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Properly managing the intraoperative complications of
cataract surgery facilitates their treatment.
By Rahul Patel, MD, and Suber S. Huang, MD, MBA
WOUND INTEGRITY AND CORNEAL CLARITY
In the event of intraoperative complications that may require surgical retinal management, you must seal the wound margin and test its integrity. Using stromal hydration alone may prove inadequate during vitreous surgery. A vertical mattress suture is especially useful in optimizing the wound’s integrity in the event of a wound burn.1 Limbal and sclerocorneal incisions may cause severe chemosis that can interfere with the trocar’s placement in 25-gauge pars plana vitrectomy.
Meticulously ensure that no adherent vitreous strands are present at the inner margin of the wound. Gently sweep the wound with a cyclodialysis spatula to check for and relieve vitreous traction. Vitreous incarceration may cause corneal decompensation (reducing clarity for future retinal surgery), and it provides a pathway for exogenous bacteria. Moreover, peripheral retinal traction may lead to retinal breaks, and macular traction from iridovitreal adhesions is a suggested mechanism of cystoid macular edema.2
Bullous keratopathy can arise from endothelial dysfunction, elevated IOP, and tears in Descemet’s membrane. It requires aggressive treatment. Options for treating tears in Descemet’s membrane include observation, the irrigation of the paracentesis wound, the injection of viscoelastic to unroll and reattach Descemet’s membrane, the placement of full-thickness sutures, and the use of air or an SF6 gas bubble. Severe corneal opacification may require a delay of retinal surgery or the use of a keratoprosthesis.1,3
CAPSULORHEXIS
The ideal size of the continuous curvilinear capsulorhexis has not been established. Zonular integrity, the size of the selected IOL’s optic, the cataract’s maturity, and the phaco technique are common factors that influence the surgeon’s choice on the capsulorhexis’ diameter. Nonetheless, a small continuous curvilinear capsulorhexis significantly impairs peripheral retinal visualization.4 The early detection and accurate localization of all retinal breaks allow their prompt treatment and are critical for successful retinal detachment surgery. Peripheral visualization facilitates laser therapy and the management of retinal vascular disease.
Drawbacks to a large continuous curvilinear capsulorhexis include an increased incidence of posterior capsular opacification and decentered or dislocated IOLs. Moreover, it impedes the surgeon’s ability to place a sulcus-fixated IOL in the event of a large posterior capsular tear.1,4 The benefits of a large (> 6mm), well-centered capsulorhexis in facilitating future retinal examinations and treatment cannot be overstated, however. You must weigh the pros and cons of a larger continuous curvilinear capsulorhexis in patients who may need future retinal care.
SELECTING AN IOL
The ideal lens implant is safe, optimizes the patient’s vision, and helps to stabilize the eye. A large continuous curvilinear capsulorhexis allows the placement of an IOL with a large optic, which facilitates visualization of the peripheral retina. Consider larger IOLs in patients with risk factors for retinal detachment, including vitreous loss, high myopia, lattice degeneration, trauma, and a history of retinal detachment/tear.4 The choice of IOL material also merits careful consideration, especially in diabetic patients or others at risk for future vitrectomy. In 2004, one-third of all IOLs placed during cataract surgery were silicone-based.5 Silicone IOLs develop fogging from water vapor during air-fluid exchange with intraocular gases such as perfluoropropane and SF6.6,7 Condensation significantly reduces the ophthalmologist’s ability to view the retina during retinal surgery. The use of viscoelastic and manual cleaning of condensation off the IOL are required to improve visualization, but the effect is suboptimal and transient.6,7
An acrylic or PMMA lens is recommended for patients who are likely to need vitreoretinal procedures. In cases of retinal surgery requiring silicone oil, droplets may adhere to the posterior surface of a silicone IOL and be difficult to remove, even after removal of the silicone oil. Retained oil may predispose the eye to secondary glaucoma and further diminish visual acuity.8,9
MANAGING RETAINED INTRAVITREAL LENS FRAGMENTS
The posterior dislocation of lenticular material into the vitreous is an infrequent but frustrating complication of cataract surgery. Remember that attempts to retrieve dislocated fragments may create retinal traction. During an anterior vitrectomy, the initial cutting and aspiration of vitreous must begin behind the plane of the iris (Figure 1A) to reduce the chance of transpupillary anterior traction on the vitreous base, retinal tear, or retinal detachment (Figure 1B). Refer cases with nuclear fragments that are greater than 25% to 33% of the original lens’ size without heroically attempting their retrieval. Observation may be appropriate in cases with smaller fragments (less than 25%). All eyes should undergo aggressive medical therapy.10,11
CONTROLLING IOP AND INFLAMMATION
In the event of an intraoperative complication that may require an urgent referral to a retina specialist, immediately work to control the patient’s IOP and inflammation. The aggressive use of viscoelastics is common in the setting of a posterior capsular tear with lost nuclear fragments. After inserting the IOL, perform thorough I/A of the eye to ensure the removal of all viscoelastic. The failure to do so will contribute significantly to elevated IOP postoperatively. Uncontrolled IOP worsens corneal clarity and hinders visualization of the posterior segment. Likewise, aggressively treat inflammation to help avoid elevated IOP, prevent cystoid macular edema, reduce pain, and decrease the likelihood of the eye’s developing proliferative vitreoretinopathy if a retinal detachment occurs.12,13
REFERRAL AND COMMUNICATION
Patients with endophthalmitis or a retained intravitreal lens fragment and coexisting retinal detachment require urgent evaluation and prompt treatment by a posterior segment surgeon. The exact timing of vitrectomy for retained fragments without retinal detachment is less well defined. Margherio et al reported an increased incidence of retinal detachment associated with cases of delayed vitrectomy.10,14 In another study, 57% of patients who underwent immediate vitrectomy had a final visual acuity of 20/40 or better compared with 78% of those who underwent vitrectomy within 1 week.10,15 There is no conclusive evidence that vitrectomy performed on the same day of cataract surgery results in a better visual outcome than surgery within 2 weeks.11,12,15
Timely and effective communication between you, the patient, and the retinal specialist is vital to ensuring the continuity of care, reassuring the patient, and setting realistic expectations. The discussion and planning of appropriate triage, acute management, and clinical and surgical details, all affect the surgical approach of the retinal specialist. In the setting of a subluxated or dislocated IOL, a knowledge of areas of zonular weakness helps the retinal specialist to place the IOL properly or to avoid dislodging one with tenuous security.10,12,13 Written documentation of findings and clinical events may be invaluable to the posterior segment surgeon.
Most important is maintaining the patient’s trust. The vitreoretinal specialist will be much more able to earn the confidence of one who is well informed. An excellent relationship with the patient will facilitate his visual rehabilitation and minimize medicolegal ramifications that may surface.
SUMMARY
Individualize each patient’s surgical plan according to his refractive needs and the ocular findings. Consider techniques that optimize peripheral retinal visualization in patients who are at risk for corneal opacification or peripheral retinal disease or those who may require retinal surgery. If complications occur, recognizing the importance of wound integrity and media clarity and meticulously managing acute events will afford the retinal specialist the best opportunity to provide a rapid and uneventful recovery. Prompt referral and effective communication reassure the patient and enhance the likelihood of a satisfactory outcome.
Suber S. Huang, MD, MBA, is Philip F. and Elizabeth G. Searle–Suber S. Huang MD Professor and Vice Chairman at Case Western Reserve University and is Director, Vitreoretinal Diseases and Surgery, Department of Ophthalmology, University Hospitals of Cleveland. He states that he holds no financial interest in the products or companies mentioned herein. Dr. Huang may be reached at (216) 844-7640; suber.huang@case.edu.
Rahul Patel, MD, is a third-year resident at Case Western Reserve University, Department of Ophthalmology, University Hospitals of Cleveland. He states that he holds no financial interest in the products or companies mentioned herein. Dr. Patel may be reached at (216) 844-7230; rkp1993@yahoo.com.
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