EyeWorld Asia-Pacific June 2018 issue

Figure 2A. Posterior displacement of lens and iris and sudden pupillary dilation right after the phaco tip was inserted in the anterior chamber Figure 2B. The pupillary block is reverted by pressing down the anterior capsular leaflet with the second hand instrument. Source (all): Daniel Badoza, MD 48 EWAP CATARACT/IOL June 2018 Postoperative pearls Long eyes have the same postop- erative issues as eyes with smaller axial lengths, such as cystoid macular edema, IOL miscalcula- tion, retinal detachment, endoph- thalmitis/TASS, and endothelial decompensation. The case for retinal detach- ment being a major concern in highly myopic eyes is well docu- mented. According to a study on the risk of retinal detachment in eyes that underwent cataract surgery from the Danish National Patient registry, phacoemulsifica- tion increased retinal detachment 4.23 times in the cataract popula- tion as a whole, including short, normal, and long eyes. 2 If phaco- emulsification increases the overall risk of retinal detachment, as this study suggests, it poses a particu- lar risk in long eyes, according to Dr. Badoza. Risk factors for retinal detachment are young age, male gender, and long axial length. A retrospective consecutive interventional study found the incidence of retinal detachment after coaxial phacoemulsification in 439 eyes of 274 highly myopic patients to be 2.7%. The mean axial length in the study was 28 mm. The investigators reported a trend toward an increased inci- dence and risk of retinal detach- ment in patients younger than 50 years. 3 Another retrospective medical chart review of 2,356 eyes in 1,519 consecutive patients with an axial length greater than 27 mm who had phacoemulsification with IOL implantation revealed a postoperative retinal detachment of 1.5–2.2%. 4 However, the absence of control groups matched for age, sex, and myopia preclude these studies from elucidating the exact influence of phacoemulsification as a risk factor for retinal detach- ment in eyes more than 30 mm in axial length. A study of 453 em- metropic eyes of 453 patients that had phacoemulsification with IOL implantation showed the occur- rence of posterior vitreous detach- ment (PVD) as associated with the reduction of volume occupied by the removal of the lens. The study suggested that the onset of postop- erative PVD should be considered an important risk factor for the development of retinal detachment after cataract surgery, especially in eyes with lattice areas. 5 Prevention “To assure the prevention of pseu- dophakic retinal detachment in very long eyes, it is important to assess the indications for surgery and intraoperative prophylaxis,” Dr. Badoza said. “Patients up to 55 years of age with a clear lens and satisfactory BCVA are questioned about contact lens tolerance. If they can wear contact lenses, we prefer to defer surgery. If they are contact lens intolerant, how- ever, then we consider posterior chamber phakic IOL implantation. Preoperatively, it is very important to give patients a detailed explana- tion about the pros and cons of this indication. Intraoperatively, to prevent severe or abrupt AC decompressions that would pro- voke vitreous traction and PVD, we need to keep the AC stable. To achieve that, we try to decrease the infusion bottle height before introduction or withdrawal of the infusion. We set slow phacody- namic parameters and perform phacoemulsification through the smallest incision our machine is able to work with, a 1.8-mm primary incision. After emulsify- ing the nucleus, we inject air or balanced salt solution through the paracentesis while withdrawing the phaco tip to prevent the anterior chamber from flattening. The same care should be taken after cortical cleanup; instead of air, we inject OVD while removing the I/A tip before implantation of the IOL.” EWAP References 1. Cionni RJ, et al. Management of lens-iris diaphragm retropulsion syndrome during phacoemulsi- fication. J Cataract Refract Surg. 2004;30:953–6. 2. Bjerrum SS, et al. Risk of pseu- dophakic retinal detachment in 202,226 patients using the fellow nonoperated eye as reference. Oph- thalmol. 2013;120:2573–9. 3. Alio JL, et al. The risk of retinal detachment in high myopia after small incision coaxial phaco- emulsification. Am J Ophthalmol. 2007;144:93–98. 4. Neuhann IM, et al. Retinal detachment after phacoemulsifica- tion in high myopia: analysis of 2356 cases. J Cataract Refract Surg. 2008;34:1644–57. 5. Ripandelli G, et al. Posterior vitreous detachment and retinal detachment after cataract surgery. Ophthalmol. 2007;114: 692–7. Editors’ note: Dr. Badoza has no financial interests related to his com- ments. Contact information Badoza: dabadoza@gmail.com Managing eyes – from page 47