A patient travelling for several hours from the backcountry of the Everglades (in Florida) to my practice inquired about the possibility of improving his sight. When he presented for cataract evaluation, he was almost completely blind and deaf. He had lost his fellow eye to trauma early in life and had no other significant ocular history except that his vision has slowly worsened over the years. Several other ophthalmologists had told him that cataract surgery was not a good idea.
The patient’s vision was hand motions, and his intraocular pressure was 18 mm Hg. There was no view of the retina, and I therefore performed an ultrasound B-scan, which showed no abnormalities. I told the patient that, although his looked like a tough case, the odds were well in his favor of seeing better than he currently did by undergoing cataract surgery. He reluctantly agreed.
The slit-lamp exam revealed a fibrotic anterior capsule and grade 4+ brunescent cataract. I knew the procedure would be challenging, and I scheduled it as the last case of the day so that I would have plenty of time to operate. I asked the operating room team to be prepared with a capsular tension ring, sutures, vitrectomy set-up, and a selection of IOLs intended for sulcus implantation.
This case is documented in a video available at eyetube.net/?v=pevop. I made two standard bimanual 1.6-mm incisions, and I then injected trypan blue dye under air, followed by a cohesive ophthalmic viscosurgical device to displace the air bubble. The capsulorrhexis was difficult because of a thick, fibrotic membrane adhered to the central capsule. I quickly realized that I needed to stay away from the membrane and tear the more normal peripheral capsule (Figure 1). The membrane was thick and rubbery, and it would not come out of the wound (Figure 2), forcing me to use ultrasound and chopping maneuvers to get it out of the eye.
The cataract was extremely dense, and I bumped the phaco energy up to 50% in order to achieve meaningful sculpting. After many passes centrally, I was finally able to crack the lens into quadrants. Disassembly of the first half of the lens went well with a combination of chopping, cracking, and using the irrigating chopper to mash the particles into the phaco tip. My settings were as follows: 30% phaco power and 400 mm Hg maximum dual-linear vacuum.
PRESENTATION OF VITREOUS
While removing the first half of the lens, I noticed a bright red reflex and a change in fluid dynamics and flow of debris (Figure 3). Small cataract particles appeared below the level of the posterior capsule. With virtually a whole hemisphere of cataract left and concern of losing it into the vitreous cavity, I decided to use the phaco needle to impale the cataract and bring it higher into the anterior chamber to emulsify it. I noticed vitreous present in the anterior chamber, and I proceeded to do a limited anterior vitrectomy followed by a more thorough core vitrectomy to remove the microscopic cataract particles from the eye. This was done with my assistant holding a handheld posterior segment viewing lens on the eye for better visibility of the mid-vitreous and posterior pole.
Once the eye was clear of the lens particles and there was no vitreous present in the anterior chamber, I returned to performing bimanual irrigation and aspiration of the white, fluffy cortex hiding underneath the iris in the capsule. I finished the case by placing a SofPort LI61AO three-piece IOL (Bausch + Lomb) in the sulcus space.
When the patient returned on postoperative day 1, his vision was 20/100, and, over several weeks, it improved to 20/20. I was happy to see him return to the Everglades knowing he could at least now see the alligators and mosquitos.
Robert J. Weinstock MD, is a cataract and refractive surgeon in practice at The Eye Institute of West Florida in Largo, Florida. Dr. Weinstock may be reached at tel: +1 727 585 6644; e-mail: firstname.lastname@example.org.