Pearls for managing tricky cataracts in post-vitrectomy eyes

Cataract surgery in the post-vitrectomized eye is considerably tricky but with some surgical experience and implementing some valuable pearls-including whether to hydrodissect or hydrodelineate-surgeons can avoid surprises, according to Bonnie An Henderson, MD.

Boston–Cataract surgery in the post-vitrectomized eye is considerably tricky but with some surgical experience and implementing some valuable pearls-including whether to hydrodissect or hydrodelineate-surgeons can avoid surprises, according to Bonnie An Henderson, MD.

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“First, ensure you are not hydro-dissecting these eyes, but hydro-delineating,” said Dr. Henderson, partner at Ophthalmic Consultants of Boston and clinical professor at Tufts University, Boston. “The telltale sign of a successful hydrodelineation is the ‘golden ring.’ Be aware these lenses are unlikely to rotate well, so carefully proceed with chopping and removing the fragments to debulk the nucleus.”

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Dr. Henderson presented this case during a panel discussion on cataract complications at the 2015 meeting of the American Academy of Ophthalmology.

When performing such surgeries, Dr. Henderson prefers to move her phaco tip “to get to the different areas of the bisected nucleus and then try to segment them into smaller pie pieces,” rather than attempting to rotate the entire lens and keeping the phaco tip in the center.

Patience is required

She added that surgeons need patience, and be even more meticulous than normal in vacuum and removal. Once the epinuclear shell is the only object left, removal will be trickier with hydrodissection, but necessary.

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“I try to maneuver my phaco by rotating the face of the opening to try to occlude the tip against the nuclear fragment,” Dr. Henderson said.

When the epi-nuclear shell is difficult to mobilize, she uses a second instrument, like a chopper, to assist in the removal. But, when hydrodissection is not performed, there may not be an obvious “good plane to insert the chopper.”

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The options with an adherent epi-nucleus are to hydro- or viscodissect, switch to bimanual irrigation and aspiration (I/A) without hydrodissection, or create a new incision for a coaxial I/A. If the surgeon is suspicious of a posterior capsule breach, further hydrodissection is not a good option.

Zonules also can be compromised, and surgeons “should always assume there’s going to be a problem in patients post-vitrectomy,” added panelist Alan Crandall, MD, senior vice chairman and clinical professor of ophthalmology and visual sciences, University of Utah, Salt Lake City.

He recommended that surgeons obtain an ultrasound biomicroscopy to make sure the posterior capsule is in tact.

“Particularly when the nucleus is dense enough you cannot see anything,” he said.

The question remains whether a dispersive or cohesive viscosurgical device (OVD) would be preferred. To maintain the space without a quick egress of the OVD during manipulation, a dispersive may be best. However, to viscodissect behind the lens initially with easy removal afterward, a cohesive is best.

Dr. Henderson, however, noted that in order for the case to be successful, other variables need consideration. In this case, because the incision construction was not ideal as tri- or bi-planar, she encountered an iris prolapse.

“Fortunately, the iris stayed dilated even with the prolapse,” Dr. Henderson said.

Posterior capsule intact

After the lens nucleus was removed, the posterior capsule appeared intact. Dr. Henderson proceeded to remove the epinucleus, but it remained stuck.

She attempted a hydrodissection and at that point, the posterior capsule ruptured, she said. She carefully injected OVD to stabilize the eye before removing the phaco tip.

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“The good news is there’s no vitreous coming forward in post-vitrectomy eyes,” she said. “But the bad news is that there’s no support.”

Dr. Henderson used a chondroitin sulfate OVD to inject underneath the fragment and elevate it with a cannula. She then used a vitrector to clean up any residual cortical material that is warranted even in post-vitrectomy eyes.

In eyes like these, “if there is a rapid onset cataract, you have to be worried,” Dr. Henderson explained. “Look at the formation of the cataract. If the posterior aspect of the cataract is irregular, it is possible that there is a weakening of the posterior capsule. Always skip the hydrodissection; even after the nucleus is removed it is probably best not to hydrodissect with balanced salt solution.”

Finally, after the cataract surgery is complete and if there is retained nucleus, the cataract surgeon and referring retina specialist should work in unison to determine the best follow-up plan. Follow-up should be a few weeks after the surgery.

Surgeons might also consider using steroids for a few weeks to control the inflammation. If the epinucleus fragment is large, it may cause patients visual disturbances or floaters that would warrant an earlier removal, the panelists added.

Dr. Crandall pointed out that intraoperatively, staining could help since it is variable how the eye will react. If surgeons opt to hydrodissect, it is “highly recommended” to proceed slowly and hydrodelineate if necessary. He added that using a low-flow pattern so the surgical occlusion will not pop the bag is another little trick.

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Bonnie An Henderson, MD

P: 781/487-2200

E: BAHenderson@eyeboston.com

Dr. Henderson is a consultant to Abbott Medical Optics, Alcon Laboratories, Bausch + Lomb, ClarVista, Regeneron Pharmaceuticals, and Stealth. She also holds a patent with Massachusetts Eye and Ear Infirmary.