JAN 2006 ISSUE
5 Questions With Alan S. Crandall, MD
Dr. Crandall describes his current research and shares a few of his pearls.
Have you and your colleagues gained any further understanding of late dislocation of the bag/IOL complex? Although our surgical techniques have advanced significantly, the answer is still technically no. However, we are continuing to look for clues about which patients are at risk for late dislocation. There are several factors to consider. First, dislocation occurred less often prior to the advent of the capsulorhexis procedure. This finding may be attributable to (1) the fact that patients are undergoing surgical procedures at an earlier age or (2) the presence of capsular phimosis and weakened zonules (caused by the stress placed on them as the bag contracts). Some surgeons place the lens in the bag during surgery and immediately make anterior radial cuts so the capsule cannot contract. Others wait 3 or 4 weeks postoperatively to let it seal and may use a YAG laser after the bag tightens. These technique variations may be responsible for dislocation. Another concern is whether inserting a capsular tension ring (CTR) during surgery has any effect on the risk of late dislocation. Although most surgeons do not agree, CTRs may potentially delay or decrease capsular phimosis. The problem remains that in most cases, these complications arise long after surgery (usually between 8 and 9 years postoperatively), which makes it hard to determine the causative mechanism or anticipate the condition.
What are your top pearls for cases of combined cataract and glaucoma surgery? I am a big proponent of the combined procedure. Although the postoperative healing period is longer and patients’ vision does not return as quickly as with cataract surgery alone, lowering IOP and getting patients off most, if not all, of their medications with a single procedure is worthwhile. Patients’ IOP is better controlled postoperatively, and they can receive medicine down the line if necessary. My pearls for combined cases are as follows. First, one must use mitomycin C and antimetabolites. Second, it must be a clear corneal case. The temporal clear corneal technique has a significant advantage, because it allows for at least 1mm extra of central corneal dome, which reduces the risk of difficulties with corneal decompensation. Third, using either a new-generation acrylic or silicone lens makes no difference in terms of postoperative inflammation. Surgeons should use the lens with which they are most comfortable. Last, there are opportunities to combine cataract extraction and a nonpenetrating procedure. I use the Aquaflow procedure with excellent results, and I recommend it for every surgeon’s armamentarium, because the device decreases the risk of hemorrhage and other complications.
What is your most memorable surgical experience? After performing cataract surgery for approximately 3 years, I treated a young black woman in Philadelphia who unfortunately suffered a choroidal hemorrhage intraoperatively. She had serious glaucoma and hypertension. Basically, the eye was gone. There was nothing I could do. Discussing the reality of the situation with her and her husband taught me a lot about honesty. It was one of my toughest yet most memorable days, and it was not even a success! The trust in our patient/doctor relationship allowed us to maintain a 15-year friendship following her surgery.
What is the current focus of your research? My colleagues and I are focusing on the surgical management of complicated pediatric glaucoma and cataract cases. I work closely with our pediatric group here at the John A. Moran Eye Center in Salt Lake City. We have evaluated the Morcher Cionni CTRs for scleral fixation in children with Marfan’s syndrome and Weil-Marchesani syndrome. We are preparing to publish the results of a large series of patients who received the CTRs. We have obtained long-term results (2- to 5-year data) on approximately 30 children.
What would you like to accomplish over the course of the next 5 years? Every year, my colleagues and I travel to Africa, and one of our goals is to create a teaching facility where we can promote the exchange of knowledge with West Africa, an area that is in dire need of assistance. Geoffrey Tabin, MD, Co-Director of the Himalayan Cataract Project, has joined us at the Moran Eye Center, and he and I will go to Ghana in April. We are working with the University of Ghana in Kumasi to establish a program that will allow the residents of our two universities to swap places in an effort to improve the skillfulness of the surgeons available to the people of Ghana. The goal is not just to perform surgery, but to teach the local physicians. Restoring the sight of a young adult allows him to become a productive member of his society.
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