A 13-year-old black male was trying to re-twist a wire coat hanger back into its original form when the metal end snapped into his left eye. The patient's emergency eye care included repairing an irregular, full-thickness corneal laceration. After 3 weeks, he was referred to our medical center for further treatment. Upon initial examination, the patient's BCVA was light perception. His eye examination revealed a well-repaired horizontal corneal laceration, and the anterior chamber had 1+ cell. The anterior lens capsule appeared to have been pierced, and the capsule adhered to the corneal wound. The lens was dense white and there was no view of the retina. I obtained a B-scan that revealed echoes consistent with a vitreous hemorrhage and no obvious detachment.
1. How would you approach the cataract removal?
2. How could you improve the surgeon's visibility?
3. What type of lens would you use?
4. What prognosis would you provide to the patient and family?
Prior to the operation, I felt it was necessary to have a discussion with the patient and his family that included an honest, detailed assessment of the injuries and the potential limits of the surgery. This dialogue included the fact that I was unable to examine the retina, and therefore unable to comment on the patient's ultimate prognosis. Because the anterior capsule was not intact, I determined the need for prompt lens removal, and we chose to defer further corneal surgery.
I obtained parental consent for cataract surgery, IOL implantation, potential vitrectomy, and posterior segment surgery. In addition, I performed A-scans on both eyes for anterior and posterior chamber lens calculations. (Note that a retina specialist had seen the patient preoperatively.) I decided to use general anesthesia due to the patient's age and our inability to predict the length of the operation. Once the patient was intubated, I gently prepped and draped the eye. I chose a temporal approach for the improved visibility. I created a paracentesis at the
1 o'clock position, and I used a Kuglen hook (Katena Products, Inc., Denville, NJ) to evaluate the adherence of the capsule to the repaired corneal laceration. I made a few gentle passes with this instrument in an attempt to tease the capsule out. Once I determined that this was not a successful maneuver, I stopped and focused my attention on the fact that I had a compromised view of the anterior chamber due to the corneal injury. Because adequate visualization is critical for successful cataract surgery, I employed capsule staining as a visual aid. By using dye, I was able to enhance the contrast of the capsule and the cortex. (This is an off-label use of indocyanine green [Akorn, Inc. Buffalo Grove, IL].) The solution is prepared by carefully mixing ICG, 25 mg in 0.5 mL of aqueous solvent mixed with 4.5 mL of BSS plus (Alcon Laboratories Fort Worth, TX).
I placed an air bubble into the anterior chamber and a small amount of Viscoat (Alcon Laboratories) into the paracentesis to keep the air in the anterior chamber. I then placed six to eight drops of the dye onto the capsule using a 30-gauge cannula on a 1-mm syringe. After 15 seconds, I irrigated the anterior chamber using BSS. I filled the anterior chamber with Viscoat to protect the cornea and to maintain the chamber.
In order to create a near-clear, 3-mm corneal incision at the 3 o'clock position, I used the Rhein 3-D diamond blade (Rhein Medical, Inc., Tampa FL). I used a Vannas scissors (Katena Products, Inc.) (Figure 1) to gently cut the tented capsule away from the repaired corneal laceration, and I used a cystitome to pierce the anterior capsule to create a flap. Finally, I used a Utrata forceps (Duckworth & Kent, St. Louis, MO) (Figure 2) to create a continuous curvilinear capsulorhexis. The capsulorhexis was continued up to the sight of the trauma, and after two attempts, I concluded I could not continue around the trauma site. I then returned to the origin of the continuous curvilinear capsulorhexis, and I used the cystitome to nick the capsule and the utrata to continue the capsulorhexis in the opposite direction up to the trauma site.
Because this was a traumatic cataract, I was unsure of the integrity of the posterior capsule, and I elected not to hydrodissect the lens. I was quite sure that I would be able to remove the cataract without phacoemulsification due to the patient's age. I used the I/A handpiece to gently aspirate the cataract, which worked quite well and without difficulty (Figure 3). Once this was completed, I inspected the anterior chamber to ensure that it did not contain any vitreous. Upon inspecting the posterior capsule, I observed that it was intact and the anterior puncture appeared to be limited. I gently inflated the capsule and anterior chamber with ProVisc (Alcon Laboratories). I placed an MA60 acrylic lens (Alcon Laboratories) in the bag; I chose an acrylic lens because it is an excellent lens that can be placed into a capsular bag with an incomplete capsulorhexis. I suspected that this patient would require retinal surgery and perhaps silicone oil in the future. A silicone lens would be a poor choice due to the tendency of silicone oil to accumulate on a silicone lens. Finally, if we needed to exchange the lens in the future, the acrylic is easily folded inside the eye and removed through a small incision.
I used I/A to remove the viscoelastic, placed a 10–0 nylon (Ethicon, Cornelia, GA) suture into the temporal incision, and performed an indirect fundoscopic examination in order to evaluate the posterior segment. Our suspicion of a vitreous hemorrhage was confirmed. Unfortunately, this was accompanied by a temporal retinal tear with subretinal and choroidal hemorrhage. The retinal team was invited into the operating room and performed a posterior vitrectomy along with a focal laser and scleral buckle. The team filled the posterior chamber with silicone oil.
On postoperative day 1, the patient's vision was 20/400 uncorrected. His IOP was 24 mm Hg. Two months postoperatively, after the removal of silicone oil, his vision improved to 20/100. Future surgical plans for this patient involve possible corneal surgery.