When a bad outcome occurs in a patient’s first eye and he or she ultimately decides to proceed with surgery on the second eye, the potential for disaster that day in the OR is palpable. This article details my worst case ever and how I avoided totally blinding the patient when it came time to operate on her second eye.
HISTORY AND PHYSICAL
The patient was a pleasant, frail, 90-year-old woman with a visual acuity of 20/60 OU. The examination was relatively normal and revealed 3+ nuclear sclerosis bilaterally. The corneas were healthy and the anterior chambers adequately deep, but her pupils only dilated to about 5 or 6 mm. The patient had pseudoexfoliation (PXF) in both eyes, but this diagnosis was missed in her first eye due to the mildness of the condition and the poorly dilating pupils. The case should have been routine.
THE FIRST EYE
Signs of Trouble
I decided first to operate on the patient’s right eye using topical anesthesia and a bimanual phaco technique. Because the pupil dilated to between 6 and 7 mm, a pupil ring and hooks seemed unnecessary. I completed the capsulorhexis without difficulty using microincisional forceps and perceived no zonular weakness. Immediately after cortical cleaving hydrodissection and decompression of the lens, however, the inferior pole of the lens dropped posteriorly at a 30° angle. I made a paracentesis inferiorly and attempted to place a capsular hook along the inferior capsulorhexis, but the distance was too great to engage the capsule’s edge with the hook.
In retrospect, I could have tried to lift the inferior portion of the lens by passing a cyclodialysis spatula through the superior bimanual incision, placing the spatula under the capsulorhexis, and lifting anteriorly, after which I could have engaged the capsulorhexis with the capsular hook. Another option would have been to place hooks in the horizontal meridians and then to lift and support the lens while working my way inferiorly with additional hooks until the inferior pole of the lens rose enough anteriorly for me to place the final inferior hook. In the heat of the moment, I did not consider these options.
Instead, I created a 2.2-mm temporal incision to permit the placement of a capsular tension ring (CTR), with the hope that this device might help me to better orient the lens for the capsular hook’s placement. During insertion of the CTR with an injector (Geuder AG, Heidelberg, Germany), the lens demonstrated further posterior instability. I decided to retract and remove the CTR and convert to a posterior-assisted levitation (PAL) of the entire lens—a decision I would soon regret.
A Bold Move
I passed a single 10–0 nylon suture through the 2.2-mm incision, and the patient received a retrobulbar injection of lidocaine and bupivacaine for the ensuing maneuvers. After the anesthesia, I placed five iris hooks around the pupil to help avoid iris trauma during the PAL. I made an inferotemporal peritomy, followed by scleral cautery and the creation of a 20-gauge pars plana incision 3.5 mm posterior to the limbus. I placed a viscoelastic cannula through the pars plana incision and injected a dispersive viscoelastic behind the lens, which I then prolapsed into the anterior chamber using the cannula (Figure 1). After removing the iris hooks, I widened the clear corneal incision to 8 mm using a diamond keratome. Next, I removed the cataract with a lens loop and placed two 10–0 nylon sutures to stabilize the anterior chamber.
There was significant vitreous prolapse, which I excised from the wound with a Westcott scissors. I decided to perform an anterior vitrectomy before placing additional sutures in order to avoid incarcerating more vitreous within the wound—another decision I would soon regret.
Disaster With an Audience
After injecting Miochol-E (Bausch + Lomb) into the anterior chamber, I performed an anterior vitrectomy with a high cutting rate and low vacuum. The vitrectomy proceeded routinely with what I believed to be adequate anterior chamber infusion, but the lack of a watertight wound allowed enough balanced salt solution to exit the eye to create relative hypotony. Five minutes into the vitrectomy, a dark mound suddenly appeared, its origins in the inferotemporal red reflex (Figure 2). Several seconds later, the red reflex was gone. I had never seen a choroidal hemorrhage through the operating microscope before, but I had enough sense to recognize what was happening.
I do not often encounter complications, but when they occur, for some reason, a visiting ophthalmologist is usually in the OR. This day was no different. The Iranian ophthalmologist looking over my shoulder seemed vibrant with joy over the “learning experience” this US doctor was giving him.
Somehow, I secured the wound without an expulsion of the intraocular contents, and then I cleaned up the vitreous to the best of my abilities. The retinal specialist at the practice performed two choroidal drainages over the next month. I sheepishly brought the patient back to the OR for a pupilloplasty and insertion of an ACIOL using an anterior chamber maintainer to keep the eye pressurized. Her final visual acuity was between 20/80 and 20/100.
THE SECOND EYE
The patient declined further surgery until the visual acuity in her unoperated eye dropped to 20/200 from 4+ nuclear sclerosis several years later. Despite the abysmal result in her first eye and my attempts to palm this patient off on my partners, she requested that I perform the surgery on her left eye. I, in turn, asked that the retinal specialist be present in the OR during the procedure—preferably holding my hand—in case the same situation developed.
After the eye was blocked, the case unfortunately proceeded along the same course as the first surgery. The zonules appeared fine during the capsulorhexis’ formation, so I did not place capsular hooks. By the time I realized the inferior pole of the lens had poor support, it was too late. As the crystalline lens hung by a few remaining zonules, I was more than happy to hand off the dropping lens to my retinal colleague for an appropriate pars plana approach. Interestingly, he commented that there appeared to be a small choroidal hemorrhage in the patient’s second eye. This finding suggested that, if I had been foolish enough to attempt a PAL in this case, the final result might have been disastrous. An ACIOL was placed at the time of the lensectomy, and the patient’s final visual acuity was 20/40 OS. She was thrilled, and I was relieved.
These experiences gave me a newfound caution with regard to 90-year-old patients with PXF. Progressive zonular degradation occurs with increasing age, and I consider these individuals to be at high risk regardless of the degree of nuclear sclerosis. Ordinarily, I am very lowkey regarding cataract patients and inform them that they may have surgery whenever they are ready. When PXF patients ask me when they should have surgery, I now tell them the sooner, the better. Moreover, I routinely place CTRs in these cases and have capsular hooks at the ready.
Hindsight is 20/20. In retrospect, I should have made more of an attempt to extract this woman’s first cataract through a small incision. A more aggressive use of capsular hooks might have allowed me to remove the lens with phacoemulsification. Even if the bag could not have been salvaged, I might have avoided a prolonged vitrectomy and an 8-mm incision.
After enlarging an incision for a PAL, I now know to suture the wound until it is watertight despite vitreous prolapse. Incarcerated vitreous can be cut free using the vitrector. I can then replace sutures one by one until the wound is cleared of severed vitreous. By only placing two sutures in the wound with the hope that I could clear the vitreous before placing additional sutures, I set my patient up for a choroidal hemorrhage from hypotony.
Second eyes many times mimic first eyes. By having the retina surgeon in the OR for the surgery, under the assumption that the same course of events might happen, I was able to hand the case off before attempting another PAL. My colleague was thus able to remove the lens in a safer fashion with an appropriately pressurized globe, and the patient achieved a better outcome.
Section Editor David F. Chang, MD, is a clinical professor at the University of California, San Francisco. Dr. Chang may be reached at (650) 948-9123; email@example.com.
Richard S. Hoffman, MD, is a clinical associate professor of ophthalmology at the Casey Eye Institute, Oregon Health & Science University, and he is in private practice at Drs. Fine, Hoffman & Packer in Eugene, Oregon. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Hoffman may be reached at (541) 687-2110; firstname.lastname@example.org.