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Up Front | Jul 2011

Challenging Cataract Cases

As a specialized cataract surgeon, I am always excited for CRST Europe’s annual cataract complications issue. Cataract extraction is the most frequently performed surgical procedure in the world, and it is therefore not surprising that special, challenging, and complicated cataract cases alike remain among the most interesting topics for surgeons of all levels to read about.

For the experienced cataract surgeon, a successful outcome after a challenging case often is the highlight of the week or month. For the beginner surgeon, unforeseen complications and hidden challenges can be the most nervewracking events of the week, possibly leading to restless nights and tremors during future surgeries. But for every cataract surgeon, complicated cases put to test all of the skills and training we have garnered over the years.

This month’s cover focus helps all cataract surgeons devise and/or revisit strategies to combat complicated cases. In the following pages, some of today’s leading surgeons describe 11 of the most challenging situations in cataract surgery, sharing the ways they handle or have overcome surgical nightmares. Several articles have accompanying video components on Eyetube.

We are practicing ophthalmology in the era of refractive cataract surgery, and with this change has come an increase in patient expectations. Now more than ever, suboptimal refractive outcomes cause the surgeon a lot of disappointment and stress. With a challenging case, however, the patient should already have been made aware of the increased risks and potential complications, and a less favorable outcome is therefore often more readily accepted. In these cases, the surgeon’s efforts are highly appreciated; when everything goes well, the patient’s gratitude can be extremely heart-warming, which helps the surgeon to forget the stress before and during the operation. When surgery does not go smoothly, postoperative management and patient counseling are crucial.

In his contribution, Ian John Dooley, MB, BAO, BCh, MSc, MRCSI (Ophth), MRCOphth, covers many aspects of surgically induced astigmatism, recommending toric IOL implantation as one possible solution. Dr. Dooley also mentions intraoperative aberrometry as a promising development. I think that the SMI Surgical Guidance system (SensoMotoric Instruments GmbH, Teltow, Germany) is a useful adjunct for the accurate placement of toric IOLs.

Another interesting contribution comes from Hüseyin Bayramlar, MD, and Cihan Ünlü, MD, who describe causes and consequences of incision complications. For me, endophthalmitis is the most feared complication and is probably most frequently related to inadequate wound closure. Proper incision construction deserves even more attention than it already receives. Maybe this is one of the greatest attributes of laser cataract surgery—although a somewhat pricey solution.

Simonetta Morselli, MD, and Antonio Toso, MD, present a few tricky cases of refractive surprises, and Isabel Prieto, MD, supplies tips for tackling pupil problems. Rudy M.M.A Nuijts, MD, PhD, and Muriel Doors, MD, provide excellent pearls for discerning the most important risk factors for postoperative corneal decompensation in Fuchs dystrophy cases, and Zsolt Biró, MD, PhD, describes his approach to confronting the shallow anterior chamber with adequate preoperative oculopression. My own article describes the necessary measures to prevent the Argentinean flag sign in hypermature white intumescent cataract cases. I also uploaded an Eyetube video of a mysterious occlusion break surge case, which explains a common cause of posterior capsule breaks. The video is available at http://eyetube.net/?v=pubet.

Arup Chakrabarti, MBBS, MS, covers the ins and outs of pseudoexfoliation syndrome and the use of capsular tension rings to deal with zonular weakness; on a similar topic, Boris Malyugin, MD, PhD, describes how he uses the Malyugin modified CTR to handle profound zonular weakness. Dr. Malyugin is an innovative and expert surgeon, and his pupil ring helps me staying out of trouble in difficult small pupil cases—as I am sure it has helped many of you too.

My young fellow countryman Nic Reus, MD, PhD, gives an overview of managing anterior and posterior capsular tears, which continues to be one of the most common and awkward complicated situations for cataract surgeons. But the most thrilling story of the month is from Brian Little, MA, FRCS, FRCOphth, FHEA. Dr. Little shows a horrible case of a suprachoroidal hemorrhage; I am impressed that he has the courage to share his experience with us.