This unusual case resulted in a reasonably good outcome despite an unexpected event. The experience emphasized to me that, regardless of how straightforward or mundane things appear at the outset of an operation, surgeons need to remain vigilant throughout the entire procedure.
PATIENT'S HISTORY
A healthy 67-year-old man presented with a history of pseudoexfoliation, open-angle glaucoma, and a progressive cataract in his better-seeing right eye. His fellow eye was nonglaucomatous and severely amblyopic. The patient complained of diminishing visual quality related to the progressive cataract, and he was highly motivated to have cataract surgery to improve his symptoms. The glaucoma appeared to be quite asymmetric, primarily affecting his right eye. The patient had maintained steady pressure control for several years with latanoprost (Xalatan; Pfizer, Inc.).
PREOPERATIVE EXAMINATION
The patient's BCVA was 20/60 OD with a mildly hyperopic correction and 20/400 OS. Pseudoexfoliation was more evident in his right than left eye. Mydriasis was less effective in his right eye; the pupil dilated to about 5 mm. The patient had a prominent nuclear sclerotic cataract in his right eye, but there was no evidence of phacodonesis. His IOP measured 20 mm Hg OD and 17 mm Hg OS. The right optic disc exhibited minimal inferior glaucomatous cupping, and the visual field test was normal. The left disc was normal.
I explained to the patient that, although a cataract associated with exfoliation can present some challenges, I felt he had an excellent chance of dramatically improving his vision with surgery. The glaucoma was mild and well controlled, and I did not see any dramatic findings that would preclude a successful surgical outcome. I envisioned the need for pupillary expansion and planned to use iris retractors, which support the capsular bag when repositioned to the capsulorhexis. I anticipated an uneventful case, but I told him that an additional IOPlowering medication might be needed in the immediate postoperative period because of the increased risk of a spike in IOP after the procedure.
SURGICAL COURSE
The surgery was carried out under minimal intravenous sedation, topical anesthesia, and intracameral lidocaine 1.5%. I created a 2.4-mm temporal clear corneal incision and then injected Viscoat (Alcon Laboratories, Inc.) into the anterior chamber to deepen it. I placed four iris retractors through limbal incisions in a diamondshaped configuration to expand and stabilize the pupil. I performed the capsulorhexis with a cystotome. I did not detect undue laxity of the capsular bag complex, and therefore, I did not advance the iris retractors to the edge of the capsulorhexis. During phacoemulsification, I performed deep sculpting to create quadrants that I then divided and aspirated with a flow rate of 45 mL/min and vacuum of 400 mm Hg.
Other than the need for iris retractors, the case up to this point was routine. With the uneventful capsulorhexis and the apparent stability of the capsular bag and lens, I was feeling confident that the case would progress without incident. Just as the last nuclear fragment disappeared into the phaco handpiece, however, I noticed a subtle but sudden bounce in the posterior capsule and saw a relatively large irregular central tear there. I had been so focused on the stability of the capsulorhexis and zonule that I felt as if I had been kicked from behind. I forlornly dropped back to foot position one to allow ongoing infusion, and I instructed my staff to lower the bottle height and hand me the closest available viscoelastic agent (Figure 1).
At this juncture and for some inexplicable reason, my assistant instructed the circulator to get a new container of viscoelastic rather than hand me the readily available syringe of ProVisc Ophthalmic Viscosurgical Device (Alcon Laboratories, Inc.). In an articulate and a relatively calm tone, I endeavored to obtain any already available viscoelastic agent. My eyes had not deviated from the microscope during this episode, and I was delighted that none of the vitreous had moved through the capsular tear. I had requested the bottle height be lowered immediately upon noticing the tear, but I had yet to ask for the aspiration flow rate to be reduced. As a discussion between my scrub technician, the circulator, and myself ensued, my right foot somehow dropped from position one into position two. In the absence of viscoelastic, this sudden and unplanned onset of aspiration produced an immediate, dramatic, and complete clean out of the posterior chamber in about 1 second, including the entire capsular bag and any residual cortex (Figure 2).
I was now staring at a most remarkable unobstructed red reflex through a beautifully maintained pupil. I moved back to foot position one and was quite impressed with the behavior of the vitreous body (Figure 3). Nevertheless, as my scrub technician jabbed me with the viscoelastic syringe, I felt a blanket of gloom descend upon me, and I sensed a long day ahead with the so-called more complex cases after this one. I replaced the infusion fluid with Provisc followed by additional Viscoat to stabilize the posterior and anterior chambers and tamponade what appeared to be an intact vitreous face. I began to consider IOLs for this active and relatively young man, who had already asked me if he could play golf the next day.
The entire surgical game plan had suddenly and drastically changed, yet despite the loss of all available posterior support for an IOL, I had managed to keep the vitreous at bay. I simply had to convince myself that I was still in control and that I could select an IOL that would work out well in the long term. With this patient's history of glaucomatous disc damage, I wanted to avoid an ACIOL. I did not consider aphakia to be an acceptable option and therefore decided to suture fixate a PCIOL.
I inflated both the posterior and anterior chambers with adequate viscoelastic. I enlarged the incision to approximately 3.2 mm and folded a three-piece acrylic IOL in a mustache configuration. I placed the lens in the anterior chamber with the haptics extending down through the pupil. The lens unfolded in such a way as to allow the haptics to extend behind the iris plane while the optic positioned itself centrally on the pupil. I secured the haptics to the peripheral iris through clear corneal paracentesis tracks using a modified McCannel suturing technique. I placed a double throw around each of the haptics with a Siepser sliding knot and then prolapsed the optic into the posterior chamber. This allowed me to confirm the centration of the IOL and round out the pupil with some microforceps by pulling the iris centrally in the meridian of each of the knots. I finished the knots with three single throws on top of the underlying double throw (Figure 4). Using simple irrigation, I removed as much of the viscoelastic as possible from the anterior chamber. Carbachol was placed in the anterior chamber, and the patient was given oral acetazolamide in the recovery room as well as later that evening. He was instructed to continue with latanoprost, and I added bromfenac sodium ophthalmic solution 0.09% (Bromday; Ista Pharmaceuticals, Inc.) to the usual postoperative antibiotic and corticosteroid regimen.
POSTOPERATIVE COURSE
I discussed the course of events with the patient and his family in the recovery room. Fortunately, they were already familiar with and accepting of the patient's likelihood of experiencing complications because of the pseudoexfoliation. He was referred to me because of the pseudoexfoliation and because of his monocularly functional status. Other than some mild elevation of the IOP in the early postoperative course, the patient did well and had a final BCVA of 20/25 and a mildly myopic refractive error.
LESSONS LEARNED
This case maintains a prominent position in my mind and reminds me always to anticipate the potential for the unexpected. In this case, my attention was initially focused entirely on the stability of the capsular bag and zonule. Once I felt confident that they were not going to be a problem, I dropped my guard and let something completely unanticipated happen instead. Then, I did it again!
Pseudoexfoliation, like life, is the proverbial box of chocolates. You never know what you are going to get. It is vital to prepare the patient preoperatively by clearly explaining the potential for complications in the OR that are not anticipated in the examination room. I have come to enjoy taking care of this particular patient. He has enhanced my surgical acumen, and he delights in knowing that he is now one of my teachers.
Section Editor David F. Chang, MD, is a clinical professor at the University of California, San Francisco, and is in private practice in Los Altos, California. Dr. Chang may be reached at (650) 948-9123; dceye@earthlink.net.
Garry P. Condon, MD, is an associate professor of ophthalmology at Drexel University College of Medicine in Pittsburgh. He is a speaker for and a consultant to Alcon Laboratories, Inc., Allergan, Inc., and MicroSurgical Technologies. Dr. Condon may be reached at (412) 359-6298; garrycondon@gmail.com.
