INTRA-OPERATIVE MANAGEMENT OF CATARACT SURGERY COMPLICATIONS Dr. H. Razmjoo Isfahan University of Medical Sciences
1- Loose zonules & Phacodonesis 2- Lens subluxation 3- Miotic pupil 4- Glucomatus cases with shallow AC 5- Brunescent lenses 6- High refractory errors High Risk Cases for VL
7 -Pseudoexfoliation Syndrome 8 -Traumatic Cataract 9- Fellow eye of Complicated Cataract Surgery 10 - Eyes with Transillumination defects in Iris 11- Previously Vitrectomized eyes 12- Hypermature cataracts 13- Very Aged patient 14- Intra operative floppy iris syndrome
Chopping technique is preferred for phacoemulsification Use CTR Lens removal in the presence of severe phacodonesis can be facilitated by temporary suspension of the capsule using iris hooks. Management of Phacodonesis
A capsular tension ring alone is not sufficient if the zonular defect is larger than 5 h (150 Degree)
Capsule Tension Rings Dialysis of 2–3 h (<90°)—CTR is an option, not a necessity. Dialysis of 3–5 h (90–150°)—CTR is required to assure capsular stability and IOL centration. Dialysis of 5–7 h (150–210°)—CTR can be used, but may not be sufficient. The lens or the ring should also sutured to adjacent structures.
Dialysis of more than 7 h usually requires complete lens removal and implantation of an AC-IOL (angle or iris supported) or PC-IOL sutured to the sclera and/or iris.
Insertion of CTR An intact capsular bag and a continuous capsulorhexis are prerequisites for using a CTR.
Starting the surgery Intracameral 0.5 cc of unpreserved lidocaine 1% with 1:100,000 unpreserved epinephrine. Injection of viscoelastic. Inspection of the iris with an instrument to identify synechia.
The most common cause of a small surgical pupil is the pseudoexfoliation syndrome.
Methods of pupil dilation (1) Two-Instrument Iris Stretch
Methods of pupil dilation (2) use of instruments that have been designed to produce a three- or four- point stretch with one hand.
Methods of pupil dilation (3) Iris retractors There are both nylon and titanium iris retractors available to dilate the pupil.
Methods of pupil dilation (4) Pupil Expanders: silicone or PMMA
Methods of pupil dilation (5) Multiple Sphincterotomies
Broken capsules occur at a rate between 0.45% for very experienced surgeons And up to 14.7% for residents in training. Broken capsules occur at a rate between 0.45% for very experienced surgeons And up to 14.7% for residents in training.
FIRST Do not pull out of the eye when recognizing a complication. The phaco tip between the lips of the wound controls the intraocular environment.
Upon recognition of a problem go to foot position zero but do not move the phaco tip. Remove the non-dominant hand instrument from the paracentesis Prepare to inject OVD (Ophthalmic Viscosurgical Device ) through the paracentesis incision.
Only after OVD injection can the phaco tip be withdrawn from the eye. If not, the chamber will collapse and the stage of complication may progress from capsular rupture to vitreous prolapse or to vitreous loss.
Avoid reintroduction of intracameral unpreserved 1% xylocaine with broken zonules or a capsule rupture. There will be a transient amaurosis, This can be disconcerting or even frightening to both patient and surgeon.
compartmentalization with a dispersive OVD. If the rent in the posterior capsule is central, this must be converted to a circular posterior capsulorhexis
Tear is redirected to a posterior capsulorrhexis
Posterior chamber nuclear fragments must be raised above the iris plane into the anterior chamber with OVD.
If the lens fragment is below the posterior capsule and has descended into the posterior segment, the fragments should be left in place for later removal with a full three-port pars plana vitrectomy.
Lens material cannot damage the retina, unless manipulated by a surgeon. Posterior assisted levitation to raise a dropped nucleus into the anterior chamber for removal creating unsafe vitreoretinal traction.
If a capsular defect is observed and the nucleus has not dropped, viscoelastic injection should be used to create a barrier over the capsular defect.
If the nucleus drops…. Focus upon safe management of the vitreous. Consider lens implantation Manage the wound Refer to posterior segment surgeon
The timing of the deep vitrectomy is determined on an individual case basis. Early vitrectomy (fewer than 3 weeks) was associated with better visual results.
Continue Phaco… It is essential there be no admixture of vitreous and lens material. vitreous will be attracted to the phaco port displacing nucleus and preventing aspiration of lens material with a high likelihood of retinal tear and detachment.
Unless vitreous can be isolated and compartmentalized away from lens fragments, the phaco hand piece should not be used.
In the presence of a controlled capsule tear Tear must be adequately covered by OVD, or a lens glide to minimize the risk of forcing nuclear fragments posteriorly or displacing vitreous.
Small rent in post capsule Lowering the infusion bottle Full occlusion of the aspiration port Minimal phaco power. Will reduce the risk of further damage to the capsule and aspiration of vitreous.
Capsular rupture If the majority of the nucleus remains and the capsular tear is large further attempts at phaco should be abandoned.
A slow motion technique should be employed with low flow, moderate vacuum and appropriate pulses of energy adequate flow to avoid wound burn to promote follow ability and to minimize chatter.
How convert to ECCE? Choose the incision based on the size of the remaining fragments. If the fragment is judged to fit 4mm, the clear corneal incision can be utilized.
If you need > 4mm incision Move superiorly and perform an adequate limbal or scleral tunnel incision appropriate to the fragment size.
Removal of remained lens material. Surgeon should enlarge the incision and remove the nucleus with a lens loop or spoon.
Do not express with external pressure Remove the fragment with a cystotome, forceps or a vectus glide
Vitreous is virtually invisible Preservative free triamcinolone acetate (Kenalog) particulate marking of the vitreous should be used to identify its presence and to delineate the extent of prolapse.
Insertion of a second instrument On lens glide behind the nuclear remnant may help prevent its dislocation in to the vitreous.
Remove as much triamcinolone as possible. Some patients may show a steroid response of ocular hypertension.
Cellulose sponges are used by many surgeons for anterior vitrectomy as well as for testing for vitreous in the anterior chamber, in the wound, or on the iris.
It inherently causes marked instantaneous vitreoretinal traction.
Traction on the anterior vitreous is particularly dangerous because of proximity to the vitreoretinal adherence at the vitreous base peripheral retina is more fragile
The vitreous cutter should be used to amputate any posterior connection to wound-entrapped vitreous. In some instances OVD can be used to reposit vitreous.
Vitrectomy Perform anterior vitrectomy to avoid vitreous prolapse.
Cut rate: Fast cutting rate reduces vitreoretinal traction. Fast cut increase fluidic stability
Suction: Low suction levels and low flow rates are safer. The suction or flow rate should be slowly increased until vitreous starts being removed.