Small-gauge transconjunctival vitrectomy with phacoemulsification in the pupillary plane of dense retained lens matter on perfluorocarbon liquids after complicated cataract surgery

Trocar blade-assisted skewer technique for phacoemulsification of a dislocated lens

A posteriorly dislocated lens is often managed with a fragmatome through a pars plana approach because it is difficult to manage anteriorly. The lens often sinks to the surface of the retina or floats around in the vitreous cavity during pars plana lensectomy. Mechanical trauma can occur while removing the dislocated lens fragments. However, sometimes the lens can be confined to the anterior vitreous cavity even though the zonules are completely disrupted. It would be ideal if there was a simple way to stabilize and support the lens so that the lens could remain in the posterior chamber while phacoemulsification is performed through a corneal incision as usual. We describe a technique using a trocar blade to stabilize the lens while performing phacoemulsification through a corneal incision. We found it to be a useful and safe instrument to support the subluxated lens during phacoemulsification.

Factory-Made Elastic Silicone Sheet as an Alternative for the Posterior Capsule of the Lens During Phacoemulsification for Dislocated/Subluxated Lenses

Background

We previously reported a novel technique using an elastic silicone bowl, which was handmade from a phaco test chamber, to salvage dislocated lenses and perform phacoemulsification and aspiration (PEA) on the bowl. However, creating the bowl was challenging.

Methods

A factory-made elastic silicone sheet (ESS), a ready-to-use alternative for the posterior capsule of the lens, was prepared. We used this sheet to salvage and support the dislocated/subluxated lenses in 11 eyes of nine patients.

Results

We could use a sheet immediately after we opened the package. In all the cases, we could insert a sheet beneath the lens and PEA performed at the center of the operative field. There was only one incident where the lens could not be placed onto the disc at the first attempt, but the lens was eventually salvaged. There was no risk of rupture during PEA, and the ESS could be removed completely without any complications.

Conclusion

The factory-made ESS described here can be used for salvaging dislocated/subluxated lenses and safely performing PEA.

Analysis of retinal and optic nerve electrogenesis dynamics after vitrectomy for complicated catarct surgery

Background. The article presents impact results of vitrectomy for complicated cataract surgery on retinal and optic nerve electrogenesis. Materials and methods. 30 patients (30 eyes) with history of dropped nucleus (1st group) or intraocular lens dislocated into the vitreous cavity after phacoemulsification (2nd group) underwent electrophysiological examination before vitrectomy, and on Day 1, Day 3, Day 7, Day 14, Day 30, Day 60, and Day 180 after surgery. Results. In the 1st and 2nd groups, on the 1st day after vitrectomy, we observed a significant decrease in retinal and optic nerve electrogenesis in comparison to normal indices (p > 0.01); to Day 180, electrophysiologic indices returned to normal values. In the 1st group, baseline retinal and optic nerve electrogenesis was decreased in comparison to normal parameters. In the 1st and 2nd groups, the electrogenesis of photoreceptors recovered twice as rapidly, as that of bipolar cells; papillomacular bundle neurons were more resistant to vitrectomy. Conclusion. Thus, the presence of lens nucleus fragments in the vitreous cavity results in a reliable inhibition of the retinal and optic nerve electrogenesis due to phacotoxic effect. Vitrectomy causes a short-term depression of the retinal and optic nerve electrogenesis, followed by normalization of indices to Day 180. Photoreceptors have greater rehabilitation activity than bipolar cells. The neurons of axial topographic orientation have the highest resistance to vitrectomy impact.

SUTURELESS CLEAR CORNEAL ULTRASONIC FRAGMENTATION FOR RETAINED LENS FRAGMENTS: A Pilot Study

PURPOSE

To describe the safety and efficacy of removing posteriorly dislocated lens fragments with the use of intravitreal ultrasonic fragmentation through a limbal, clear cornea self-sealing incision.

METHODS

Patients presenting with posteriorly luxated nuclei were enrolled in this prospective case series. Preoperative examination included evaluation of the corneal endothelium by means of specular microscopy. A 3-port 25+ pars plana vitrectomy was initially performed. Following vitrectomy, sclerotomies were sealed using scleral plugs and a limbal/clear corneal incision was performed for the insertion of the fragmatome probe. The incision was slightly larger (1 mm) than the diameter of the fragmatome probe (20 gauge = 0.81 mm) to avoid wound overheating. At the end of the procedure, an appropriate intraocular lens either sulcus-fixated or angle-supported was implanted. Primary outcome measures were mean postoperative best-corrected visual acuity, intraoperative or postoperative complications, and intraoperative challenging features.

RESULTS

In all eyes, fragmentation was completed successfully with a mean total ultrasound time of 113.4 seconds. Nucleus density was ≥3 in all cases (mean ± SD = 3.8 ± 0.4). Intraoperative challenges included viewing difficulties because of corneal distortion, fragment turbulence, and leakage through the limbal incision potentially compromising fundus visualization. There was statistically nonsignificant reduction in endothelial cell density ranging between 1932 ± 187 cells per square millimeter preoperatively to 1789 ± 213 cells per square millimeter at the first month postoperatively (P = 0.79).

CONCLUSION

Clear corneal, sutureless ultrasonic fragmentation seems to be a novel, safe, and efficient method for the removal of hard posteriorly dislocated lens fragments, sparing the need for a 20-gauge scleral port.

Perfluorocarbon liquid: its application in vitreoretinal surgery and related ocular inflammation

The application of perfluorocarbon liquids has been well acclaimed in vitreoretinal surgery. Its unique physical properties make it an ideal intraoperative tool to improve the efficiency and safety of surgical procedures in complicated cases. The main functions of perfluorocarbon liquids in vitreoretinal surgery include relocating and fixing the detached retina, displacing the subretinal and subchoroidal to fluid anteriorly, revealing proliferative vitreous retinopathy (PVR) for further maneuvers, protecting the macula from exposure to chemicals with potential toxicity, and assisting the removal of foreign body. The related clinical applications include retinal detachment with severe proliferative vitreoretinopathy, giant tear, diabetic retinopathy (DR), retinopathy of prematurity (ROP), and posterior dislocated crystalline and intraocular lenses. The application of perfluorocarbon liquids has been expended over the past fewer years. Several PFCLs related ocular inflammations have been observed in in vitro studies, animal studies, and clinical follow-up. The complete removal of PFCLs is recommended at the end of the surgery in most cases.

2013 update on the management of posterior capsular rupture during cataract surgery

PURPOSE OF REVIEW

Posterior capsular rupture (PCR) is an infrequent complication of cataract surgery that can lead to significant ocular morbidity and permanent vision loss. In the setting of PCR, the primary objective is the safe and thorough evacuation of vitreous and lens fragments from the anterior segment. The secondary objective is the stable placement of an intraocular lens (IOL) selected for best refractive outcomes. Expedited referral to vitreoretinal specialists is recommended for management of posteriorly dislocated lens material and surveillance for retinal injury. It is the intention of this review to present current guidelines for the management of PCR.

RECENT FINDINGS

There are new techniques available to anterior and posterior segment surgeons in the setting of PCR. Endoillumination may facilitate visualization during anterior vitrectomy and the IOL may be used as a pupillary barrier to prevent loss of lens fragments. When secondary procedures are needed, early return to the operating room and small-gauge pars plana techniques may reduce patient morbidity.

SUMMARY

When approached carefully and systematically, patients may have good outcomes in the setting of PCR. Recent advancements in instrumentation and technique encourage further study and may lead to new standards of care.