EWAP DECEMBER 2023 3 EDITORIAL EyeWorld Asia-Pacific • December 2023 • Vol. 19 No. 4 Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific • China • Korea • India A s phacoemulsification technology and surgical techniques have vastly improved over recent decades, complications are less frequent but still can occur. When they do, with appropriate management, surgeons and patients can “sail through” complications to a favorable outcome. One of the more challenging complications covered in the issue is that of malignant glaucoma, also called ciliary block glaucoma. This occurs most frequently in eyes with very short axial lengths, particularly in nanophthalmic eyes. During surgery, typically toward the end of the procedure, the anterior chamber may become progressively shallow due to fluid misdirection. This may preclude the implantation of an IOL. Historically, aspiration of vitreous with a fine needle has been suggested. A more elegant solution would be a 25-gauge pars plana vitrectomy to relieve the pressure, though caution is required with nanophthalmic eyes as the ora serrata extends more anteriorly. Prior to performing either of these interventions, it is important to examine the red reflex and the fundus to ensure there is no choroidal hemorrhage. If present, then the eye should be closed and the surgery completed at a later date with drainage of the choroidal hemorrhage if required. My personal suggestion in these cases is to first exclude choroidal hemorrhage and then, rather than removing vitreous, simply close the eye, administer mannitol 0.25 g/kg. Typically, the eye will soften. Rescheduling the surgery towards the end of the list allows sufficient time for the pressure to reduce and the anterior chamber to deepen so the surgery can be completed. In extremely short including nanophthalmic eyes, the risk of expulsive hemorrhage can be reduced by using prophylactic mannitol 0.25 g/kg; also, avoid shallowing of the chamber when removing instruments during surgery. Cycloplegics such as atropine also reduce the likelihood of malignant glaucoma occurring in the postoperative period. Although scleral drainage procedures such as sclerotomy or sclerectomy have been recommended with modern phacoemulsification, this is probably not required. Choroidal efffusion can occur in the postoperative period and requires treatment with systemic steroids. One important consideration in a nanophthalmic eye is to avoid trabeculectomy or other drainage procedures as these are likely to precipitate the development of ciliary block. Removal of the lens is a more effective treatment with the additional precautions noted previously. If cycloplegics do not address malignant glaucoma then a pars plana vitrectomy combined with irido-zonular hyloidectomy is required to establish continuous flow of fluid from the posterior segment. Perhaps the best recommendation for managing complications in cataract surgery is to be prepared. The measures described above in relation to malignant glaucoma are a good example but equally relevant is having additional devices at hand prior to surgery such as CTRs, Ahmed segments, and Cionni rings, as well as an alternative lens for scleral fixation in patients with pseudoexfoliation, zonular dialysis, and subluxated cataracts. I hope you find this issue interesting and useful in your clinical practice.
RkJQdWJsaXNoZXIy Njk2NTg0