Acute intraoperative rock-hard eye syndrome and its management

Double trouble in DMEK surgery: Learning experience and review of the literature

PURPOSE

To report a challenging Descemet Membrane Endothelial Keratoplasty (DMEK) case, complicated by intraoperative aqueous misdirection and spontaneous anterior chamber fibrin reaction.

METHODS

A 70-year-old female affected by corneal edema due to Fuchs endothelial dystrophy underwent a triple procedure (cataract extraction - IOL implantation - DMEK surgery) in her left eye. This report illustrates the management of the intraoperative complications of aqueous misdirection syndrome and anterior chamber fibrin reaction.

RESULTS

Despite the optimal management of the posterior pressure and the thorough removal of the fibrinous reaction during the case, the DMEK graft was not completely unfolded and centred at the end of the surgical procedure. Nonetheless, the patient showed good long-term anatomical and functional recovery: at the last follow-up (2 years after surgery), central corneal thickness was 526 µm with a best corrected visual acuity of 20/25 and an endothelial cell density of 1112 cell/mm2.

CONCLUSION

Early recognition and prompt management of intraoperative aqueous misdirection syndrome and anterior chamber fibrin reaction during DMEK surgery is essential to ensure good functional and anatomical outcomes.

Needle aspiration for management of acute intraoperative fluid misdirection during phacoemulsification

Purpose

Acute intraoperative fluid misdirection is a serious complication that may occur during phacoemulsification. We provide a detailed description and a video of our preferred technique for prompt management of acute intraoperative fluid misdirection.

Observations

A 79-year-old male developed sudden shallowing of the anterior chamber and marked elevation of intraocular pressure at hydrodissection during phacoemulsification surgery. Treatment consisted of a needle aspiration of trapped fluid from the retrolental space, employing a 5/8th inch, 25-gauge needle on a medium-size syringe leading to immediate softening of the globe and deepening of the anterior chamber. The rest of the case proceeded uneventfully. The patient had uncomplicated recovery and final best-corrected visual acuity of 20/20.

Conclusions and importance

Acute subcapsular infusion fluid entrapment may occur during uneventful phacoemulsification. Needle aspiration of retrolental fluid is a simple and inexpensive method for immediate resolution of high IOP and deepening of the anterior chamber, allowing the case to proceed.

Treatment of Nanophthalmos Cataracts: Surgery and Complications

PURPOSE

Cataract surgery in patients with nanophthalmos is complicated for ophthalmologists to perform. Due to the unique ocular anatomy, there is a high incidence of complex complications such as angle-closure glaucoma, fluid misdirection syndrome, and uveal effusion syndrome (UES) in the perioperative period of cataract surgery. This article will discuss the management options for cataract surgery in nanophthalmic eyes and complications.

METHODS

This review is searched through PubMed, focusing on articles published in the past 20 years. Articles were reviewed on the anatomical structure of nanophthalmic cataracts, the pathogenesis of complications, the selection of intraocular lenses, and surgical methods.

CONCLUSION

There is a strong correlation between abnormal ocular anatomy and complications in patients with nanophthalmos. Clinicians must not only select the appropriate intraocular lens formula based on the depth of the anterior chamber but also formulate personalized surgical methods based on its unique anatomical structure to avoid complications.

Intraoperative malignant glaucoma during femtosecond laser-assisted cataract surgery: A case report

RATIONALE

Femtosecond laser-assisted cataract surgery (FLACS) has grown in popularity among ophthalmologists as a novel surgical technique. However, malignant glaucoma (MG) is a complication of FLACS. Herein, we report a case of MG following FLACS.

PATIENT CONCERNS

A 66-year-old woman presented with complaints of blurred vision in the right eye and a foreign body sensation in both eyes. Ophthalmological examinations showed that the corrected distance visual acuity was 20/50 and 20/25 in the right and left eyes, respectively. Without any topical anti-glaucoma medication, the intraocular pressure (IOP) was 20 mmHg in the right eye and 17 mmHg in the left eye. Slit-lamp examination of the right eye revealed a transparent cornea with a defect in the punctate overlying epithelium; the central anterior chamber depth was shallow the peripheral iris laser shot was visible, the pupil was normal, and the lens was mainly cortical opacified.

DIAGNOSES

Based on the patient's symptoms, examination results, and preliminary diagnoses, age-related cataract in the right eye, binocular post-antiglaucoma surgery, pseudophakicin in the left eye, and Sjogren syndrome were included.

INTERVENTIONS

FLACS was performed to facilitate anterior capsulotomy and segmentation of the nucleus in the right eye. MG occurred after the femtosecond procedure, and with the treatment of medicines combined with phacoemulsification, IOP was eventually normal without further antiglaucoma therapy.

OUTCOMES

IOP was 16 mmHg on postoperative day 1. Ocular ultrasonography revealed no choroid detachment or hemorrhage in the right eye. Two weeks postoperatively, uncorrected visual acuity was 20/25, and IOP remained normal with no further antiglaucoma treatment on 1 month postoperatively.

CONCLUSIONS

We describe the occurrence of MG after FLACS and illustrate that miosis and bubble formation after FLACS may be risk factors for MG during FLACS.

Netzhaut-Glaskörperchirurgie bei Glaukom

Abstract (deutsch): Die Glaukome gehen mit einem Untergang von retinalen Ganglienzellen und deren Axonen einher, welche sich vornehmlich in der Netzhaut befinden. Die Vitreoretinale- und die Glaukomchirurgie überschneiden sich bei bestimmten Krankheitsbildern in einem nicht geringen Ausmaß. Ziel des vorliegenden Übersichtsartikels ist es diese Krankheitsbilder darzustellen und Behandlungsstrategien und die jeweiligen Wirkungsweisen gesammelt aufzuzeigen. Im Rahmen des vorliegenden Artikels werden die Themen malignes Glaukom / aqueous misdirection syndrome, Netzhautchirurgie bei Aderhautamotio und expulsiver Aderhautblutung, postoperative Blebitis und Endophthalmitis nach Glaukomoperation und Vitrektomie nach Glaukomoperationen zusammen beschrieben und die bestehenden Therapiepfade beim Management von auftretenden Komplikationen aufgezeigt. Insgesamt sind die Bereiche Glaukom- und Netzhaut-Glaskörperchirurgie eng miteinander verbunden. Kollegen beider Subspezialitäten sollten Kenntnisse über diese sie beide betreffenden Krankheitsbilder haben. Abstract (englisch): Glaucoma is associated with the demise of retinal ganglion cells and their axons, which are primarily located in the retina. Vitreiretinal and glaucoma surgery overlap to a not inconsiderable extent in certain diseases. The aim of this overview article is to present these diseases and to highlight treatment strategies and the respective modes of action in a collective manner. Within the scope of this article, the topics of malignant glaucoma / aqueous misdirection syndrome, retinal surgery for choroidal detachment and expulsive choroidal hemorrhage, postoperative blebitis and endophthalmitis after glaucoma surgery and vitrectomy after glaucoma surgery are described together and the existing therapeutic paths for the management of complications are shown. The areas of glaucoma and vitreoretinal surgery are tightly linked. Colleagues from both subspecialties should be familiar with a certain overview of diseases concerning both subject areas.

Three Cases of Intraoperative Acute Fluid Misdirection Syndrome during Cataract Surgery

Purpose: We report the management of three cases of intraoperative acute fluid misdirection syndrome during cataract surgery.Case summary: Cataract surgery was performed in one eye of an 82-year-old woman with pseudoexfoliation syndrome, one eye of an 80-year-old man with end-stage glaucoma, and both eyes of a 72-year-old man with pseudoexfoliation syndrome. In the first two cases, the capsular bag space decreased during cortex aspiration and after removal of the cortex, respectively. After intravenous mannitol and intake of oral acetazolamide, the intraocular lens was successfully inserted in the first two cases on the same day. In the third case, after first removing the nucleus and cortex of the right eye, the capsular bag space decreased and an intraocular lens was carefully inserted. No intraoperative complications were seen during the left eye operation. One month after the operation, the best-corrected visual acuity had improved and the intraocular pressure was within normal limits for all three cases.Conclusions: A relatively shallow chamber, pseudoexfoliation, zonular laxity, and use of high molecular weight ophthalmic viscosurgical devices may cause acute fluid misdirection syndrome during cataract surgery. Pars plana vitrectomy may be required. However, intravenous high osmotic agent treatment should be attempted first, followed by intraocular lens insertion on the same day.

Successful surgical management of interlenticular membrane by vitreoretinal interlenticular membranectomy (VIM)

The formation of a light scattering interlenticular membrane (ILM) is a known complication of polypseudophakia and has been particularly noted with the use of dual intracapsular Alcon AcrylSof intraocular lenses (IOLs). The treatment options for this condition have largely been restricted to either Nd:YAG laser membranotomy or explantation of the dual IOL complex. In this case report, we describe an unusual case of ILM in a 76-year-old woman whose ILM had formed between her primary intracapsular IOL and her piggyback sulcal IOL. Furthermore, we describe vitreoretinal interlenticular membranectomy (VIM), a novel technique involving a translimbal anterior interlenticular membranectomy using vitreoretinal instrumentation. There were no intraoperative or postoperative complications. Postoperative best-corrected visual acuity was 6/4, maintained for 3 years of follow-up. VIM is offered as a management option for surgeons to address ILM when Nd:YAG laser therapy fails, and the IOLs cannot be safely explanted.

[Bilateral postoperative myopic shift and rise in intraocular pressure after cataract surgery]

Malignant glaucoma describes a rare constellation with shallowing of the anterior chamber and raised intraocular pressure, which can occur after ocular surgery, trauma or spontaneously. The pathophysiological mechanism seems to consist of a posteriorly directed flow of the aqueous humor formed in the ciliary body into or behind the vitreous body. Most cases can only be treated by surgical intervention. This article describes a bilateral postoperative occurrence, which could be successfully treated with medication alone and no need for surgery.

Fluid-jet technique to polish the posterior capsule for phacoemulsification surgeries: efficacy and safety evaluation

PURPOSE

To compare the efficacy and safety of a fluid-jet technique with capsular polish in reducing residual lens fibers (RLFs) in phacoemulsification surgery.

SETTING

Single center.

DESIGN

Prospective nonrandomized comparative study.

METHODS

Patients receiving phacoemulsification were included. Consecutive eligible patients alternately underwent either removal of RLFs on the posterior capsule using capsular polish after irrigation and aspiration, and before intraocular lens (IOL) implantation, or RLF removal using a fluid-jet technique after IOL implantation. Posterior capsular images were used to quantify RLFs. Visual parameters were evaluated at 1 day, 1 week, and 1 year postoperatively. The proportion of capsule occupied by posterior capsule opacification (PCO) (area %) and incidence of protocol-driven laser posterior capsulotomy were recorded at 1 year in masked fashion.

RESULTS

Seven hundred forty eyes were allocated to polishing (n = 370) or fluid-jet technique (n = 370). Polishing required 70.4 ± 17.5 seconds and fluid-jet 32.2 ± 9.9 seconds (P ≤ 0.001). Compared with the polishing group, capsular area occupied by RLFs in the fluid-jet group was significantly smaller (3.5% vs 0.5%, P = .031) at the end of surgery. One day postoperatively, the fluid-jet group had more desirable corrected distance visual acuity, objective scattering index, and Strehl ratio (all P < .05). PCO area percentage did not differ between groups (6.5% vs 4.5%, P = .252) 1 year postoperatively, but incidence of posterior capsulotomy was lower in the fluid-jet group (3.2% vs 0.8%, P = .019).

CONCLUSIONS

Fluid-jet removed RLFs effectively and had lower incidence of postoperative capsulotomy than capsular polishing.

Acute and chronic fluid misdirection syndrome: pathophysiology and treatment

Purpose

To summarize our current understanding of the specific pathogenic mechanisms of the fluid misdirection syndrome and possible treatment methods.

Methods

We used the PubMed web platform to find relevant studies using the following keywords: infusion misdirection syndrome, aqueous misdirection syndrome, ciliary block, ciliovitreal block, capsular block, intraoperative fluid misdirection, subcapsular fluid entrapment, acute intraoperative rock-hard eye syndrome, positive vitreous pressure glaucoma, and malignant glaucoma. Other publications were also considered as a potential source of information when referenced in relevant articles.

Results

We collected and analyzed 55 articles dated from 1951 to 2016. Acute intraoperative rock-hard eye syndrome is characterized by a very shallow anterior chamber with the absence of suprachoroidal effusion or hemorrhage and no noticeable pathology of the iris–lens diaphragm. It usually occurs during uneventful phacoemulsification, particularly in hyperopic eyes. The pathophysiology of acute fluid misdirection syndrome is based on inappropriate movement of balanced salt solution via the zonular fibers. This syndrome has also been described as occurring from hours to months, or years, after the initial surgery. The pathophysiology of malignant glaucoma is based on similar mechanisms of cilio-lenticular block of aqueous flow leading to the misdirection of aqueous posteriorly into or besides the vitreous gel. Faced with these situations, vitreous decompression is required, preferably with hyaloido-capsulo-iridectomy. In phakic eyes, concomitant cataract extraction would be desirable.

Conclusions

We believe both of these clinical conditions should be considered as one syndrome. We suggest the term acute fluid misdirection syndrome for the cascade of events during phacoemulsification surgery. Chronic fluid misdirection syndrome better describes the nature of malignant glaucoma.

Avoiding Complications From Patient Positioning for Intraocular Surgery

Collaboration of the surgical and anesthesia teams for patient positioning is essential to assure patient comfort and safety, preventing systemic and ophthalmic complications. The goals and rationales of positioning for intraocular surgery are discussed including placing the head above the heart, elevating the chin, using a head rest that is sufficiently firm, maximizing anesthesia care team access and minimizing fire risk, and taping the patient's head to the operating table to reduce unexpected movement with intraocular injury.

Retrospective Study of Vitreous Tap Technique Using Needle Aspiration for Management of Shallow Anterior Chamber during Phacoemulsification

Purpose

To evaluate the technique of vitreous tap using needle aspiration for management of anterior chamber shallowness during phacoemulsification.

Methods

A retrospective study included 26 eyes of 17 patients who underwent phacoemulsification in which vitreous tap was performed using a 27-gauge needle attached to a 5 ml syringe, inserted 3.5 mm from the limbus to aspirate 0.2 ml of liquefied vitreous if a cohesive (OVD) failed to sufficiently deepen the anterior chamber.

Results

Preoperative anterior chamber depth was 2.31 ± 0.26 mm, axial length was 21.7 ± 0.67 mm, lens thickness was 4.5 ± .19 mm, and cataract grade was 3.77 ± 1.4. Preoperative CDVA in LogMAR units was 0.98 ± 0.75. Coexisting angle closure glaucoma was present in 7 patients (26.92%) preoperatively. Vitreous needle tap was successful in vitreous removal on the first attempt in 26 eyes (100%). Postoperative follow-up period was 22.88 ± 10.24 (4–39) months. The final postoperative CDVA in LogMAR units was 0.07 ± 0.1, while the final postoperative IOP was 16.54 ± 1.45 mmHg. No complications related to vitreous tap were noted.

Conclusion

Vitreous needle tap is a simple, cost-effective, and safe technique for management of shallow anterior chamber in phacoemulsification.

Hydropolish: a controlled trial on a technique to eradicate residual cortical lens fibers in phacoemulsification cataract surgery

PURPOSE

To assess the efficacy and safety of a noncontact, fluid-based capsular polishing technique (hydropolish) to remove residual cortical fibers (RCFs) and epithelial cells from the posterior and equatorial capsule in phacoemulsification cataract surgery.

METHODS

Hydropolish involved manual irrigation of the posterior and equatorial capsule after irrigation/aspiration, using a 27-G hydrodissection cannula. This prospective, consecutive, single surgeon controlled trial was conducted at a dedicated ophthalmic surgery center in Sydney, Australia, between December 20, 2006, and July 14, 2010. Single eyes of consecutive patients underwent cataract surgery without use of hydropolish (control group), while those on or after July 21, 2010, underwent hydropolish (intervention group). Corrected distance visual acuity (CDVA) up to 1 month postoperatively, surgical complications, and hydropolish time were documented.

RESULTS

A total of 1531 eyes were included in this study (hydropolish n = 682; control n = 849). After adjusting for age, sex, and nuclear sclerosis grade, no significant difference was found between hydropolish and control groups when preoperative CDVA was compared against postoperative CDVA at 1 day, 1 week, and 1 month (p&gt;0.05).

CONCLUSIONS

Hydropolish is a rapid and safe technique that can remove RCFs from the posterior and equatorial capsule in phacoemulsification cataract surgery. It does not compromise postoperative CDVA.