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February consultation #1
CONSULTATION SECTION
Cataract Surgical Problem Edited by Samuel Masket, MD Online Video
About 2 hours before the photograph in Figure 1 was taken, the right eye of an active, medically healthy 64-year-old woman sustained an inadvertent laceration of the anterior capsule during treatment for a submacular choroidal neovascular membrane (CNVM) under the care of a retinal specialist. According to the history, the patient had had multiple intravitreal anti– vascular endothelial growth factor injections. On this day, immediately after the injection, the intraocular pressure (IOP) in the right eye was elevated and an anterior chamber paracentesis was created by a retinal specialist to reduce the IOP. However, because of abrupt ocular movement, the inferior nasal periphery of the anterior lens capsule was inadvertently ruptured by the 30-gauge hypodermic needle. Examination just after the event showed a corrected distance visual acuity (with spectacles) of 20/30 with –4.0 diopters (D) in the right eye and 20/20 with –4.0 D in the left eye. The IOP was 14 mm Hg in both eyes. Ocular examination was remarkable in the right eye only for a sealed limbal paracentesis, a laceration of the anterior capsule in the inferior nasal periphery (5 o’clock position), and an inactive submacular
Figure 1. A laceration of the anterior capsule is noted inferonasally for the right eye. Although a tract into the lens cortex is visible, the posterior capsule appears intact. Q 2015 ASCRS and ESCRS Published by Elsevier Inc.
CNVM. The left eye was normal in all aspects. The patient is comfortable with wearing spectacles and has been unsuccessful with contact lens trials. Given this patient’s history and findings, what would you advise as the best course of action?
- This case presents a clinical conundrum on multiple fronts. The patient has sustained an iatrogenic injury (capsule tear) during an intervention for an iatrogenic complication (elevated pressure after intravitreal injection). Further intervention must limit the potential for additional complications. Regarding the problem at hand, we have to consider the patient's current and future ophthalmic prognosis. Based on Figure 1, the patient appears to have a good red reflex, indicating that the lens opacification and cataract are not advanced. Also, it is particularly important to maintain the view to the retina because this patient has wet age-related macular degeneration (AMD) and the macula will have to be monitored closely to titrate the anti-VEGF therapy. With penetration of the anterior capsule, it is likely that a cataract will form as a sectoral cortical wedge or develop into a frank mature or hypermature white cataract. Given the current scenario, I would be inclined to offer cataract surgery to this patient within 24 hours. Waiting longer would allow inflammation and fibrosis to start altering the lens capsule defect, making it more difficult to visualize and manage. In the interim, I would pretreat the eye with steroid drops and nonsteroidal antiinflammatory drugs (NSAIDs) to prevent undue inflammation. From a cataract surgery standpoint, there are multiple considerations. The first is whether to try to incorporate the capsular defect into the capsulorhexis. The advantage of this is that it would reduce the chances of extending the defect and destabilizing the lens. The disadvantage is that it might be technically difficult to perform because it is quite peripheral. When the capsule tear extends to the anterior zonular fibers, which it appears to do, the surgeon's ability to direct the vector shear forces is greatly reduced. So although I would consider this option, I would also consider leaving it alone. If I thought I could not safely lift the capsule flap and incorporate it into the continuous capsulorhexis, I http://dx.doi.org/10.1016/j.jcrs.2014.12.024 0886-3350
471
Cataract Surgical Problem Edited by Samuel Masket, MD Online Video
About 2 hours before the photograph in Figure 1 was taken, the right eye of an active, medically healthy 64-year-old woman sustained an inadvertent laceration of the anterior capsule during treatment for a submacular choroidal neovascular membrane (CNVM) under the care of a retinal specialist. According to the history, the patient had had multiple intravitreal anti– vascular endothelial growth factor injections. On this day, immediately after the injection, the intraocular pressure (IOP) in the right eye was elevated and an anterior chamber paracentesis was created by a retinal specialist to reduce the IOP. However, because of abrupt ocular movement, the inferior nasal periphery of the anterior lens capsule was inadvertently ruptured by the 30-gauge hypodermic needle. Examination just after the event showed a corrected distance visual acuity (with spectacles) of 20/30 with –4.0 diopters (D) in the right eye and 20/20 with –4.0 D in the left eye. The IOP was 14 mm Hg in both eyes. Ocular examination was remarkable in the right eye only for a sealed limbal paracentesis, a laceration of the anterior capsule in the inferior nasal periphery (5 o’clock position), and an inactive submacular
Figure 1. A laceration of the anterior capsule is noted inferonasally for the right eye. Although a tract into the lens cortex is visible, the posterior capsule appears intact. Q 2015 ASCRS and ESCRS Published by Elsevier Inc.
CNVM. The left eye was normal in all aspects. The patient is comfortable with wearing spectacles and has been unsuccessful with contact lens trials. Given this patient’s history and findings, what would you advise as the best course of action?
- This case presents a clinical conundrum on multiple fronts. The patient has sustained an iatrogenic injury (capsule tear) during an intervention for an iatrogenic complication (elevated pressure after intravitreal injection). Further intervention must limit the potential for additional complications. Regarding the problem at hand, we have to consider the patient's current and future ophthalmic prognosis. Based on Figure 1, the patient appears to have a good red reflex, indicating that the lens opacification and cataract are not advanced. Also, it is particularly important to maintain the view to the retina because this patient has wet age-related macular degeneration (AMD) and the macula will have to be monitored closely to titrate the anti-VEGF therapy. With penetration of the anterior capsule, it is likely that a cataract will form as a sectoral cortical wedge or develop into a frank mature or hypermature white cataract. Given the current scenario, I would be inclined to offer cataract surgery to this patient within 24 hours. Waiting longer would allow inflammation and fibrosis to start altering the lens capsule defect, making it more difficult to visualize and manage. In the interim, I would pretreat the eye with steroid drops and nonsteroidal antiinflammatory drugs (NSAIDs) to prevent undue inflammation. From a cataract surgery standpoint, there are multiple considerations. The first is whether to try to incorporate the capsular defect into the capsulorhexis. The advantage of this is that it would reduce the chances of extending the defect and destabilizing the lens. The disadvantage is that it might be technically difficult to perform because it is quite peripheral. When the capsule tear extends to the anterior zonular fibers, which it appears to do, the surgeon's ability to direct the vector shear forces is greatly reduced. So although I would consider this option, I would also consider leaving it alone. If I thought I could not safely lift the capsule flap and incorporate it into the continuous capsulorhexis, I http://dx.doi.org/10.1016/j.jcrs.2014.12.024 0886-3350
471