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Modified Radial Iridotomy for Small Pupil Phacoemulsification
REFERENCES 1. Mamalis N, Johnson MD, Haines JM, et al. Corneal-scleral melt in association with cataract surgery and intraocular lenses: a report of four cases. J Cataract Refract Surg 1990; 16:108-115 2. Yang HK, Kline OR Jr: Corneal melting with intraocular lenses. Arch Ophthalmol1982; 100:1272-1274
POSTERIOR CAPSULAR RUPTURE AT HYDRODISSECTION To the Editor: The patient is an 81-year-old white female with low tension glaucoma. Her glaucoma was found to be progressive at pressures in the upper teens. With punch sclerectomy, the patient achieved intraocular pressures consistently less than lO mm Hg. She had been intolerant of all topical medications and carbonic anhydrase inhibitors. There was significant cupping and field loss in the left eye and a dense paracentral scotoma in the right eye. In both eyes, the defects were close to fixation . She slowly developed cortical and nuclear sclerotic cataracts in both eyes and complained of glare that reduced her visual function. She requested cataract surgery in her left eye , which was performed superotemporally to avoid the previous filtering bleb. The pupil dilated well. A circular tear capsulorhexis was performed. On hydrodissection of the nucleus, it became immediately apparent that the posterior capsule had ruptured. The hydrodissection was done in a standard fashion using a 27 -gauge needle and a 3-cc syringe with balanced salt solution. The hydrodissection was no more forceful than usual. When the capsule rupture was recognized , the anterior capsule was immediately opened with multiple radial cuts in the edges of the anterior capsular opening. The nucleus was then gently removed with a spoon, after the surgical wound was opened to approximately 11 mm in chord length. After the nucleus was removed, an Ocutome vitrectomy of vitreous in the anterior chamber was performed. Some of the remaining cortical material was then stripped out with irrigation/aspiration after the vitrectomy, which was performed in a "dry" fashion. The capsular break was extremely large and there was not enough capsular material to support a posterior chamber intraocular lens. An anterior chamber lens implant was inserted. The eye subsequently developed failure of the previous filtering bleb and cystoid macular edema. The cystoid macular edema eventually resolved with sub-Tenon's steroid injections and topical therapy. However, her 866
J CATARACT REFRACT
intraocular pressure increased into the 20's. She required further glaucoma filtering surgery.
COMMENT Hydrodissection of the nucleus is an important step in modern phacoemulsification. 1 -3 This case is presented to make surgeons aware that posterior capsular rupture can occur during hydrodissection of the nucleus before phacoemulsification. It is not known whether this patient's glaucoma or glaucoma surgery was a contributing factor to the rupture in the posterior capsule. However, I have had considerable experience in performing cataract surgery on glaucoma patients and have never experienced this particular complication. Lawrence M. Hurvitz, M.D.
Sarasota, Florida
REFERENCES 1. Faust KJ. Hydrodissection of soft nuclei. Am Intra-Ocular Implant Soc J 1984; 10:75-77 2. Nishi O. Extracapsular cataract extraction with keyhole capsulorhexis and lens epithelial cell removal. J Cataract Refract Surg 1990; 16:249-252 3. Koch DD, Liu JF. Multilamellar hydrodissection in phacoemulsification and planned extracapsular surgery. J Cataract Refract Surg 1990; 16:559-562
MODIFIED RADIAL IRIDOTOMY FOR SMALL PUPIL PHACOEMULSIFICATION To the Editor: A standard tunnel incision for phacoemulsification is made 2 mm behind the limbus and beveled forward into clear cornea. The wound is opened with the 3.2 mm keratome and sodium hyaluronate (Healon®) is injected. A counter puncture is made at the 2:30 limbus. The Healon cannula is inserted through the counter puncture and passed under the iris in front of the keratome incision (Figure 1). A small amount of Healon is inserted to separate the iris from the lens capsule. The iris should not be elevated too high or too far toward the wound because it will interfere with inserting the scissors between the iris and cornea. Any posterior synechias can by lysed with the cannula at this time. A sharp-pointed capsule scissors with long, thin blades (Katena K4-5122 or comparable) is passed through the wound with the blade penetrating the iris at midperiphery and passing through into the sub-iris space where Healon is present (Figure 2). The pass should be horizontal to avoid the capsule. When the blade tip reaches the pupillary margin, the cut is made , producing a modified radial iridotomy. At the same time sphincterotomies can be performed at the
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Fig. 3.
Fig. 1.
(Faust) Healon insertion under iris.
(Faust) Modified radial iridotomy.
peripheral iris protects the capsule and the zonules in the area in which most instruments and irrigation are used.
6
Kenneth
J.
Faust, M. D.
Leesburg, Florida
COMBINING EPIKERATOPLASTY AND PHOTOREFRACTIVE KERATECTOMY
Fig. 2.
(Faust) Special capsule scissors penetrating iris.
4 o'clock and 7 o'clock positions. More Healon is inserted to expand the pupil and capsulorhexis is performed with forceps. Phacoemulsification with hydrodissection and nucleus cracking is performed and the incision widened to allow posterior chamber lens insertion. The radial iridotomy can be sutured or left unsutured (Figure 3). This modified radial iridotomy is compatible with small incisions and is easy and safe. It can be tailored to the size of the pupil, either three quarters, one half, or one quarter the width of the iris. It can be done at any time during the procedure should the pupil become too small for safety. Maintaining
J CATARACT REFRACT
To the Editor: We are still searching for more accurate and safer refractive surgical ·procedures. One of the safest is epikeratoplasty, which is reversible; not reversible but fairly predictable is photo refractive keratectomy. I would suggest combining these two techniques. This should result in safety and reversibility, from the epikeratoplasty, and precision, from excimer laser corneal shaping. Part of the desired effect (myopic or hyperopic) could be corrected by the epikeratoplasty and the remaining error could then be eliminated by laser shaping. Even large refractive deviations could be safely neutralized by this combination of methods. Larger optical zones and deeper keratectomies could be routinely used without any significant risk to the patient's cornea. In addition, shaping procedures could be repeated several times to achieve optimal results. It remains to be seen whether subepithelial haze develops to a greater extent in the transplanted lenticle than in normal corneas. Klaus D. Teichmann, M.D.
Riyadh, Saudi Arabia
SURG-VOL 17. NOVEMBER 1991
867
POSTERIOR CAPSULAR RUPTURE AT HYDRODISSECTION To the Editor: The patient is an 81-year-old white female with low tension glaucoma. Her glaucoma was found to be progressive at pressures in the upper teens. With punch sclerectomy, the patient achieved intraocular pressures consistently less than lO mm Hg. She had been intolerant of all topical medications and carbonic anhydrase inhibitors. There was significant cupping and field loss in the left eye and a dense paracentral scotoma in the right eye. In both eyes, the defects were close to fixation . She slowly developed cortical and nuclear sclerotic cataracts in both eyes and complained of glare that reduced her visual function. She requested cataract surgery in her left eye , which was performed superotemporally to avoid the previous filtering bleb. The pupil dilated well. A circular tear capsulorhexis was performed. On hydrodissection of the nucleus, it became immediately apparent that the posterior capsule had ruptured. The hydrodissection was done in a standard fashion using a 27 -gauge needle and a 3-cc syringe with balanced salt solution. The hydrodissection was no more forceful than usual. When the capsule rupture was recognized , the anterior capsule was immediately opened with multiple radial cuts in the edges of the anterior capsular opening. The nucleus was then gently removed with a spoon, after the surgical wound was opened to approximately 11 mm in chord length. After the nucleus was removed, an Ocutome vitrectomy of vitreous in the anterior chamber was performed. Some of the remaining cortical material was then stripped out with irrigation/aspiration after the vitrectomy, which was performed in a "dry" fashion. The capsular break was extremely large and there was not enough capsular material to support a posterior chamber intraocular lens. An anterior chamber lens implant was inserted. The eye subsequently developed failure of the previous filtering bleb and cystoid macular edema. The cystoid macular edema eventually resolved with sub-Tenon's steroid injections and topical therapy. However, her 866
J CATARACT REFRACT
intraocular pressure increased into the 20's. She required further glaucoma filtering surgery.
COMMENT Hydrodissection of the nucleus is an important step in modern phacoemulsification. 1 -3 This case is presented to make surgeons aware that posterior capsular rupture can occur during hydrodissection of the nucleus before phacoemulsification. It is not known whether this patient's glaucoma or glaucoma surgery was a contributing factor to the rupture in the posterior capsule. However, I have had considerable experience in performing cataract surgery on glaucoma patients and have never experienced this particular complication. Lawrence M. Hurvitz, M.D.
Sarasota, Florida
REFERENCES 1. Faust KJ. Hydrodissection of soft nuclei. Am Intra-Ocular Implant Soc J 1984; 10:75-77 2. Nishi O. Extracapsular cataract extraction with keyhole capsulorhexis and lens epithelial cell removal. J Cataract Refract Surg 1990; 16:249-252 3. Koch DD, Liu JF. Multilamellar hydrodissection in phacoemulsification and planned extracapsular surgery. J Cataract Refract Surg 1990; 16:559-562
MODIFIED RADIAL IRIDOTOMY FOR SMALL PUPIL PHACOEMULSIFICATION To the Editor: A standard tunnel incision for phacoemulsification is made 2 mm behind the limbus and beveled forward into clear cornea. The wound is opened with the 3.2 mm keratome and sodium hyaluronate (Healon®) is injected. A counter puncture is made at the 2:30 limbus. The Healon cannula is inserted through the counter puncture and passed under the iris in front of the keratome incision (Figure 1). A small amount of Healon is inserted to separate the iris from the lens capsule. The iris should not be elevated too high or too far toward the wound because it will interfere with inserting the scissors between the iris and cornea. Any posterior synechias can by lysed with the cannula at this time. A sharp-pointed capsule scissors with long, thin blades (Katena K4-5122 or comparable) is passed through the wound with the blade penetrating the iris at midperiphery and passing through into the sub-iris space where Healon is present (Figure 2). The pass should be horizontal to avoid the capsule. When the blade tip reaches the pupillary margin, the cut is made , producing a modified radial iridotomy. At the same time sphincterotomies can be performed at the
SURG-VOL 17, NOVEMBER 1991
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6
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- - -9
I
12
Fig. 3.
Fig. 1.
(Faust) Healon insertion under iris.
(Faust) Modified radial iridotomy.
peripheral iris protects the capsule and the zonules in the area in which most instruments and irrigation are used.
6
Kenneth
J.
Faust, M. D.
Leesburg, Florida
COMBINING EPIKERATOPLASTY AND PHOTOREFRACTIVE KERATECTOMY
Fig. 2.
(Faust) Special capsule scissors penetrating iris.
4 o'clock and 7 o'clock positions. More Healon is inserted to expand the pupil and capsulorhexis is performed with forceps. Phacoemulsification with hydrodissection and nucleus cracking is performed and the incision widened to allow posterior chamber lens insertion. The radial iridotomy can be sutured or left unsutured (Figure 3). This modified radial iridotomy is compatible with small incisions and is easy and safe. It can be tailored to the size of the pupil, either three quarters, one half, or one quarter the width of the iris. It can be done at any time during the procedure should the pupil become too small for safety. Maintaining
J CATARACT REFRACT
To the Editor: We are still searching for more accurate and safer refractive surgical ·procedures. One of the safest is epikeratoplasty, which is reversible; not reversible but fairly predictable is photo refractive keratectomy. I would suggest combining these two techniques. This should result in safety and reversibility, from the epikeratoplasty, and precision, from excimer laser corneal shaping. Part of the desired effect (myopic or hyperopic) could be corrected by the epikeratoplasty and the remaining error could then be eliminated by laser shaping. Even large refractive deviations could be safely neutralized by this combination of methods. Larger optical zones and deeper keratectomies could be routinely used without any significant risk to the patient's cornea. In addition, shaping procedures could be repeated several times to achieve optimal results. It remains to be seen whether subepithelial haze develops to a greater extent in the transplanted lenticle than in normal corneas. Klaus D. Teichmann, M.D.
Riyadh, Saudi Arabia
SURG-VOL 17. NOVEMBER 1991
867