The key to approaching a difficult surgery is to use a stepwise approach. In the case presented here, we have a high risk case with multiple challenges present. The patient is also monocular due to a long-standing funnel retinal detachment in the other eye.
This eye has the following issues which will complicate the cataract surgery:
- glaucoma which is controlled with an Ahmed Valve device
- a small pupil with extensive synechiae
- a dense, brunescent cataract
- a large corneal scar which limits the surgical view
The first step is to achieve sufficient anesthesia for a surgery which is anticipated to be more involved. In this case, the resident surgeon decided that a retro-bulbar block would be best, so that was administered without issues. The patient also received a moderate degree of intravenous sedation with midazolam.
For the small pupil, the synechiae were mechanically separated by lifting the iris off the surface of the anterior capsule, then a pupil expansion ring was inserted to give adequate exposure. We used a superior incision to avoid proximity to the tube from the Ahmed valve. At this point, the viscoelastic was aspirated from the eye and then the anterior lens capsule was stained with trypan blue dye.
Following a good fill of the anterior chamber with dispersive viscoelastic, a large capsulorhexis was created. This was done with only a partial view and care was taken not to let go of the edge which the view was the most obscured. A round, continuous, curvilinear capsulorhexis with a diameter of about 5.5 mm was created without issues.
The dense cataract was disassembled using phaco chop. Due to the dense, fibrous nature of the cataract, it required many chops to finally break it apart. Because the corneal scar obscured much of the view, the quadrant with the least scarring (the patient’s infero-lateral quadrant of the anterior chamber) is where most of the chopper maneuvers were performed.
For IOL selection, we opted for a three-piece acrylic, monofocal IOL. This was chosen just in case there was a capsule issue during insertion, in which case this IOL could be dialed securely into the sulcus. Fortunately, all proceeded normally and this IOL was placed in the capsular bag.
Click below to learn from this challenging case: