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Cataract Surgery | May 2013

Surgical Nightmares, Management Strategies Caught on Camera

Peers share tips for dealing with difficult cases.

By now, readers of CRST Europe know that Eyetube is ophthalmologyís leading source for high-quality, fully narrated ophthalmic surgery videos. The beauty of this website, which simplifies online video archiving and sharing for ophthalmologists, is that it can be accessed by anyone, at any time, and in any corner of the world to promote peer education.

The feedback we have received from our readers and from Eyetube subscribers confirms that Eyetube is often used as a way to sharpen skills and study surgical techniques. Another popular use of Eyetube is for viewing complicated cases that other surgeons have encountered. Therefore, it is only fitting that we feature several Eyetube videos as part of this cover focus, which is dedicated to showcasing surgical nightmares and management strategies.


In one case featured on Eyetube, Michael Snyder, MD, details his strategy for managing a traumatic cataract with vitreous prolapse (eyetube.net/?v=wuwab). First, Dr. Snyder addresses the vitreous by making a paracentesis and placing a 23-gauge pars plana vitrectomy cannula and trocar about 3.5 mm posterior to the limbus. After removing all vitreous gel from the anterior chamber using a high cut rate and low aspiration (Figure 1), Dr. Snyder places a plug in the cannula and pressurizes the anterior chamber. He double-checks that the anterior chamber pressure is higher than the vitreous pressure, with the hope of avoiding subsequent prolapse, and uses trypan blue dye to enhance visualization and reduce the elasticity of the capsulorrhexis.

In this case, the rhexis is corrugated, and Dr. Snyder attempts to peel the capsulorrhexis around the area of plaque and uses 23-gauge microscissors to cut through the fibrotic area. The cut, he cautions, should incorporate the end of the most recent tear (Figure 2). After gentle hydro- and viscodissection, Dr. Snyder performs a horizontal chop technique to fragment the nucleus and uses the chopping device to distend the equator of the capsular bag. He also injects a dispersive ophthalmic viscosurgical device (OVD) into the capsular fornix to maintain space between the capsular bag and the nucleus, which is especially important when removing the final pieces of nucleus from the bag.

Dr. Snyder then uses a 27-gauge cannula to manually aspirate the cortical material. The small-bore cannula minimizes flow within the anterior chamber and decreases the risk of capturing the capsule. Next, he places a capsular tension ring (CTR) using manual forceps, allowing him to feel if the CTR catches on the capsular bag (Figure 3). Thereafter, he creates two openings in the scleral wall, approximately 3.5 mm apart, to affix the CTR. He positions the lens centrally in the capsular bag, repairs the iris defect using a sliding knot technique, and removes the trocar and cannula.


In another video, Ike K. Ahmed, MD, shares his management of a case involving blunt trauma with multiple complications (eyetube. net/?v=veliq). This patient has a dislocated cataract, atonic pupil, and hypotony secondary to a cyclodialysis cleft of approximately 2 clock hours. Dr. Ahmed starts by injecting dispersive and cohesive OVDs and staining the anterior capsule with trypan blue. He notes that the lens material is dense in the center but absent peripherally; the lens is also subluxated nasally.


CRST Europe: What was your worst surgical nightmare, and how did you resolve it?

I performed a penetrating keratoplasty (PKP) under parabulbar anesthesia. During the second radial corneal suture, an expulsive choroidal hemorrhage occurred, and the crystalline lens surged through the corneal opening. I extracted the lens, pressed one finger on the graft, and tried to reduce the patientís intraocular pressure. After a few minutes, I sutured the transplant as quickly as possible. At the end of surgery, a large temporal choroidal detachment was visible, and vitreous strands were incarcerated in the wound; however, the wound was still watertight. The choroidal detachment resolved within the following 2 weeks, and I then performed a pars plana vitrectomy to overcome the vitreoretinal traction. Finally I sutured an IOL to the sclera.

CRST Europe: When a surgical complication occurs, what is your first action?

I always try to identify the cause and extent of the complication. Then I create a plan for solving the problem.

CRST Europe: What surgical nightmare are you most afraid of dealing with?

Expulsive choroidal hemorrhage.

CRST Europe: Are there any general precautions you take to avoid surgical nightmares from occurring?

Now I perform all PKPs under general anesthesia with low blood pressure. I do perform lamellar corneal procedures when indicated.

CRST Europe: What is the best piece of advice you have received from a colleague with regard to dealing with an extremely difficult case or complication?

This answer is threefold: (1) If it is too late to avoid the complication, think first and then create a surgical solution; (2) Not every complication has to be treated during the same surgery, as it sometimes makes sense to perform a subsequent procedure under more controlled conditions (eg, closed system, general anesthesia); and (3) Always analyze a complication at a later time, so as to avoid it in the future.

Michael Amon, MD, is Professor and Head of the Department of Ophthalmology, Academic Teaching Hospital of St. John, Vienna, Austria. Dr. Amon is a member of the CRST Europe Editorial Board. He may be reached at tel: +43 1 211 21 1140; e-mail: amon@augenchirurg.com.

Dr. Ahmed centers the capsulorrhexis on the capsular bag, places two iris hooks on the temporal edge, uses a cohesive OVD to separate the anterior and posterior capsular leaflets and create space, and injects a CTR. The iris hooks remain on the capsulorrhexis temporarily for additional support as he removes the lens and cortical materials and places a one-piece acrylic IOL into the capsular bag. He follows by rotating the lens into the correct position, removing the iris hooks, and confirming that the IOL is well centered.

Next, Dr. Ahmed places tension on the atonic pupil and performs iris cerclage with a baseball-type stitch using 10-0 polypropylene suture on a bent needle, taking five or six small bites over each quadrant of the pupillary edge (Figure 4). A micrograsper in the nondominant hand allows Dr. Ahmed to hold the iris in place and move tissue toward the needle (Figure 5). Using a cannula to avoid trapping corneal tissue, he then passes the needle through the paracentesis and continues suturing the inferior quadrant with a similar number of small bites to accomplish 180∫ of suture passage along the pupillary margin. He makes one more pass, ensuring that sutures are placed around 360∫, and ties the suture temporarily, as repairing the cleft could change the iris position. The goal is to make sure that the iris is tied down without over-tightening the tension of the sutures, Dr. Ahmed explains.

Dr. Ahmed opens the conjunctiva near the area of the cyclodialysis cleft, from approximately the 11:30- to 1:30-oíclock positions, exposes the sclera (Figure 6), and creates a scleral flap. He then dissects the flap toward clear cornea to reveal a half-thickness bed of sclera. Using the same 10-0 polypropylene suture and bent needle, Dr. Ahmed passes through the full-thickness sclera and into the anterior ciliary body tissue and comes out through the posterior lip of the sclera using a cross-mattress suture. This reattaches the ciliary body to the sclera in the area of the cleft. Allowing the OVD to remain in the eye during these maneuvers ensures that there is some degree of ocular tension, Dr. Ahmed explains.

Because the affected area is larger than expected, he places a second cross-mattress suture, thus avoiding a potential residual cleft. He closes both cross-mattress sutures, followed by closure of the scleral flap and the conjunctiva with 8-0 polyglactin sutures.

Afterward, Dr. Ahmed closes the iris cerclage suture with a single throw in the reverse direction of the initial triple throw (Figure 7). He uses a micrograsper to help titrate the tension to an adequate size and finally places one last suture to complete the case.


Robert J. Weinstock, MD, describes his management of an unintentional posterior capsular tear in an eye with a dense cataract and a fibrotic membrane on the anterior capsule, in a patient who has been taking tamsulosin (eyetube. net/?v=pevop). After Dr. Weinstock injects trypan blue under air and a cohesive OVD to displace the air bubble, he uses microcapsulorrhexis forceps to initiate the anterior capsulorrhexis, making sure to remain just outside the fibrotic membrane. When the capsulorrhexis begins to travel peripherally, he pulls it back toward the central pupillary axis. Repeatedly he grabs the capsule to complete the continuous curvilinear capsulorrhexis.

Because the capsule is too thick to be removed through the microincision (Figure 8), Dr. Weinstock proceeds to mobilize the nucleus with hydrodissection and hydrodelineation. He uses bimanual phaco (irrigation on the left side and a sleeved phaco needle on the right) to sculpt an initial deep groove in the center of the nucleus. Dr. Weinstock then rotates the lens 90∫, uses the irrigating chopper and phaco needle to chop the nucleus into two pieces, and makes a second groove across the distal hemisphere (Figure 9). He places the instruments inside the groove and cracks the distal hemisphere into two quadrants (Figure 10). After injecting a dispersive OVD, Dr. Weinstock removes the dense quadrant using high vacuum and phaco power.

At this point, the pupil moves forward, a behavior common in intraoperative floppy iris syndrome; then the anterior chamber deepens, and a visible hole forms in the posterior capsule. Employing a bimanual technique and keeping irrigation superior, Dr. Weinstock sustains the nuclear quadrants high in the anterior chamber and capsular bag (Figure 11). Dr. Weinstock keeps the quadrants in one piece by lowering the bottle height and employing additional tension, and then he removes them in large pieces using a modified chopping technique. He impales the final quadrant, pulls it into the pupillary space, and gently facilitates removal with the irrigating chopper to prevent particles from dislodging and traveling into the vitreous cavity.

When vitreous enters the wound and blocks the phaco tip, Dr. Weinstock injects more OVD. Then he rotates the nucleus to remove the final quadrant from the eye. At this time, he leaves the irrigating chopper in the eye and inserts a sleeveless vitrectomy handpiece to perform limited anterior vitrectomy. Next, he performs irrigation and aspiration. To remove residual cortical material located behind the iris, Dr. Weinstock switches back to vitrectomy. He then continues with more irrigation and aspiration.

Dr. Weinstock notices further areas of fibrosis and posterior capsular opacity; however, in this case, removing them would induce further capsular damage. Therefore, he enlarges the wound and implants a posterior chamber IOL between the iris and the anterior lens capsule, placing the leading haptic directly into the sulcus. The trailing haptic remains outside the eye until more OVD is injected. Then he uses a Kuglen hook to dial the trailing haptic into positionóunder the iris and into the sulcus spaceóand places sutures to close the wound, leaving the eye relatively soft to avoid residual vitreous prolapse. He then irrigates the wound and injects acetylcholine chloride to shrink the pupil and ensure that the lens is fully captured.


Many years ago, when I was performing cataract surgery on a one-eyed patient who had lost his other eye as a result of retinal detachment, I experienced my worst surgical nightmare. I was doing a retrobulbar injection, and after injecting the anesthetic it felt as if the eye was moving a little bit with the needle. I was afraid that I had perforated the eyeball, so I did not remove the syringe. I had a surgical staff member place an indirect ophthalmoscope on my head, and I was able to look in and see that I had doubly perforated the eye. There was an entrance wound in the inferior temporal quadrant and an exit wound nasally, slightly remote from the macula.

My greatest concern was how to fix this nightmare. The thought occurred to me that I could create a chorioretinal scar at both perforation sites by freezing the hub of the needleóbecause metal is a good conductoróand, if so, the scars would seal both of those sites. Without removing the indirect ophthalmoscope or moving the needle, I froze the hub of the needle with an Amoils retinal cryoprobe, watched the ice ball grow at both perforation sites, watched it melt, and then withdrew the needle. I then proceeded to do the cataract surgery.

I followed the patient for the rest of his life, and, although he had a chorioretinal scar at both perforation sites and a vitreous band between them, he never had a problem as a result of this.

That was my worst nightmare, and it ended up all right, I am happy to say.

I. Howard Fine, MD, is a Clinical Professor of Ophthalmology at the Casey Eye Institute, Oregon Health & Science University, and he is in private practice at Drs. Fine, Hoffman, & Sims LLC, Eugene, Oregon. Dr. Fine is a member of the CRST Europe Global Advisory Board. He may be reached at tel: +1 541 687 2110; e-mail: hfine@ finemd.com.


The three cases outlined above are just a sampling of the educational video material available to viewers of Eyetube. Perusing the wide video selection of complicated surgeries featured on Eyetube (see Other Surgical Videos to Check Out for more recommended videos) will hopefully encourage wider dissemination of surgical techniques to manage any number of challenging situations.