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Cataract Surgery: Point/counterpoint | Feb 2011

What to Do When Phacoemulsification Goes Bad

Keep the incision small.

Keep the incision small.

DAVID A. GOLDMAN, MD

During phacoemulsification, if the posterior capsule tore and nuclear material remained, I would first inject a dispersive viscoelastic to stabilize the anterior chamber and prevent vitreous prolapse. My options would then be as follows. I could enlarge the original corneal incision or create a scleral tunnel incision and convert to an extracapsular cataract extraction (ECCE). Alternatively, I could continue phacoemulsification using modified settings. I favor the second approach.

ENLARGING THE INCISION
The majority of cataract surgeons today perform phacoemulsification under topical anesthesia. Continuing topical anesthesia and enlarging the corneal wound to remove the nuclear fragments could induce significant astigmatism and dry eye as well as increase regular and possibly irregular astigmatism. Furthermore, manipulation of the iris or the IOL’s insertion might cause the patient discomfort that would lead to eyelid squeezing, which, with a larger wound, might result in devastating complications.

CONVERTING TO AN ECCE
Creating a scleral tunnel incision for the conversion to an ECCE technique would require blocking the eye while the patient was on the table. Although a retrobulbar block can be performed after capsular rupture, the posterior pressure exerted for the block on this now unicameral eye could be a setup for vitreous prolapse or, worse, a suprachoroidal hemorrhage. There are risks even in cases where the patient’s eye has been blocked preoperatively. Because the posterior capsule has been compromised, any manipulation to express lenticular material might result in vitreous prolapse. A vitrectomy should be performed in a closed system; attempting a vitrectomy via an extracapsular wound would be ineffective and unsafe. Although the enlarged incision could temporarily be closed and a second incision made for a vitrectomy, three large incisions would then have been created, which would have cut multiple corneal nerves and raised the risk of a postoperatively neurotrophic cornea. Folding and inserting an IOL into this eye might cause further vitreous loss, which would necessitate challenging maneuvers to clear the anterior chamber at the end of the case.

The integrity of large extracapsular incisions, even if “completely healed,” is never perfect. As the baby boomers age, more people will trip and fall, which will translate into a higher incidence of traumatic rupture of these wounds with destructive outcomes. Finally, the majority of US residency programs today do not provide sufficient training for graduating ophthalmologists to feel comfortable with the ECCE technique.

KEEPING THE INCISION SMALL
If I keep the incision small, I can often safely remove the cataractous material with a careful technique and use of a viscoelastic. Should vitreous prolapse, I can perform an anterior vitrectomy. Staining the vitreous with triamcinolone helps to ensure complete cleanup.

I can employ a posterior-assisted levitation (PAL) technique if nuclear material descends posteriorly. Several studies have demonstrated the PAL approach’s safety.1-3 If cataractous material descends too posteriorly or the surgeon is uncomfortable with PAL techniques, he or she can allow the cataract to fall and ask a retinal colleague to recover it later. The retinal specialist will likely also prefer to operate on an eye with smaller wounds than one with a large extracapsular incision. Today’s retinal surgeons are experts at removing retained nuclear material. If a vitrectomy is performed relatively quickly, there should not be any negative consequences, particularly if the patient is appropriately managed pharmacologically with steroids, nonsteroidal anti-inflammatory drugs, and antibiotics.

As for the IOL’s insertion, I believe that keeping the incision small allows for safer implantation. Three-piece lenses dense nuclear cataract with a low endothelial cell count, zonular laxity or dialysis, poor visualization, and a capsular tear that has gone posteriorly2 (Figure 2). For example, in an eye with endothelial instability, a posterior capsular tear, and a dense nucleus, the surgeon will likely be unable to continue phacoemulsification without a significant risk of corneal decompensation and/or loss of a nuclear fragment into the vitreous. Hard nuclei can lead to prolonged phaco times and corneal decompensation. A tightly constructed incision with an extended phaco time can result in a corneal thermal burn. Surgeons with less clinical experience may be wise to convert to an ECCE early, whereas more experienced surgeons may be able to manage a difficult situation.

Dada et al3 performed a retrospective review of 540 eyes undergoing clear corneal phacoemulsification by an experienced surgeon in India. They found a 3.7% rate of conversion to ECCE (20 cases). The reasons for conversion were pupillary miosis (six cases), posterior capsular rupture (five cases), prolonged phaco time (four cases), posterior extension of the capsulorhexis (two cases), corneal thermal burn (one case), subluxation of the lens (one case), and malfunctioning of the phaco handpiece (one case). Mean endothelial cellular loss was 14.8% in patients undergoing conversion to an ECCE. Ninety percent (18 cases) achieved a visual acuity of 20/40 or better at 6 weeks.

CONCLUSION
Although ECCE patients have a lengthier recovery time and the larger incision is associated with a greater degree of astigmatism, a skilled surgeon can minimize these disadvantages by means of a streamlined approach to ECCE and appropriate management of astigmatism postoperatively. No matter how experienced the surgeon may be, however, it is important that he or she know how and when to switch to an ECCE—before any complications may arise.

Ultimately, the decision to convert to an ECCE can occur at any time during the pre- or intraoperative period. The surgeon must determine how a case can most safely be carried out based on his or her surgical experience and ability. In situations of zonular instability, dense nuclear lenses, and unstable posterior capsular tears, changing to an ECCE is an appropriate alternative to continuing phacoemulsification.

Richard E. Braunstein, MD, is the Miranda Wong Tang professor of clinical ophthalmology and the chief of the Division of Anterior Segment and Refractive Surgery at the Edward S. Harkness Eye Institute of Columbia University Medical Center in New York. Dr. Braunstein may be reached at (212) 305-3015; reb10@columbia.edu.

Anu P. Gupta, MD, is the cornea fellow at the Edward S. Harkness Eye Institute at Columbia University Medical Center in New York. Dr. Gupta may be reached at (212) 305-3015; apg2126@columbia.edu.

  1. Henderson BA.Essentials of Cataract Surgery.Thorofare,NJ:Slack Inc.:2007.
  2. Weinstock R,Desai N.Successful management of complicated cataract cases.Ophthalmology Management.May 2009.http://www.ophmanagement.com/article.aspx?article=102956.Accessed January 10,2011.
  3. Dada T,Sharma N,Vajpayee RB,Dada VK.Conversion from phacoemulsification to extracapsular cataract extraction: incidence,risk factors,and visual outcome.J Cataract Refractive Surg.1998;24(11):1521-1524.

 

Convert to extracapsular cataract extraction.
BY ANU P. GUPTA, MD, AND RICHARD E. BRAUNSTEIN, MD

The decision to convert to anextracapsular cataract extraction(ECCE) often comes at astressful and challengingmoment in the OR. Numeroussituations makeswitching to an ECCE a superior alternative to theattempted continuation of phacoemulsification in theeye.

One of the most important aspects of the preoperativeevaluation of cataract patients is the assessment andidentification of risk factors that may increase surgicaldifficulty and the likelihood of conversion. Several intraoperativefactors can also prompt the switch to anECCE, however, especially by a novice surgeon. Optimalpreoperative preparation and the prompt recognition ofcomplications can permit a timely and safe transitionwith excellent visual results. If there is a consideration ofconverting the case to an ECCE, it is generally preferableto start with a peribulbar block.

PREOPERATIVE FACTORS
Preoperative risk factors to consider when evaluatingeach cataract patient include, but are not limited to,zonular laxity (ie, a history of trauma, pseudoexfoliation,phacodonesis, Marfan’s syndrome), grade 3 to 4 nuclearsclerosis, a small pupil, and an underlying predispositionto corneal decompensation (ie, Fuchs’ dystrophy, posteriorpolymorphous dystrophy) (Figure 1). Each ophthalmologistmay approach these circumstances differently.Experienced cataract surgeons may be comfortableplanning the phacoemulsification of more complexcataracts using advanced techniques such as suturedcapsular support. Alternatively, beginning surgeons andmany experienced ophthalmologists may prefer aplanned ECCE to ensure the safe removal of the crystallinelens and implantation of the IOL.1

INTRAOPERATIVE FACTORS
Appropriate preoperative counseling of the patientshould include the possible need to convert to an ECCEprocedure if clinical conditions make it a reasonable alternative. Sometimes, the surgeon simply cannot preoperativelypredict the need for this change.

An intraoperative change to ECCE should be consideredwhen phacoemulsification is proving unsuccessful.Whether the lens is falling posteriorly due to inadequatezonular support, or the remaining lens nucleus is rockhard in the presence of an unstable posterior capsulartear, it is sometimes more prudent to convert than tocontinue with phacoemulsification. This is most truewhen the risks of the latter outweigh those of conversion.Indications to consider the change include mechanicalfailure of the phaco handpiece or machine, ineffectivephacoemulsification due to excessive lenticular density, a are available in injector systems that now require no enlargementof the cataract incision. For example, the iSert PC-60AD (Hoya Surgical Optics, Inc., Chino Hills, CA) is capableof injecting a lens through a 2.4-mm incision. The MonarchB cartridge/injector can inject the MA60AC or MA50BMlenses (products from Alcon Laboratories, Inc., Fort Worth,TX) through a 2.75-mm incision. Bausch + Lomb’s(Rochester, NY) LI6AO series is capable of planar injection,very simple for sulcus delivery, via a 2.75-mm incision.

CONCLUSION
I distinctly remember the first patient whose capsule Ibroke as an attending surgeon on a cataract procedure.Nuclear material descended posteriorly, and vitreous prolapsedanteriorly. I performed a triamcinolone-assistedanterior vitrectomy and placed a three-piece lens in thesulcus. I explained everything to the patient postoperatively,and the following week, he underwent a pars plana vitrectomy.To this day, his UCVA remains 20/20. If capsularrupture occurred in my own eye, I would much prefer thatcataract surgery continue via a small incision than that thesurgeon convert to an ECCE.

David A. Goldman, MD, is an assistant professor of clinicalophthalmology at Bascom Palmer Eye Institute in Palm BeachGardens, Florida. He acknowledged no financial interest in theproducts or companies mentioned herein. Dr. Goldman maybe reached at (561) 515-1543;dgoldman@med.miami.edu.

  1. Por YM,Chee SP.Posterior-assisted levitation:outcomes in the retrieval of nuclear fragments and subluxated intraocularlenses.J Cataract Refract Surg.2006;32(12):2060-2063.
  2. Lifshitz T,Levy J.Posterior assisted levitation:long-term follow-up data.J Cataract Refract Surg.2005;31(3):499-502.
  3. Chang DF,Packard RB.Posterior assisted levitation for nucleus retrieval using Viscoat after posterior capsule rupture.JCataract Refract Surg.2003;29(10):1860-1865.
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