day for 3 days in the left eye. I would also do an endothelial cell count to determine endothelial status in an eye with previous surgery and a history of a prolonged shallow anterior chamber postoperatively. Intraoperatively, I would use fortified balanced salt solution (BSS Plus威) if the endothelial cell count were low. I would use Healon GV for the capsulorhexis to avoid anterior chamber shallowing. I would place an anterior chamber maintainer during phacoemulsification and irrigation/aspiration (I/A) to help prevent anterior chamber shallowing when the phaco and I/A tips are removed. Next, I would give a 5-FU injection near the bleb in an attempt to preserve the bleb function. I would implant a 6.0 mm or smaller IOL. (Aqueous misdirection has been reported with 7.0 mm IOLs, especially in small eyes.) I would check the IOP at the end of the procedure and aim for the mid-teens. I would do the surgery in the morning and recheck the patient in the afternoon in the office to monitor anterior chamber depth and IOP. If the chamber is shallow, I would consider an anterior chamber sodium hyaluronate 1% (Healon威) injection at the slitlamp. If aqueous misdirection occurs intraoperatively, I would perform a pars plana vitreous tap to remove a pocket of aqueous or a pars plana limited mechanical vitrectomy with anterior chamber infusion to deepen the anterior chamber. Postoperatively, I would continue the atropine and phenylephrine 4 times a day with a 1-month taper and then continue the atropine 1% once a day for 1 year or longer. (Aqueous misdirection has been associated with cessation of cycloplegia in some eyes.) I would increase the postoperative steroids to Pred Forte 8 times a day with a 1-month taper and give additional 5-FU injections over 1 to 2 months, depending on the bleb status and IOP.
BRADFORD J. SHINGLETON, MD Boston, Massachusetts, USA
J CATARACT REFRACT SURG—VOL 28, AUGUST 2002
1315
CONSULTATION SECTION
If aqueous misdirection occurs postoperatively, I would first treat it medically. If this is not successful in breaking the aqueous misdirection in 1 to 3 days, I would use an argon laser to the ciliary processes through the peripheral iridectomy along with an Nd:YAG laser anterior hyaloid face disruption through the peripheral iridectomy or centrally if necessary along with an Nd: YAG capsulotomy through the peripheral iridectomy or centrally. In my experience, one sees a small anterior chamber deepening almost immediately and then a gradual improvement with resolution over 1 to 5 days. If there is no resolution over 1 to 5 days or the IOP threatens optic nerve function, I would refer the patient for a pars plana core vitrectomy and hyaloid face removal to reestablish anterior flow of aqueous humor. STUART A. TERRY, MD San Antonio, Texas, USA
f There are 2 concerns when considering cataract surgery in this eye: intraoperative rupture of the thin-walled bleb as well as a postoperative pressure rise, bleb failure, or both. I would recommend standard cataract surgery under topical anesthesia with a few adjustments. Regarding the incision, conjunctival bleeding must be avoided as it may initiate bleb scarring. Therefore, I would create a temporally located corneal step incision with a precut just inside the limbal vascular arcade and a short corneal tunnel. For the viscoelastic material, I would use hyaluronic acid because in normal eyes, it causes less frequent and less pronounced postoperative pressure rises than dispersive agents such as sodium hyaluronate 3%– chondroitin sulfate 4% (Viscoat威) or hydroxypropyl methylcellulose (OcuCoat威).1,2 Should pupil dilation be unsatisfactory, I would try to avoid iris retractors. These cause considerable iris trauma which can lead to iridocapsular synechias and uveal cell precipitate formation on the optic. After performing synechiolysis, I would make multiple sphincterotomies, if necessary over the whole circumference with retinal scissors passed through the paracentesis openings. If the use of iris retractors cannot be avoided, I would insert only 3, 1 temporally beneath the cataract incision and the other 2 through superotemporal and inferotemporal paracenteses. The resulting triangular pupil distension provides satisfactory access while precluding subincisional iris chafe. Staining the 1316
anterior capsule may enhance control of the capsulorhexis should it be necessary to perform it beneath the iris. I would implant an open-loop IOL with a 6.0 mm optic and a contiguous posterior sharp edge. Should a well-centered 5.0 to 5.5 mm capsulorhexis be attained (primarily or by reshaping with the optic in place), the IOL material of choice would be silicone or hydrophobic acrylic; however, silicone provokes more fibrotic response than acrylic. With a smaller capsulorhexis opening, acrylic would be preferred. In the presence of pseudoexfoliation, silicone would be contraindicated. Effort should be made to completely remove the viscoelastic material after IOL implantation. This includes thorough retrolental aspiration. At the conclusion of surgery, the incision would be secured with a nylon suture through clear corneal tissue as the strength of wound closure may be compromised in case of postoperative hypotony. Also, the bleb should be checked for leakage using fluorescein. Immediate postoperative topical therapy should include a fixed combination of dorzolamide and timolol (Cosopt威) as it has proved effective in preventing postoperative IOP increases.3,4 With hyaluronic acid, IOP spikes are most frequent and pronounced 6 to 8 hours postoperatively3; thus, the IOP should be measured at this point. Medication would be adjusted, including oral acetazolamide if needed. In the case of bleb leakage, a topical antibiotic would be added. In the rare case of concomitant hypotony and choroidal effusion, a cycloplegic would be given. Bleb leaks usually seal off and reepithelialize quickly. If not, a patch or a bandage lens is helpful. In the rare case of permanent pressure decompensation not responding to maximum tolerable medication, I would rather resort to a drainage implant than a repeat trabeculectomy given the diffuse thin-walled bleb described. RUPERT MENAPACE, MD Vienna, Austria
References 1. Rainer G, Menapace R, Findl O, et al. Intraocular pressure rise after small incision cataract surgery; a randomised intraindividual comparison of two dispersive viscoelastic agents. Br J Ophthalmol 2001; 85:139 –142 2. Rainer G, Menapace R, Findl O, et al. Intraocular pressure after small incision cataract surgery with Healon5 and Viscoat. J Cataract Refract Surg 2000; 26:272–276
J CATARACT REFRACT SURG—VOL 28, AUGUST 2002