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Cover Focus | May/June '19

Surgical MacGyvering

A 65-year-old white woman presented with a visually significant posterior polar cataract and high axial myopia. When managing posterior polar cataracts, my routine approach begins with supplemental preoperative patient counseling regarding the increased risks and a preference for retrobulbar anesthesia.

Intraoperatively, I create a 2.8-mm keratome incision and a 5.0-mm continuous curvilinear capsulorhexis to facilitate possible three-piece IOL implantation in the sulcus with optic capture. Hydrodissection is risky, and therefore I proceed directly to gentle hydrodelineation. After achieving a golden ring, I disassemble the nucleus using a nonstop horizontal chop technique and leave a protective epinuclear shell. This way, when the posterior capsule subsequently tears, any remaining lens material that might drop is relatively soft cortex and epinucleus, which are manageable with a vitrectomy cutter.

IN THIS CASE

In the case shown in the video below, however, the entire nucleus dropped immediately, before I could complete the first chopping maneuver. This likely occurred as a result of inadvertent downward pressure from the phaco needle when impaling the nucleus. I was wary of closing and referring to retina, as it was already late and I anticipated a robust inflammatory reaction if the patient was made to wait until the next day.

I set up for a 25-gauge pars plana vitrectomy but wanted to avoid using the fragmatome with its larger sclerotomy port, not to mention the lack of perfluorocarbon at the surgery center. I considered levitating the entire nucleus back into the anterior chamber after vitrectomy. From there, I could use an irrigating vectis to extract the nucleus à la manual small-incision cataract surgery. I expected the patient’s sclera to be thin and leaky, given her high axial myopia, so I elected against a scleral tunnel incision. Besides, the nuclear component was not terribly dense. I decided to instead attempt the scaffold technique, with which I would first inject the IOL into the sulcus under the nucleus and then disassemble it in the anterior chamber.

Just one problem: The nucleus was too large to prolapse anteriorly back through the posterior capsular tear and capsulorhexis. I had to fragment it in the posterior segment, at least into heminuclei. I figured I could then perhaps deliver the fragments anteriorly and proceed with the scaffold technique. I decided to try using a normally endocapsular nitinol ring fragmentation device (miLoop, Carl Zeiss Meditec), reasoning that the mechanics would be similar if I could levitate the nucleus close to the posterior capsule.

I placed the light pipe in my dominant hand and the cutter in my nondominant hand. With the cutter bored into the initial phaco chop groove, the nucleus was purchased using a minimum cut rate with maximum vacuum and was then levitated by lifting the cutter. Once in the anterior vitreous cavity, I exchanged the light pipe for the miLoop device in my dominant hand and passed it through the main corneal incision, the capsulorhexis, the posterior tear, and around the nucleus. Fortunately, cinching the miLoop produced the desired cleavage.

When aspirating the heminuclei to levitate them, they began to disassemble, so I abandoned the scaffold technique in favor of direct nuclear disassembly in the posterior segment. I expedited the process by using the light pipe to mechanically chop the fragments and feed them into the cutter. The case then returned to plan, with endocapsular epinuclear and cortical cleanup followed by successful placement of a three-piece IOL in the sulcus with optic capture.

One week postoperatively, the patient had a UCVA of 20/25.

author
Matthew T. Feng, MD
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