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Sutureless single-port transconjunctival pars plana limited vitrectomy combined with phacoemulsification for management of phacomorphic glaucoma
TECHNIQUE
Sutureless single-port transconjunctival pars plana limited vitrectomy combined with phacoemulsification for management of phacomorphic glaucoma Tanuj Dada, MD, Sanjeev Kumar, MBBS, Ritu Gadia, MD, DNB, Anand Aggarwal, MD, Viney Gupta, MD, Ramanjit Sihota, MD, FRCS
We describe a technique that uses a small-gauge, single-port, sutureless transconjunctival limited pars plana vitrectomy to facilitate phacoemulsification in eyes with a shallow anterior chamber and high intraocular pressure (phacomorphic glaucoma). These eyes have positive vitreous pressure, and anterior chamber formation with an ophthalmic viscosurgical device may not be possible. Surgery is difficult and prone to various intraoperative complications. J Cataract Refract Surg 2007; 33:951–954 Q 2007 ASCRS and ESCRS
Cataracts in eyes with a very shallow anterior chamber and high intraocular pressure (IOP) present difficult situations during phacoemulsification. These eyes have a positive vitreous pressure, and anterior chamber formation with an ophthalmic viscosurgical device (OVD) may not be possible. There is an increased risk for peripheral capsulorhexis tears, corneal decompensation, iris prolapse, and intraoperative suprachoroidal hemorrhage during cataract surgery.1,2 In eyes with phacomorphic glaucoma, swelling of the lens leads to a progressive reduction in the iridocorneal angle. Angle closure may be secondary to a pupillary block mechanism or it may be due to forward displacement of the lens–iris diaphragm. Pupillary block glaucoma is caused by changes in the size of the crystalline lens and its relatively anterior position. It is a common entity in developing countries owing to decreased awareness of the cataract and delay in having it removed and the preponderance of cortical matter compared with that in eyes in a western
Accepted for publication December 21, 2006. From the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Tanuj Dada, MD, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 110029, India. E-mail: [email protected]. Q 2007 ASCRS and ESCRS Published by Elsevier Inc.
population.3 Cataract extraction is the only definitive treatment for an intumescent cataract. The reported success following cataract surgery in phacomorphic eyes is less than that in eyes with age-related cataract.4–7 The anterior segment can be deepened prior to phacoemulsification in these eyes using a pars plana vitreous tap, described previously,8 or a mechanized cutter, described by Chang.9 We evaluated small-gauge pars plana vitrectomy as an aid to facilitate the surgical management of this common emergent condition. SURGICAL TECHNIQUE Step 1: Small-Gauge Limited Vitrectomy Surgery is performed under peribulbar anesthesia. An Eckardt trocar (23 gauge) and a pneumatic vitrectome (23 gauge/0.6 mm) system (DORC International) was used. The entry site of the vitrectomy probe is made 3.5 mm posterior to the limbus through the pars plana inferotemporally using an Eckardt pressure plate. A sclerotomy is made at the selected site using a special 23-gauge MVR blade (Figure 1, a). The 23-gauge trocar is introduced transconjunctivally through the sclerotomy (Figure 1, b). A 23-gauge, high-speed vitreous cutter (1500 cuts per minute) is then introduced through the trocar (Figure 1, c). A partial-core vitrectomy is performed (1000 cuts/min, 100 mm Hg vacuum) to decompress and soften the eye, and an OVD is injected simultaneously to deepen the anterior chamber through a clear corneal side-port incision. After the limited vitrectomy, the vitrectomy 0886-3350/07/$dsee front matter doi:10.1016/j.jcrs.2006.12.037
951
952
TECHNIQUE: SMALL-GAUGE LIMITED VITRECTOMY WITH PHACOEMULSIFICATION FOR PHACOMORPHIC GLAUCOMA
Figure 1. Performance of the 23gauge vitrectomy. a: MVR entry is made at the pars plana 3.5 mm from the limbus with an Eckardt plate in position. b: The trocar is introduced. c: The vitrectomy probe is inserted. d: The entry site is plugged.
probe is removed and a plug put over the trocar opening (Figure 1, d). The trocar is then removed and pressure applied with a swab stick over the scleral opening for 30 seconds. The natural elasticity of the sclera adequately approximates the sclerotomy wound so no sutures are required. Step 2: Phacoemulsification of the Nucleus Lens extraction using the phacoemulsification technique is performed through a superior clear corneal incision. The anterior capsule is stained with trypan blue to facilitate capsulorhexis. Standard phacoemulsification is performed using the stop-and-chop nucleotomy procedure followed by automated irrigation/aspiration and insertion of a foldable acrylic intraocular lens in the capsular bag. Results This technique was used in 2 cases of phacomorphic glaucoma with successful results and no complications. The first case was a 60-year-old man with an IOP of 54 mm Hg and visual acuity of hand movements close to the face. Preoperatively, the anterior chamber was very shallow (Figure 2, a) and ultrasound biomicroscopy (UBM) showed appositional closure of the anterior chamber angle (Figure 2, c). Small-gauge limited vitrectomy, as described above, was performed, followed by phacoemulsification (Figure 2, b). One day postoperatively, the visual acuity was 20/40 and the IOP was 14 mm Hg without
antiglaucoma medication. At 1 week, UBM showed wide-open angles (Figure 2, d). The second case was a 55-year-old woman with an intumescent lens, an IOP of 46 mm Hg, and visual acuity of hand movements close to face. One day postoperatively, the visual acuity was 20/30 and the IOP was 12 mm Hg with no medication. Neither case developed intraoperative complications such as extension of the capsulorhexis, iris prolapse, posterior capsule rupture, or suprachoroidal hemorrhage, and phacoemulsification was relatively easy. Indirect ophthalmological evaluation was done at 1 week and 4 weeks and no retinal tear, dialysis, or detachment was detected in either case. DISCUSSION A shallow anterior chamber with high IOP due to phacomorphic glaucoma is a common occurrence in developing countries. In this situation, most surgeons perform extracapsular cataract extraction because phacoemulsification is very difficult. Various intraoperative problems can be encountered: A clear corneal incision may be difficult to construct because of peripheral iridocorneal apposition or proximity; the chance of iris–instrument contact and iris prolapse, both of which cause intraoperative pupil constriction, may increase because of the anterior iris location; the use of a capsulorhexis forceps and other interventions for intraoperative pupillary enlargement may be constrained by a very shallow anterior chamber;
J CATARACT REFRACT SURG - VOL 33, JUNE 2007
TECHNIQUE: SMALL-GAUGE LIMITED VITRECTOMY WITH PHACOEMULSIFICATION FOR PHACOMORPHIC GLAUCOMA
953
Figure 2. a and b: Pre- and post-vitrectomy anterior chamber in a case of phacomorphic glaucoma. c and d: Preoperative and postoperative UBM of the same case showing opening of the anterior chamber angle.
capsulorhexis is difficult to control because of the increased convexity of the anterior capsule and tends to extend to the periphery; the risk for endothelial cell loss is greater because of the close proximity of the phaco tip during nucleus emulsification and the reduced endothelial reserve in these patients; and the chance of suprachoroidal hemorrhage is high due to rapid fluctuation of IOP during the procedure. Injection of any OVD to deepen the anterior chamber leads to excessive IOP elevation with corneal edema and iris prolapse and should be avoided. The use of a sutureless, small-gauge, pars plana partial-core vitrectomy is an effective technique to overcome these problems. The controlled debulking of the anterior vitreous leads to posterior displacement of the lens, deepening the anterior chamber and thus facilitating surgical manipulations within the chamber. The IOP is also lowered, decreasing the positive vitreous pressure and the chance of posterior capsule rupture, iris prolapse, and suprachoroidal hemorrhage. Thus, a controlled capsulorhexis and uneventful phacoemulsification are possible, with decreased risk for damaging the corneal endothelium. The limitations of this technique are that direct visual control is often not possible because of the dense cataracts and there is a small risk for retinal detachment, as reported after small-gauge vitrectomy for various posterior segment disorders.10,11 It is therefore essential that an indirect ophthalmological evaluation
be done in the immediate postoperative period and at the 4-week follow-up to rule out port-site dialysis and retinal tear or detachment. Many patients in developing countries cannot afford a foldable IOL so the incision has to be enlarged for insertion of a (PMMA) (polymethyl methacrylate) IOL, which can lead to iris prolapse and expulsive hemorrhage if the IOP is high. Decompressing the vitreous facilitates insertion of a large-optic PMMA IOL in such cases without any risk for intraoperative complications. Limited pars plana vitrectomy done through the small-gauge sclerotomy is a relatively simple technique that can easily be adopted by the anterior segment surgeon. No suturing is required as the natural elasticity of the sclera leads to close approximation of the wound. The technique facilitates phacoemulsification with IOL implantation in a high-risk situation and significantly decreases the risk for intraoperative complications. Further long-term studies are required to evaluate this technique in the management of eyes with phacomorphic glaucoma.
REFERENCES 1. Rao SK, Padmanabhan P. Capsulorhexis in eyes with phacomorphic glaucoma. J Cataract Refract Surg 1998; 24:882–884 2. Masket S, ed. Consultation section. Cataract surgical problem. J Cataract Refract Surg 2000; 26:12–20
J CATARACT REFRACT SURG - VOL 33, JUNE 2007
954
TECHNIQUE: SMALL-GAUGE LIMITED VITRECTOMY WITH PHACOEMULSIFICATION FOR PHACOMORPHIC GLAUCOMA
3. Pradhan D, Hennig A, Kumar J, Foster A. A prospective study of 413 cases of lens-induced glaucoma in Nepal. Indian J Ophthalmol 2001; 49:103–107 4. McKibbin M, Gupta A, Atkins AD. Cataract extraction and intraocular lens implantation in eyes with phacomorphic or phacolytic glaucoma. J Cataract Refract Surg 1996; 22:633–636 5. Jain IS, Gupta A, Dogra MR, et al. Phacomorphic glaucomad management and visual prognosis. Indian J Ophthalmol 1983; 31:648–653 6. Prajna NV, Ramakrishnan R, Krishnadas R, Manoharan N. Lens induced glaucomas – visual results and risk factors for final visual acuity. Indian J Ophthalmol 1996; 44:149–155 7. Angra SK, Pradhan R, Garg SP. Cataract induced glaucoma - an insight into management. Indian J Ophthalmol 1991; 39:97–101 8. Sethi H, Dada T. Pars plana vitreous tap in crowded eyes [letter]. J Cataract Refract Surg 2002; 28:1897 9. Chang DF. Pars plana vitreous tap for phacoemulsification in the crowded eye. J Cataract Refract Surg 2001; 27:1911–1914
10. Lakhanpal RR, Humayun MS, de Juan E Jr, et al. Outcomes of 140 consecutive cases of 25-gauge transconjunctival surgery for posterior segment disease. Ophthalmology 2005; 112:817– 824 11. Hilton GF, Josephberg RG, Halperin LS, et al. Office-based sutureless transconjunctival pars plana vitrectomy. Retina 2002; 22:725–732
J CATARACT REFRACT SURG - VOL 33, JUNE 2007
First author: Tanuj Dada, MD Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
Sutureless single-port transconjunctival pars plana limited vitrectomy combined with phacoemulsification for management of phacomorphic glaucoma Tanuj Dada, MD, Sanjeev Kumar, MBBS, Ritu Gadia, MD, DNB, Anand Aggarwal, MD, Viney Gupta, MD, Ramanjit Sihota, MD, FRCS
We describe a technique that uses a small-gauge, single-port, sutureless transconjunctival limited pars plana vitrectomy to facilitate phacoemulsification in eyes with a shallow anterior chamber and high intraocular pressure (phacomorphic glaucoma). These eyes have positive vitreous pressure, and anterior chamber formation with an ophthalmic viscosurgical device may not be possible. Surgery is difficult and prone to various intraoperative complications. J Cataract Refract Surg 2007; 33:951–954 Q 2007 ASCRS and ESCRS
Cataracts in eyes with a very shallow anterior chamber and high intraocular pressure (IOP) present difficult situations during phacoemulsification. These eyes have a positive vitreous pressure, and anterior chamber formation with an ophthalmic viscosurgical device (OVD) may not be possible. There is an increased risk for peripheral capsulorhexis tears, corneal decompensation, iris prolapse, and intraoperative suprachoroidal hemorrhage during cataract surgery.1,2 In eyes with phacomorphic glaucoma, swelling of the lens leads to a progressive reduction in the iridocorneal angle. Angle closure may be secondary to a pupillary block mechanism or it may be due to forward displacement of the lens–iris diaphragm. Pupillary block glaucoma is caused by changes in the size of the crystalline lens and its relatively anterior position. It is a common entity in developing countries owing to decreased awareness of the cataract and delay in having it removed and the preponderance of cortical matter compared with that in eyes in a western
Accepted for publication December 21, 2006. From the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Tanuj Dada, MD, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 110029, India. E-mail: [email protected]. Q 2007 ASCRS and ESCRS Published by Elsevier Inc.
population.3 Cataract extraction is the only definitive treatment for an intumescent cataract. The reported success following cataract surgery in phacomorphic eyes is less than that in eyes with age-related cataract.4–7 The anterior segment can be deepened prior to phacoemulsification in these eyes using a pars plana vitreous tap, described previously,8 or a mechanized cutter, described by Chang.9 We evaluated small-gauge pars plana vitrectomy as an aid to facilitate the surgical management of this common emergent condition. SURGICAL TECHNIQUE Step 1: Small-Gauge Limited Vitrectomy Surgery is performed under peribulbar anesthesia. An Eckardt trocar (23 gauge) and a pneumatic vitrectome (23 gauge/0.6 mm) system (DORC International) was used. The entry site of the vitrectomy probe is made 3.5 mm posterior to the limbus through the pars plana inferotemporally using an Eckardt pressure plate. A sclerotomy is made at the selected site using a special 23-gauge MVR blade (Figure 1, a). The 23-gauge trocar is introduced transconjunctivally through the sclerotomy (Figure 1, b). A 23-gauge, high-speed vitreous cutter (1500 cuts per minute) is then introduced through the trocar (Figure 1, c). A partial-core vitrectomy is performed (1000 cuts/min, 100 mm Hg vacuum) to decompress and soften the eye, and an OVD is injected simultaneously to deepen the anterior chamber through a clear corneal side-port incision. After the limited vitrectomy, the vitrectomy 0886-3350/07/$dsee front matter doi:10.1016/j.jcrs.2006.12.037
951
952
TECHNIQUE: SMALL-GAUGE LIMITED VITRECTOMY WITH PHACOEMULSIFICATION FOR PHACOMORPHIC GLAUCOMA
Figure 1. Performance of the 23gauge vitrectomy. a: MVR entry is made at the pars plana 3.5 mm from the limbus with an Eckardt plate in position. b: The trocar is introduced. c: The vitrectomy probe is inserted. d: The entry site is plugged.
probe is removed and a plug put over the trocar opening (Figure 1, d). The trocar is then removed and pressure applied with a swab stick over the scleral opening for 30 seconds. The natural elasticity of the sclera adequately approximates the sclerotomy wound so no sutures are required. Step 2: Phacoemulsification of the Nucleus Lens extraction using the phacoemulsification technique is performed through a superior clear corneal incision. The anterior capsule is stained with trypan blue to facilitate capsulorhexis. Standard phacoemulsification is performed using the stop-and-chop nucleotomy procedure followed by automated irrigation/aspiration and insertion of a foldable acrylic intraocular lens in the capsular bag. Results This technique was used in 2 cases of phacomorphic glaucoma with successful results and no complications. The first case was a 60-year-old man with an IOP of 54 mm Hg and visual acuity of hand movements close to the face. Preoperatively, the anterior chamber was very shallow (Figure 2, a) and ultrasound biomicroscopy (UBM) showed appositional closure of the anterior chamber angle (Figure 2, c). Small-gauge limited vitrectomy, as described above, was performed, followed by phacoemulsification (Figure 2, b). One day postoperatively, the visual acuity was 20/40 and the IOP was 14 mm Hg without
antiglaucoma medication. At 1 week, UBM showed wide-open angles (Figure 2, d). The second case was a 55-year-old woman with an intumescent lens, an IOP of 46 mm Hg, and visual acuity of hand movements close to face. One day postoperatively, the visual acuity was 20/30 and the IOP was 12 mm Hg with no medication. Neither case developed intraoperative complications such as extension of the capsulorhexis, iris prolapse, posterior capsule rupture, or suprachoroidal hemorrhage, and phacoemulsification was relatively easy. Indirect ophthalmological evaluation was done at 1 week and 4 weeks and no retinal tear, dialysis, or detachment was detected in either case. DISCUSSION A shallow anterior chamber with high IOP due to phacomorphic glaucoma is a common occurrence in developing countries. In this situation, most surgeons perform extracapsular cataract extraction because phacoemulsification is very difficult. Various intraoperative problems can be encountered: A clear corneal incision may be difficult to construct because of peripheral iridocorneal apposition or proximity; the chance of iris–instrument contact and iris prolapse, both of which cause intraoperative pupil constriction, may increase because of the anterior iris location; the use of a capsulorhexis forceps and other interventions for intraoperative pupillary enlargement may be constrained by a very shallow anterior chamber;
J CATARACT REFRACT SURG - VOL 33, JUNE 2007
TECHNIQUE: SMALL-GAUGE LIMITED VITRECTOMY WITH PHACOEMULSIFICATION FOR PHACOMORPHIC GLAUCOMA
953
Figure 2. a and b: Pre- and post-vitrectomy anterior chamber in a case of phacomorphic glaucoma. c and d: Preoperative and postoperative UBM of the same case showing opening of the anterior chamber angle.
capsulorhexis is difficult to control because of the increased convexity of the anterior capsule and tends to extend to the periphery; the risk for endothelial cell loss is greater because of the close proximity of the phaco tip during nucleus emulsification and the reduced endothelial reserve in these patients; and the chance of suprachoroidal hemorrhage is high due to rapid fluctuation of IOP during the procedure. Injection of any OVD to deepen the anterior chamber leads to excessive IOP elevation with corneal edema and iris prolapse and should be avoided. The use of a sutureless, small-gauge, pars plana partial-core vitrectomy is an effective technique to overcome these problems. The controlled debulking of the anterior vitreous leads to posterior displacement of the lens, deepening the anterior chamber and thus facilitating surgical manipulations within the chamber. The IOP is also lowered, decreasing the positive vitreous pressure and the chance of posterior capsule rupture, iris prolapse, and suprachoroidal hemorrhage. Thus, a controlled capsulorhexis and uneventful phacoemulsification are possible, with decreased risk for damaging the corneal endothelium. The limitations of this technique are that direct visual control is often not possible because of the dense cataracts and there is a small risk for retinal detachment, as reported after small-gauge vitrectomy for various posterior segment disorders.10,11 It is therefore essential that an indirect ophthalmological evaluation
be done in the immediate postoperative period and at the 4-week follow-up to rule out port-site dialysis and retinal tear or detachment. Many patients in developing countries cannot afford a foldable IOL so the incision has to be enlarged for insertion of a (PMMA) (polymethyl methacrylate) IOL, which can lead to iris prolapse and expulsive hemorrhage if the IOP is high. Decompressing the vitreous facilitates insertion of a large-optic PMMA IOL in such cases without any risk for intraoperative complications. Limited pars plana vitrectomy done through the small-gauge sclerotomy is a relatively simple technique that can easily be adopted by the anterior segment surgeon. No suturing is required as the natural elasticity of the sclera leads to close approximation of the wound. The technique facilitates phacoemulsification with IOL implantation in a high-risk situation and significantly decreases the risk for intraoperative complications. Further long-term studies are required to evaluate this technique in the management of eyes with phacomorphic glaucoma.
REFERENCES 1. Rao SK, Padmanabhan P. Capsulorhexis in eyes with phacomorphic glaucoma. J Cataract Refract Surg 1998; 24:882–884 2. Masket S, ed. Consultation section. Cataract surgical problem. J Cataract Refract Surg 2000; 26:12–20
J CATARACT REFRACT SURG - VOL 33, JUNE 2007
954
TECHNIQUE: SMALL-GAUGE LIMITED VITRECTOMY WITH PHACOEMULSIFICATION FOR PHACOMORPHIC GLAUCOMA
3. Pradhan D, Hennig A, Kumar J, Foster A. A prospective study of 413 cases of lens-induced glaucoma in Nepal. Indian J Ophthalmol 2001; 49:103–107 4. McKibbin M, Gupta A, Atkins AD. Cataract extraction and intraocular lens implantation in eyes with phacomorphic or phacolytic glaucoma. J Cataract Refract Surg 1996; 22:633–636 5. Jain IS, Gupta A, Dogra MR, et al. Phacomorphic glaucomad management and visual prognosis. Indian J Ophthalmol 1983; 31:648–653 6. Prajna NV, Ramakrishnan R, Krishnadas R, Manoharan N. Lens induced glaucomas – visual results and risk factors for final visual acuity. Indian J Ophthalmol 1996; 44:149–155 7. Angra SK, Pradhan R, Garg SP. Cataract induced glaucoma - an insight into management. Indian J Ophthalmol 1991; 39:97–101 8. Sethi H, Dada T. Pars plana vitreous tap in crowded eyes [letter]. J Cataract Refract Surg 2002; 28:1897 9. Chang DF. Pars plana vitreous tap for phacoemulsification in the crowded eye. J Cataract Refract Surg 2001; 27:1911–1914
10. Lakhanpal RR, Humayun MS, de Juan E Jr, et al. Outcomes of 140 consecutive cases of 25-gauge transconjunctival surgery for posterior segment disease. Ophthalmology 2005; 112:817– 824 11. Hilton GF, Josephberg RG, Halperin LS, et al. Office-based sutureless transconjunctival pars plana vitrectomy. Retina 2002; 22:725–732
J CATARACT REFRACT SURG - VOL 33, JUNE 2007
First author: Tanuj Dada, MD Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India