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. No matter what measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.” – Atul Gawande, Complications: A Surgeon's Notes on an Imperfect Science This is what being a good surgeon is all about: Since complications are a part of every surgeon’s life, the way they are managed plays an important role in defining the surgeon’s expertise—and more importantly the patient’s life. Drs. Rai and Rubenstein discuss their pearls for dealing with anterior and posterior capsule rupture where a toric IOL was planned. In such cases, the first priority is to limit any further damage and deal with the lens material and any vitreous in the anterior chamber. Follow the principles of low aspiration and irrigation parameters and the appropriate use of adjuncts such as ophthalmic viscosurgical devices (OVDs) and triamcinolone acetonide. After, take your time to assess the situation. With any IOL, but particularly with a toric, ensuring both anteroposterior and rotational stability is of paramount importance. If one feels confident in placing the IOL and ensuring stability, one may consider going ahead with a toric IOL. However, as stressed in the feature, never implant a single-piece acrylic IOL in the ciliary sulcus. Whenever in doubt, the safer option is a three-piece foldable IOL positioned in the ciliary sulcus with optic capture or left in the sulcus. Where a three-piece toric IOL is unavailable, a monofocal IOL should be implanted. The next step is communication with the patient and subsequent follow-ups. Most of the time, being an empathetic clinician and being honest with the patient works wonders. I like to sit the patient and family down and discuss the fact that though we could not implant the IOL as planned, we have done what was best for the eye in the long term. We let them know that we are doing what is best for them and will continue to work as a team to make sure they end up with the best outcomes. These patients will require extra chair time even in the postoperative period; do not forget to involve your retinal and glaucoma colleagues whenever the need arises. The true test of any procedure is the kind and severity of complications that surgeons will face during their learning curve and how well they can be tackled. All in all, this issue is a must read, and I am sure you will all gain meaningful insights into how you can manage your complications better! Abhay Vasavada Trending in Ophthalmology Deputy Regional Editor EyeWorld Asia-Pacific “
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