EyeWorld India March 2014 Issue

March 2014 15 EWAP FEAturE She noted that the chamber would likely be bouncier as well during phacoemulsification. “The other things you have to worry about, that a lot of people don’t think of with these post-vitrectomized eyes, is obviously they have been entered through the pars plana,” Dr. Braga-Mele said. “So you have to question whether there has been any zonular trauma during the vitrectomy or any posterior capsular trauma, and you need to look for that.” Dr. Fram said there are several factors that can cause complications in cataract surgery when there was a previous pars plana vitrectomy. These factors include white or brunescent cataract development and the possibility of preexisting posterior capsular rent. There is “potential for zonular weakness, which may lead to fluid misdirection, causing paradoxical shallowing of the anterior chamber,” Dr. Fram said. She also cited compromised fluidics due to the lack of vitreous support resulting in excessive deepening of the anterior chamber as a possible factor for complications. Special pearls for phaco surgeons Dr. Braga-Mele said that one key point to remember in these patients is that because of the anterior/posterior movement of the lens, the patients will feel more pain. “Be very liberal with the use of intracameral lidocaine, and you may even consider a peribulbar block, depending on the case,” she Views from Asia-Pacific Johan A. HUTAURUK, MD Director, Jakarta Eye Center Jl. Cik Ditiro 46, Menteng, Jakarta 10310 Indonesia Tel. no. +62-21-2922-1000 Fax no. +62-21-390-4601 johan.hutauruk@jakarta-eye-center.com I agree with the Dr. Huang that the risk of complications for cataract surgery in post-vitretomy eyes is not significantly higher than with other cataract surgery, although some precautions must be taken into consideration so the surgeon can anticipate any difficulties. In my opinion, there are two main contributors for the low complications of cataract surgery in this particular cases: (1) the advancements of phaco machines that enable us to perform surgerywith smaller incision and a very stable anterior chamber; (2) the densities of cataract in post-vitrectomy eyes are usually between mild to moderate, this type of lens is not so difficult to handle compared to harder ones. But there are things that we need to consider to anticipate problems, and I would like to share my experiences dealing with post-vitrectomy eyes: • Perfect construction of clear corneal incision, preferably of smaller size (2.20 mm), certainly helps to reduce anterior chamber fluctuation due to wound leakage. • Larger capsulorhexis to easily dislodge the lens out of the bag, soft cataract and deep anterior chamber will be safe for the endothelial with modern phaco machines even if we emulsify the lens in the anterior chamber. • Our retinal colleagues will be grateful with the larger capsulorhexis should they need to perform wide field funduscopy if the patient develops capsular fibrosis in the future. • Silicone oil droplets in the anterior chamber are thought to be a sign of zonular dehiscence; the use of low parameter settings in phacoemulsification will reduce further zonular stress. • Fibrosis of the posterior capsule, especially with the silicone-filled eye, needs to be intraoperatively removed, because this type of fibrosis is difficult to YAG. I always prepare a foldable 3-piece IOL; if it is too difficult to place the IOL in-the-bag after posterior capsulorhexis, this type of lens is safe to place in the sulcus. • Some patients will have smaller pupil diameters, either due to a poorly dilated pupil or posterior synechia that can only be revealed during surgery. The use of NSAID preoperatively is mandatory for all patients with post-vitrectomy eyes. The advantages of using NSAIDs have already been mentioned by Dr. Fram. Editors’ note: Dr. Hutauruk has no financial interests related to his comments. said. This could be particularly helpful for a super dense nucleus or if there is any concern for other complications occurring. “I also would advise making a shorter rather than longer wound because you will be working more deeply within the eye due to lack of vitreous support, and if you make too long of a wound, you will have striations within the cornea and you may find it harder to see what you’re doing especially when removing the cataract in the bag,” she said. Dr. Braga-Mele advised to be very aware of the possible lack of integrity of the posterior capsule, as well as to check the zonular integrity. “With respect to zonular integrity, you may want to consider, if there’s a loose zonular complex, suturing the lens in,” she said. She said if using hydrodissection for these cases to be cautious, or it may be beneficial to use viscodissection as an alternative. Dr. Braga-Mele said planning the case is extremely important. She often tries to make a larger capsulorhexis so that she is able to flip the nucleus out of the bag so it is not necessary to work so deep in the capsular bag-zonular complex. This technique allows the surgeon to bring the nucleus into the anterior segment to deal with it there. “If you are going to work in the bag, make sure you optimize your fluidics,” she said. This can be done by lowering bottle height or putting in a posterior chamber maintainer. continued on page 17