CASE PRESENTATION
A 64-year-old man had a grade 2+ cataract with signs of pseudoexfoliation in his right eye. The same eye was previously treated for a macular pucker, and a light phacodonesis was present at slit-lamp examination.
On the day of the scheduled operation, the patient's pupil size was approximately 5 mm; I applied a topical NSAID onto the eye with no change in size. I began the procedure with three obvious risk factors in mind: (1) the pupil size, (2) the phacodonesis, and (3) the absence of vitreous.
I used the Legacy phaco machine (Alcon Laboratories, Inc., Fort Worth, Texas) with the flared microtip. My settings were: ultrasound, 50%; vacuum, 400 mm Hg; flow, 26 cc/min; and burst mode, 75 milliseconds. I used a dispersive ophthalmic viscosurgical device (OVD) during the nucleus sculpting.
After preparation of the first groove and separation of the nucleus, the first half of the nucleus was emulsified without complication; however, when I moved to capture the second half of the nucleus in the phaco tip, I noticed a tear in the capsular bag—probably due to imperfect control of the empty side of the bag.
I tamponaded the bag, refilling it with OVD. At the end of the procedure, some cortex was still present in the intact part of the bag. As the tear increased, I was afraid that some cortical material could fall into the vitreous cavity, so I decided to continue removing the lens material with an anterior vitrector. In a couple of minutes, all of the remaining material was cleared; however, I the capsular bag was not intact. I noticed that the anterior capsule was moving backward because of interruption of the zonular fibers.
I thought I could implant the IOL into the sulcus using the anterior capsule for appropriate support. I proceeded by inserting the three-piece acrylic IOL into the eye. I noticed that the IOL was unstable behind the pupil, resembling a sunset syndrome. I did not want to remove the IOL, but I could not leave it in the eye in that compromised positon.
HOW WOULD YOU PROCEED?
I considered using: (1) scleral or (2) iris fixation of the IOL. If this were your patient, how would you proceed?
HOW I PROCEEDED
I decided to use a McCannel iris suture, attaching the IOL to the iris stroma. I proceeded with the appropriate surgical steps, which I describe here. First, I refilled the anterior chamber with a cohesive OVD and captured the IOL optic in the pupillary opening with the McCannel suture. To achieve this, I bent a straight needle to a 120? angle. The suture was then passed through the corneal stroma, first into the anterior chamber and then into the iris. The suture was passed out from the iris into the stroma again, capturing each loop. The knot was buried in a scleral tunnel using a push-pull instrument. Next, I gently repositioned the optic behind the iris and applied acetylcholine drops to check that the pupil was round. Afterward, I continued with irrigation and aspiration of the anterior chamber, removing the OVD.
FOLLOW-UP
Six months later, the patient's results are satisfactory.
WHAT HAVE I LEAREND FROM THIS CASE?
I made a few mistakes during this procedure, such as forgetting that the patient had inadequate vitreous support due to previous vitreoretinal surgery. Also, although the pupillary size was sufficient, I managed it with too much confidence, and phacodonesis was a factor in the bag's instability. Furthermore, I could have used a trocar to obtain better posterior support. What I really learned from this case is that the McCannel suture is safe and easy to use if needed.
Vittorio Picardo, MD, practices at the Studio Oculistico, Rome. Dr. Picardo states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +39 06 854-7845; fax: +39 068 535 5461; e-mail: eyeboss@vpicardo.191.it.
