1542: tough resident cataract case

This is a very tough resident cataract case and there are some complications. The most important point is that the resident learned so many valuable lessons from this surgery. In his own words, this is the case:

This is my 7th cataract case (2nd year resident) with an attending surgeon assisting. The patient is a 77 yo M with a history of retinal detachment x3. Currently under SO (silicone oil) with a repeat retinal detachment. Acuity is HM, predicted acuity is around 20/100. Plan is for CE/IOL/SO removal/RD repair/SO replacement. This is done in the retina OR, and this is the OR tech’s very first phaco surgery.

The case begins with SO removal by Retina. The attending asks the retina surgeons to turn off the infusion, and a conversation ensues regarding whether the infusion should be turned off at the machine or just to clamp the infusion line. After retina ensures infusion is not reaching the eye, we begin, but the tech has pulled brilliant blue instead of trypan blue dye for the case. We don’t know if this is safe or even will work, so decision is made to proceed without staining the capsule, as we were quoted 40 minutes to get trypan to the room. The view is terrible because the retina is detached, so the red reflex does not exist, complicating the case from hence forward.

We immediately have trouble flipping the flap of the rhexis over. Placing more viscoelastic is not helping because the tech has failed to place BSS in the viscoelastic cannula when screwing on the cannula, thus trapping massive amounts of air. With each instillation of visco, the chamber depressurizes as the bubble pushes the rhexis further and further out. The edge of the rhexis disappears under the iris edge. The Little maneuver fails to create a curvilinear rhexis.

We begin anew in another area which is virgin capsule, and create 2 separate curvilinear segments which we connect together to start creating a circular opening in the rhexis. Finally at this time, we realize that infusion (set at 70 mmHg) has not been turned off or clamped, and the posterior pressure combined with all of the bubbles in the viscoelastic has created an impossible situation to tear a rhexis. We both clamp and turn off the infusion. We finish the rhexis with a fourth and final curvilinear segment.

Nucleus and cortex removal proceed uneventfully, and finally we are left with an anterior capsule rent to the equator which has not proceeded posteriorly with no vitreous loss and no prolapse of SO into the AC. Decision is made because the AC only has 1 area of weakness to place a 3 piece in the sulcus with the haptics supported by the intact areas of bag.

Unfortunately, the tech, trained to load 1 piece lenses, has trouble loading the 3 piece lens. The MD assists to load the 3 piece. The lens is advanced too far out of the eye, and the leading haptic is already out of the injector before inserting. Also in the confusion, the 3 piece in a B cartridge is inserted through a 2.4 mm wound. Fortunately the patient is highly myopic, the lens is only 7.0 D, and a wound assisted delivery is possible, though the leading haptic goes under the iris as it goes in the eye. Finally, the lens is tucked into the sulcus, the wound is sutured (retina’s preference) and the case is turned over to retina.

This highlights of the case are that it is virtually impossible to tear a rhexis with that huge amount of posterior pressure. Also, a modified can opener technique with several curvilinear segments was created which worked. Also failing to enlarge the wound worked out OK for us, but could have resulted in damage to the lens and having to cut the lens out. Good learning case for the tech and the resident.

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