This case contains several challenges that surgeons often see independently but sometimes encounter in combination. After trauma, this eye had an atonic, enlarged, fibrotic pupil; at least 6 clock hours of zonular loss; vitreous prolapsed into the anterior chamber; and a traumatic cataract with an anterior capsular fibrotic scar. The patient suffered not only reduced vision but significant photic symptoms as well.
VITREOUS MANAGEMENT
The vitreous should be managed first in any case where it has presented around the cataract into the anterior segment. I am an advocate of single-port vitrectomy using a pars plana cannula and trocar system, which provides the multiple advantages of pulling vitreous back into the posterior segment rather than forward into the anterior chamber. The system minimizes traction on the vitreous by entering the vitreous cavity through a cannula, which provides the maximal range of safety from the vitreous base. Anterior irrigation creates an anterior-to-posterior pressure gradient. Taking care to avoid the capsule, I removed the vitreous from the area in which it had prolapsed by severing the attachments to the posterior segment.
CAPSULORHEXIS
After removing the offending vitreous, I pressurized the chamber with an ophthalmic viscosurgical device to prevent further prolapse. Maintaining a high anterior chamber pressure throughout the procedure was critical. I painted trypan blue stain across the anterior capsule, both to enhance visualization and to aid my creation of the capsulorhexis by reducing the elasticity of the capsule. When the continuous curvilinear capsulorhexis reached an impenetrable area of fibrosis, I used a 23-gauge microscissors to cut the capsule and continue the tear. The key to success here was to begin the snip proximal to the point at which the tear halted so as to incorporate this junction into the removed piece (Figure).
STABILIZATION AND IMPLANTATION OF THE IOL
Hydrodissection and repeated viscodissection with a dispersive agent helped to keep the capsular equator from the phaco tip. At one point, I also used the elbow of the chopper to stent the fornix. Certainly, capsule hooks placed in this meridian also could have made this maneuver easier.
A type 1-G Cionni Ring for Sclera Fixation (Morcher GmbH, distributed in the United States by FCI Ophthalmics, Inc.) was preloaded with a CV-8 Gore- Tex suture (off-label use; W. L. Gore & Associates, Inc.). I inserted the ring into the capsular fornix with the fixation element rotated to the area of greatest weakness. Next, I created two scleral wall openings about 3.5 mm apart at the level of the ciliary sulcus/pars plicata. A microtying forceps was placed through each opening and retrieved the respective blunt suture end from the anterior chamber. With a pressurized globe, the Gore-Tex suture was snugged externally to provide just enough tension to center the bag and IOL. I then tied the suture with a 2-1-1 knot and trimmed the tags. The knot was tucked inside the scleral wall.
FINISHING STEPS
I repaired the iris with several imbricating 10–0 Prolene sutures (Ethicon, Inc.) and tied them with the Siepser sliding knot.
After removing the ophthalmic viscosurgical device and instilling carbachol intraocular solution (Miostat; Alcon Laboratories, Inc.), I removed the pars plana cannula and confirmed that the incisions were secure. A most satisfactory result was obtained.
Michael E. Snyder, MD, is in private practice at the Cincinnati Eye Institute and is a voluntary assistant professor of ophthalmology at the University of Cincinnati. He is a consultant to Alcon Laboratories, Inc. Dr. Snyder may be reached at (513) 984-5133; msnyder@cincinnatieye.com.
