EyeWorld India September 2018 Issue

12 EWAP FEATURE September 2018 Views from Asia-Paci c Pannet PANGPUTHIPONG, MD Deputy Director General Department of Medical Services Ministry of Public Health, Thailand Tel. no. +66-81-9118134 pannetp@hotmail.com Capsulorhexis in Hypermature-Intumescent Cataract I n hypermature intumescent cataracts, the lens progressively becomes swollen and the anterior chamber becomes shallow. However, the IOP often remains low. This situation may last days or months until the anterior chamber angle is closed by pupillary block mechanism or ciliary block mechanism leading to lens-induced glaucoma. In a case with shallow AC, a preop hyperosmotic agent will help to reduce the vitreous volume. Injecting viscoelastic to deepen the AC in a case with shallow AC may cause rising IOP as well as pressure inside the lens that may lead to capsule explosion when starting the capsulorhexis which is called the Argentinian Flag Sign. If the AC is very shallow, pars planar vitrectomy to remove a small amount of vitreous/fluid is life-saving. If the AC is not very shallow, proceed with the “Milky Material Drainage Technique” using the following steps:Make the side port incision; make the main incision (2.75 mm is preferred) by a quick stab in and out or use the AC maintainer at the side port before making the incision to avoid AC collapse; form the AC with air from the side port; inject trypan blue through the side port; quickly remove dye using the I/A tip (trypan blue makes the capsule fragile so do not leave it too long in AC); insert 27-G needle through the side port to make a 2-mm cut in the middle of the anterior capsule while the I/A tip continuously aspirates the milky material using irrigating bottle height at 30–40 cm; may use I/A tip to gently tap on the lens; inject dispersive viscoelastic through the side port; withdraw the I/A tip, and perform capsulorhexis using forceps. Alternative technique: After staining the capsule and aspirating the dye using the above steps, using the AC maintainer at the side port, insert a 27-G needle (connected to a 1-ml insulin syringe) through the main incision to make a 2-mm cut in the middle of the anterior capsule while pressing the posterior lip of the main incision to allow the milky fluid to leak through the incision; inject the viscoelastic through the main incision, and perform capsulorhexis using forceps. When IOP is not high and equal to lens pressure, together with the milky material that can easily flow out into the AC (no viscoelastic in AC at the beginning of capsulorhexis), the chance of capsule explosion when starting capsulorhexis is lower. At the initial stab, the milky material will try to find a way out from the lens. Viscoelastic may prevent free flow of lens material so the increased internal pressure may cause the initial tear to run out. In cases with normal AC depth, we can start the capsulorhexis under viscoelastic without problems. A study by Dick HB, et al. ( J Cataract Refract Surg. 2008), demonstrated capsular fragility after staining with trypan blue. So staining step can be omitted by the Milky Material Drainage Technique and using bright light, high magnification during capsulorhexis. Editors’ note: Dr. Pangputhipong declared no relevant nancial interests. Kazuno NEGISHI, MD, PhD Department of Ophthalmology, Keio University of Medicine 35, Shinanomachi, Shinjuku-ku, Tokyo 1608582, Japan Tel. no. +81-3-33531211 Fax no. +81-3-33598302 kazunonegishi@keio.jp Management of Argentinean ag sign: Most common complication for intumescent cataracts A rgentinean ag sign is a most common complication during capsulorhexis in white cataracts stained with trypan blue. Once it occurs, it can lead to many complications, such as posterior capsule rupture, vitreous loss, and retained nucleus. I have some comments on Prof. Braga-Mele’s case which was successfully managed. First of all, dispersive ophthalmic viscosurgical device (OVD) was used to keep the anterior chamber depth and to atten out the front in this case. However, I think highly cohesive OVD, such as Healon V (Abbott Medical Optics, Santa Ana, Calif.) or DisCoVisc (Alcon, Fort Worth, Texas) is more effective than dispersive OVD to atten the capsule and keep the anterior chamber pressurized without leakage of the OVD out of the anterior chamber during capsulotomy. Patient’s coughing was an unfortunate accident; however, if highly cohesive OVD had been properly used, it might have been avoided. Second, once the tear leads toward the periphery, the management consists of three steps: creating capsular opening, nucleus removal, and IOL implantation. In my experience, the possibility that the tear reached to posterior capsule is not so high at this time point. I usually create two semicircular capsular openings on both sides of the tear with micro- scissors and micro-forceps after removing the liquefaction of the cortical material gently and keeping the anterior chamber with OVD again. Next, I perform phacoemulsi cation at the iris plane with a soft vertical chop or with a sculpting technique carefully. It is most important to avoid perpendicular forces against the capsular tear because the risk of extending the tear toward the posterior capsule is very high. After removal of the lens material, I implant the single-piece IOL in the bag if the posterior capsule is intact. The direction of the haptics is intended to be set in the direction at right angles to the direction of the anterior capsule tear. If the posterior capsule rupture exists, I implant an IOL in the bag. If there is a signi cant vitreous loss, anterior vitrectomy may be necessary. The direction of the haptics is the same as that of the in-the-bag implantation. Editors’ note: Dr. Negishi declared no relevant nancial interests. Challenging...cataract surgery – from page 11 “ It is most important to avoid perpendicular forces against the capsular tear because the risk of extending the tear toward the posterior capsule is very high. ” - Kazuno Negishi, MD, PhD