Case Presentation
This case is based on a patient who was referred to me for treatment. The primary surgeon performed phacoemulsification on a 55-year-old myopic patient (-5.00, axial length, 26.00 mm). As the surgeon introduced the phaco tip in the anterior chamber through a clear corneal incision, he wound up with one of the deepest anterior chambers that he had ever seen—the crystalline lens was pushed back to the center of the eye! He next lowered the infusion without any effect. The incision was 3.00-mm watertight, and the surgeon decided to enlarge it, however, the anterior chamber was as deep as in the beginning; he had claimed that it seemed almost impossible to continue. The surgeon continued to work deep in the eye without a clear focus. The extreme deep anterior chamber remained deep during the whole procedure. It returned to normal only when the surgeon filled it with viscoelastic while implanting the IOL.
1. What is a technique that will give the surgeon excellent control of such a case?
2. Are there other situations for which the surgeon should consider this technique?
3. What steps are essential to protecting the corneal endothelium as well as the posterior capsule?
4. Can this technique become the method of choice for the majority of cases, routine as well as complicated?
SURGICAL COURSE
A similar case comes to mind in which I was able to predictably and reliably handle cataract extraction in an extremely hypotonic patient. A 67-year-old female presented with visual acuity that was so compromised secondary to cataract formation, that she was unable to continue her work. She was extremely myopic most of her life (-10 D) and had severe pseudoexfoliation.
As soon as I created the paracenthesis incision, the anterior chamber collapsed, and instillation of the viscoelastic pushed the cataractous lens deeply into the eye necessitating nearly vertical positioning of the cystatome and forceps to perform capsulorhexis.
Realizing that if I attempted to phaco the cataract so deeply situated, I would not be in optimum control of my phaco tip with the potential of untoward sequelae, I decided to bring the cataract out of the capsular bag and into the anterior chamber by exaggerating hydrocortical cleavage until the lens tilted out of the capsulorhexis, and then I instilled viscoelastic material into the capsular bag. This maneuver stabilized the tilted lens and allowed me to easily carousel it out of the bag and into the anterior chamber where, after bathing it in a protective coat of viscoelastic, I prechopped the cataract and phacoemulsified the lens with a minimum of ultrasound energy.
OUTCOME
Every cataract surgeon has had to operate on patients who present challenges to “in-the-bag” phacoemulsification such as patients with zonularlysis, severe pseudoexfoliation, iris schisis, and as in this case, extreme hypotony. I have found that returning the cataractous nucleus to the anterior chamber is an excellent and safer way to handle these challenging cases. The unknowing co-conspirators in this, my latest technique, read like the “Who's Who” in phacoemulsification. Chronologically, they are as follows: Charles Kelman, MD, who initially phacoemulsified the nucleus in the anterior chamber. Lack of viscoelastic with resultant compromised corneas led to “in-the-bag” procedures, and the various cracking techniques ensued until Dr. Ken Nagahara's “phaco chop” which was modified by Dr. Paul Koch's “stop and chop.” They are all very efficient methods, but they are still in the bag. David C. Brown, MD, began to revisit the anterior chamber by flipping the lens out of the bag. Bill Maloney, MD, went one step further and repositioned the flipped nucleus under the iris in which he refers to “supracapsular space.” I recently wrote a series of articles on a technique I called “phaco seduction” in which I address the two major problems of anterior chamber phacoemulsification maintaining capsulorhexis integrity and endothelial protection. The best of both worlds lies in the marriage of all of the above—chop-type phaco performed with the lens out of the bag floating in a protective layer of viscoelastic away from the capsular bag and zonules, and a safe distance from the corneal endothelium.
I am happy to report that the patient achieved a 20/20 result with this technique. I have designed a series of instruments to facilitate this procedure, however, the most “important” instrument is the viscoelastic. It must not be too cohesive, otherwise, it will not protect the endothelium. On the other hand, if it is not cohesive enough, it will increase the temperature and intensify the risk of corneal burn. Although I initially reserved this procedure for the previously mentioned case, I have now adopted this technique for most of my cases.
Robert E. Kellan, MD, is in private practice in Boston, MA, and is Assistant Professor of Ophthalmology at Boston University, and he is also Director of Kellan Eye Center. He may be reached at (508) 682-8661; bobkellan@webtv.net
