Video Journal of Ophthalmology Video

Vol XII, Number 3: June 1996

This is a video from the Video Journal of Ophthalmology from 1996, describing the safety and efficacy of an analgesia protocol that enables the surgeon to maintain control over an alert patient experiencing seemingly painless ambulatory cataract surgery, while eliminating the risks and side effects associated with general, local, topical, and intracameral anesthesia.

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Pub Med

Pub Med entry explaining in detail the Rand-Stein Analgesia Protocol.

http://www.ncbi.nlm.nih.gov/pubmed/10811080?dopt=Abstract

 

 

 

 

Case #105

A good normal case of Nuclear "Free Cracking"

This is a normal relatively straight forward case using a 2.4 mm incision Nuclear "Free Cracking" technique with an Alcon IQ IOL with Rand/Stein analgesia protocol.
This case has shows the normal manipulations done during routine surgery.

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Case #100

One of the most difficult cataracts you can encounter

This is a patient on Flomax who recently had a poor result elsewhere with cataract surgery on his other eye with a disorganized anterior segment and corneal edema. He is scheduled for DSEK procedure for the other eye next. This eye has more than a 4+ cataract with a 2.5 mm pupil. Flomax has created a most difficult floppy iris syndrome.This case is managed well without local anesthesia using Rand-Stein Analgesia Protocol with segmental pupillary expansion without iris hooks. There are many fine points for getting through this case that are illustrated in this video.

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Case #092

One eyed patient with 2 mm pupil with large corneal scar centrally

This is a typical case with floppy iris on Flomax. There are PIs in both eyes. Sphincterotomies are necessary to get the case started because there is a 2 mm pupil to start with posterior adhesions.
The pupil is enlarged and a very floppy iris is present. Nevertheless the case proceeds with relatively good control without excessive trauma and the end result appears to be quite good. This case shows interesting variations of technique using a segmental pupil expansion rather than using a number of iris hooks.

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Case #083

Small Pupil Flomax with Astigmatic Keratotomy and Toric Lens Implant

This is a very small pupil with floppy iris from Flomax. Both astigmatic keratotomy and a toric implant are utilized to achieve the appropriate astigmatism correction. This case was done using segmental pupil expansion without iris hooks using the Rand-Stein analgesia protocol and using a 2.4 mm incision.

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Case #079

Flomax Pupil: 2% Lidocaine Only

This is a difficult case, under only 2% lidocaine, with a patient with significant Flomax affecting the iris.  He has a horrible pupil and iris structure.  This case shows segmental pupillary expansion for managing this case without needing iris hooks. 

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Case #067

This is an 88-year-old patient with a history of Flomax with a classic floppy iris syndrome.  The surgery was done through 2-3 mm pupil with difficulty but successfully.  It should be noted that insertion of the implant encouraged a prolapse tendency of the iris.  This was managed by keeping the pressure low in the eye and with Viscoelastic. The insertion of the implant was difficult because the iris haptic impaled itself within the iris but this was swept out of the way with a left-handed sweep with the Bechert rotator.

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Case #044

This patient with pseudoexfoliation and a large pupil having a history of Flomax use. The pupil came down very quickly. The capsule structures can be presumed to be fragile with PEX. A relatively clean procedure is done without the need for iris hooks using the pupil expansion procedure. It was difficult to get the cortex in the eleven o’clock position and a reverse irrigation aspiration (1 mm) system was utilized to retrieve that cortex. The procedure was done under the Rand-Stein analgesia protocol with no local or intracameral anesthetics utilized.

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Case #041

The patient is on Flomax and is having a refractive lens exchange with a TECNIS™ multifocal implant.  The procedure is cleanly done. The incision is located where it can reduce 1/2 diopter of pre-existing astigmatism in that axis. The Flomax almost always creates a difficult situation with the pupil but is well handled with a pupil expansion procedure for segmentally visualizing the peripheral cortex and capsule by moving one segment of the iris at a time with a Bechert rotator. This eliminates the need for iris hooks. Careful attention is made to make sure the implant is lined up properly since it is a multifocal. The procedure is done with the Rand-Stein analgesia protocol without local injections or sutures.

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Case #036

1st Eye: This is a patient with Flomax who has an exceptionally fragile iris. The pupil does not dilate beyond 2 to 2-1/2 mm. Throughout the case with a difficult nucleus extraction and difficulty extracting the cortex but the entire procedure is done with a pupil expansion technique and with zonule protection technique making use of hydro dissection and low flow. This is a very good case for showing management of difficult nucleus and cortex delivery through a small pupil with Flomax.

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2nd Eye: This is a very small dysfunctional Flomax pupil with management without iris hooks in a small pupil.  Very difficult Flomax case.  There is very poor iris structure.  The procedure was done cleanly without local anesthesia (using the Rand-Stein analgesia protocol). 

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Case #026

1st eye. 2mm pupil with a floppy iris: Psuedoexfoliation. Toric IOL with pupil stretch.

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2nd eye. The patient is on Flomax and needs astigmatism correction and cataract removal. Astigmatic keratotomies were performed to reduce the astigmatism. Flomax has made the procedure very difficult with a pupil that will not dilate beyond 2 mm, a very small pupil. The nucleus removal is difficult but well performed. The implant insertion is also difficult but well performed with an IQ lens. This case illustrates well a low-pressure flow and hydro dissection with careful manipulation of the pupil during pupil expansion to segmentally visualize the structures under the iris and capsule as necessary.

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Case #113

How to do a mature cataract.

This is a very dense mature cataract that was done with Trypan blue. There is a white cataract with a 4+ dense nucleus. It shows the proper way to avoid tearing the posterior capsule and how to make this type of procedure routine.

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Case #078

Management of a 5+ White Extremely Hard Cataract

This is a patient with a light perception type cataract, white with exceptionally hard nucleus. The procedure was done with Rand-Stein analgesia protocol with no intracameral anesthesia or local anesthetics. The procedure shows clean management of such a hard cataract through a 2.4 mm incision. There are exceptionally sharp edges to the cataract, which put at risk the posterior capsule during surgery. This is managed well. The case begins with Trypan blue and the ultrasound is turned all the way up on the Alcon infinity cataract machine. Great care was taken to avoid having any of the sharp edges touch the capsule and avoiding the collapse of the anterior chamber. Viscoelastic was placed several times during the surgery to provide protection for the cornea. The second instrument, a Bechert nucleus rotator, is used to feed the nuclear material into the ultrasound instrument and to crack the nucleus into smaller particles that could be more readily managed. A pearl to note is the continuous return to position one to increase the pressure of the fluid in the anterior chamber so that when the ultrasound begins, the large pressure gradient between the anterior chamber and the ultrasound probe is maximized, and the nuclear material will tend to jump rapidly into the ultrasound probe making the management of these hard particles much easier. 

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Case #072

WHITE CATARACT 4+ NUCLEUS TRYPAN BLUE

This is a patient who has a 4+ cataract with a mature lens, essentially white cataract.  Trypan blue was used and cataract is exceptionally dense.  Sharp edges of the nucleus can cut through the posterior capsule.  This was avoided by reducing the equatorial diameter as the first priority.  Note that part of the peripheral nucleus was left intact so that it could serve as a cushion for the posterior capsule in case the anterior chamber might collapse during surgery.  This edge would be less likely to cut through the posterior capsule (with the blunt edge of the nucleus).

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Case #047

This is a patient that years ago suffered a severe automobile accident and has had a blind eye ever since. It was a white cataract with a fibrous anterior capsule. Trypan blue was utilized but the capsule would not tear and literally had to be cut  open with an intraocular scissors. The nucleus and cortex were exceptionally rigid and adherent firmly to the capsule structures both posterior capsule and anterior capsule including the equator. It had to be methodically picked off piece by piece in order to avoid disinserting the zonules or puncturing the posterior capsule. Repeated hydro-dissections were utilized and eventually the material was removed. Some material was left in the nasal aspect because it was so adherent to the capsule, that we would have torn the zonules trying to extricate it.  A sulcus fixated Hoya lens implant was placed. No sutures were needed. This procedure was done with Rand-Stein analgesia protocol without the need for local anesthetic injections.

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Case #033

Hyper mature white cataract. Trypan blue.

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Case #022

White cataract with a 3.5mm pupil. Trypan blue. Pupil expansion with a difficult capsulotomy. Removal of fragile capsule. IOL haptic broke; therefore, it was cut into 3 pieces in order to remove it. New Hoya IOL inserted via a 2.4mm incision.

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Case #138

LenSx®, pseudoexfoliation, Tecnis multifocal implant:

This is a patient with significant pseudoexfoliation. Procedure is cataract surgery with Tecnis multifocal lens implant, using the LenSx platform and Rand-Stein Analgesia.
Surgery is performed routinely and effectively. The zonules which might be compromised are less stressed with a LenSx® capsulotomy and the cataract procedure proceeded normally.

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Case #135

LenSx in the presence of a Molteno glaucoma valve:

This is a patient who is undergoing LenSx for cataract and astigmatism. The patient has had a long history of glaucoma with 0.85 cupping. There is a very nice clean Molteno valve. The cataract surgery is performed, and as can be seen, the LenSx does not affect the valve, even though the LenSx is done directly over the insertion site of the valve.

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Case #133

LenSx and capsulotomy for white cataract:

It is common to have difficulty with a white cataract and capsulotomy. This case shows the effect of the use of LenSx to make a safer capsulotomy and the procedure more predictable.

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Case #127

LenSx laser cataract surgery for a mature white cataract:

This is a patient who was blind with a completely white cataract. We performed a LenSx procedure.
LenSx was set for a 6 mm capsulotomy, and all of the other parameters were routine. Not a lot of laser response was seen in the nuclear fragmenting, but when the surgery was done, the nucleus was rapidly disposed of. This might have been much more difficult without the laser.
This is a very good case with the exception of the secondary incision which was difficult to open and get into initially. This sometimes happens with the laser.
For the most part, the use of one of the arms of the Bechert rotator enables an easy entry into the eye, externalizing the laser incisions that have been made.

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Case #126

LenSx in a 4.1 mm pupil:

This is a patient with a significant cataract and an irregular 4.1 mm pupil with Flomax and a very floppy iris.
This procedure is interesting because a LenSx 4.0 mm capsulotomy incision was made. A smaller lens emulsification was utilized as well.
After the LenSx, the patient was brought into the operating room and the pupil was enlarged with a bimanual sphincter stretching procedure. The capsulotomy would normally be too small for this lensectomy, but three radial can opener type incisions were made in the 4.0 mm circular capsulotomy to enable nucleus prolapsing. The nucleus was removed with a free-cracking procedure in the pupillary plane. One can see the potential for significant Flomax related iris problems, but these were all avoided. With lower bottle height the capsule tears will not extend posteriorly.
An Alcon IQ lens was utilized and placed in the capsule bag, and the surgical result appears to excellent.

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Case #125

Use of LenSx in one of the hardest cataracts:

This is a cataract that is more than 4+. It required 100% power from the phaco machine, after softening of the nucleus as much as possible with the LenSx device. The procedure was done cleanly with a very good result, and serves as a good example for management of a very dense cataract.
The procedure was done with a 2.4 mm incision with the Rand/Stein analgesic protocol.

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Case #124

Good LenSx case:

This is a good quick LenSx case. One of the problems with LenSx has been the removal of the cortex underneath the main incision at 5 o'clock in the view of the surgeon. Note the hydrodissection that is done prior to the removal of the cortex in that quadrant, and that virtually eliminates the problem providing easy aspiration of the cortex at that position.

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Case #123

Good clean LenSx with TECNIS multifocal lens:

This is a very good case for illustrating the utilization of the LenSx device with a TECNIS multifocal lens. The case is clean, straightforward and very little ultrasound energy is required for the lens exchange.

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Case #122

Good LenSx case TECNIS multifocal lens and hemi nuclear fracture infragmentation:

This is an interesting case and it shows a nuclear cracking into two pieces, with each piece elevated. The LenSx makes this procedure very straightforward and quite easy to perform.
Note the hydrodissection at the 5 o'clock position in the surgeons view. This area under the incision is normally very difficult to extract the cortex and many doctors use a bimanual approach to retrieve this cortex. With a small hydrodissection maneuver, the cortex delivers itself quite readily. Hydrodissection is performed at the 12 o'clock position and the 5 o'clock position in the surgeons view.

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Case #120

LenSx

This is a video showing the LensX procedure.

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Case #099

Intraocular Collamer lens (Staar®) with peripheral iridotomy.

This is a good example of a highly myopic person having a simple intraocular Collamer lens insertion. In this case there is a significant astigmatism as well and the patient expects to have a laser vision correction surface procedure done in approximately one month to eliminate the residual astigmatism. This video shows the surgery on both eyes performed on different days.

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Case #139

The 10+ cataract

This is a good display of a well done surgery for one of the hardest cataracts one might encounter. This was done very cleanly with a 2.4 mm incision, no stitches and no local anesthetic injections using the Rand/Stein analgesia protocol.
There are many fine points preventing the rupture of the posterior capsule and damage to the corneal endothelium with all the sharp edges.

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Case #137

Patient with ICL removal after having LenSx

This is a patient who had an ICL approximately seven years ago. She enjoyed good vision, but as the cataract developed, it became necessary to consider cataract extraction. We had done her other eye about two weeks ago with a 20/20 result.
In this case, what is unique is that the LenSx is done through the ICL, because we can image the structures of the ICL and the lens, and set the laser parameters on the appropriate structures without confusion. The LenSx produces accurate and reliable positioning for the Femtosecond laser.
The entire LenSx procedure was performed through the ICL. In the operating room, the ICL was removed through a 4.5 mm incision, which was sutured to reduce it to a 2.4 incision to be utilized for the cataract procedure. Once the ICL had been removed in one piece, the cataract procedure proceeded routinely. This was a patient who was approximately 16 diopters myopic, and the surgical procedure was uneventful. No local anesthetics were needed.

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Case #136

One eyed patient with a 2 mm pupil and a 6+ cataract with a Molteno valve

This is a patient who only has this one eye. She has a 2 mm pupil with a totally opacified black cataract, about as hard as one could imagine. There are 360 degree synechia creating a 2 mm pupil. The patient had previous glaucoma surgery. There is no way of knowing what kind of potential is in this eye, but the procedure is very well managed, leaving the eye with a crystal clear media.

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Case #134

Replacing a Tecnis multifocal with a Crystalens™:

The patient is a boat captain and cannot perform his duties because of the unwanted optical images from Tecnis multifocal. He very much wanted a Crystalens™ and this procedure was performed for him. The surgery is clean and shows the reopening of the capsule bag and the removal of the implant, and the insertion of the Crystalens™. The procedure was done without local anesthesia using the Rand/Stein analgesia protocol. No sutures were needed.

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Case #128

Removal of a small piece of retained cataract nucleus:

This is a patient who had cataract surgery with lens implantation approximately a month ago and still had some striate keratopathy. On the second postoperative visit, it was noticed that there was a small piece of nuclear fragment at the 6 o'clock position. He was brought back the next day for removal of this material and this video shows a straight forward way to accomplish this.
We reopen the incisions as possible. In this case only the main phacoemulsification incision was reopened and a new incision was made at the 2 o'clock position. The material was removed with a phacoemulsifier.
First a small amount of lidocaine was placed in the anterior chamber. The pupil has previously been constricted with pilocarpine. The Viscoat is injected into the eye to make sure that the piece of lens material would not fly around and possibly go behind the pupil. The phacoemulsifier entered into the eye with the bottle height reduced by approximately 40 points. It was found that this did not add enough infusion pressure so the bottle height was raised 10 points, still 30 points below the normal. The phacoemulsification was turned on, and the piece of lens material was brought into contact with the phacoemulsification tip and then emulsified. The viscoelastic was then removed. The postoperative result was excellent.

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Case #115

Reposition of dislocated posterior chamber lens implant

This is a myopic patient who had spontaneous subluxation of both haptics of the lens implant into the posterior chamber. Because the eye was so large, the implant actually moved freely within the chamber, but generally settled in a sunset syndrome that caused significant unwanted optical images. Approximately four months later, this patient came to surgery with a posterior capsule which was firmly adherent to a closed bag. It was reopened with viscoelastic viscodissection. The haptics were placed properly within the bag without difficulty and centration of the implant was assured. Initially the pupil was relatively small and was enlarged with epinephrine, in a so-called "sugarcane" solution.

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Case #112

Patient with a Myoclonic Disorder and constant movements and inability to cooperate due to Alzheimer's.

This is a patient with myolonic disorder with constant movements and inability to cooperate due to Alzheimer's. The surgery was performed despite constant movement and sudden unpredictable movements. The benefit of this video is to see how this is managed in such a way that no damaging movements are made by the surgeon. The surgeon maintains hands on face and continues to work as though the moving field was in one place. It is only when the surgeon begins to try to compensate for the patient's movements, that things get out of synchronization and unwanted results occur. The end result of this case is essentially a normal postoperative eye. Anesthesiology on this case consisted of intracameral anesthesia and some alfentanil ASA narcotic. No other medications could be utilized because of the patient's fragile status.

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Case #109

Removal and replacement of dislocated lens implant without vitrectomy

This is a patient who has a sunset syndrome with a subluxated plate implant. We can see that the implant is floating on an intact vitreous face. The procedure was done with Rand/Stein anesthesia protocol, without local anesthesia. The implant was able to be removed without breaking the vitreous face, and was removed from the eye and replaced with an anterior chamber lens implant, and the wound was closed with 10-0 nylon suture. An iridotomy was part of the procedure. All this was done very cleanly without having to do a vitrectomy.

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Case #107

Extremely Hard Cataract

This is one of the hardest cataracts one is likely to encounter in surgery. It was a white cataract and trypan blue was utilized for the capsulotomy. The cataract was so dense that it was almost past the ability of the Infinity machine to phaco it. It had to be done with the free-cracking technique with additional force provided by the Bechert rotator in the left hand. In these eyes the capsule can be cut very easily with just a small rotation of the sharp edges of the nucleus, and in fact, as the nucleus was removed, it was visualized that there was a small round tear in the posterior capsule, fortunately without vitreous prolapse. The bottle height was reduced and very careful low ultrasound was utilized to remove the remaining fragments, avoiding high pressure in the eye which could blow vitreous out of the eye. Very low pressure in the eye could allow the vitreous to come forward. It was decided to place a sulcus lens although we might have been able to do an in-the-bag procedure. We deemed that the sulcus would be safer and less likely to extend the tear. An AMO Sensor implant was utilized. Much of the viscoelastic was left inside and we protected the eye with Diamox as the Viscoat should be gone be the next morning. Tonight the patient will need some pressure reduction with Diamox because of all the Viscoat left inside.

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Case #103

Prevention of Complications

This is a patient with an exceptionally hard cataract and a fragile zonule in the inferior nasal aspect. During the irrigation aspiration phase, you can see unusual stress lines on the capsule in that region, which suggested that disinsertion of the lens would be likely. The cortex was carefully teased away and the manner in which this is done is a good subject for review. When the implant was being inserted, the minor force exerted by the implant haptic literally peeled away the zonules in the inferonasal area. A good maneuver was the rotation of the implant in the horizontal plane in such a way as to rotate the implant into an area of capsule integrity preserving in the bag placement. Had the implant escaped from the bag with the zonules in that area compromised, it might not have been possible to use a posterior chamber lens. As it turned out, the end result is good fixation within the bag, and the haptic spring effect, acting as a retention ring, allows the capsule to have a nearly normal status within the eye.

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Case #091

Reposition of subluxated lens

Normal sterile prep and drape was done. Adequate analgesia was obtained utilizing the RSA. A speculum was placed in the left eye. Viscoelastic was instilled into the anterior chamber through the previously made incision. Then the main incision was also opened and more Visoelastic was placed. The implant was seen to have rotated from 113 degrees to 75 degrees and under protective coating ofd Viscoat, the implant was rotated again, with the proper marker directly in the 113 degree axis. It appeared to be very safe and stable. The viscoelastic was removed. The wound was checked for leaks and no leaks were found. No suturing was necessary.

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Case #090

Patient with Previous Metal Valve for Glaucoma with Posterior Adhesions and Small Pupil with Proper Management

Cataract surgery in a patient with previous glaucoma surgery with a small metal valve. There are posterior adhesions and a small pupil.

This case is well managed and serves to illustrate proper management of such a case. Iris hooks were not used. Segmental pupil expansion was done. The Rand-Stein Analgesia Protocol was utilized for this procedure. Topical, intracameral and local anesthesia were not used. Incision size is 2.4 mm. 

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Case #086

Flipping an upside down implant

This video shows how to deepen the anterior chamber and the posterior chamber with additional Viscoelastic to allow for repositioning of the unfolded implant 180 degrees for the implant that is upside down.

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Case #085

Black Cataract

This is a 5+ black cataract, almost beyond the ability of the phacoemulsification machine to manage. It is well handled and indicates many of the principles for management of such a cataract especially avoiding allowing sharp edges of the cataract to cut the posterior capsule. Note the frequent restoration of a Viscoat layer to protect the endothelium and avoidance of the equator passing the midline in the early stages of the procedure before the equatorial diameter is significantly reduced.

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Case #082

This is an interesting case of a toric lens replacement with a different power. The implant is freed from the capsular attachments. It is important to keep the capsule intact so it can receive another toric lens precisely placed. There is a slight enlargement to the incision to 3.2 mm from the 2.4 originally created. The implant is cut and removed in two sections. The new implant is placed. The Viscoelastic (Viscoat) is placed under the lip of the wound to seal the valve eliminating the need for suturing in this case.

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Case #077

Grossly uncooperative patient with jerking motions

This case is useful for review because the patient had continuous frequent jerking motions no matter what was done for him. No medication could be utilized for this patient because of his medical status and the case was done under 2% lidocaine intracameral. What is significant to note is that at no time were any corrective motions made during the surgery to compensate for patient’s movements. Either the instruments were removed at once or the hands remain on the forehead and go with the movements of the patient (without trying to compensate at all) in such a manner that there really is no movement of the surgical instruments relative to the patient’s eye. 

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Case #075

400 lb. lady with pseudoexfoliation and positive pressure

This is a very heavy lady with pseudoexfoliation, a pupil that remains at about the 4 mm size. She could not have any medication and required surgery under 2% intracameral lidocaine. The surgery is clean and shows how this procedure can be done using a dynamic pupil expansion without hooks to enlarge the iris. The intraocular pressure was very high because of a bull neck phenomenon. Decompression of the anterior chamber was a constant risk. 

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Case #074

Shallow anterior segment; severe cataract with a floppy iris and posterior adhesions

This is a patient with count fingers vision. She was a very high hyperope with previous peripheral iridotomies and posterior adhesions and a floppy iris, which tends to prolapse. Pupil expansion was performed.  What is remarkable about this procedure is that it was able to be done under 2% lidocaine without the use of iris hooks.  This illustrates some of the low flow hydrodissection principles of the pseudoexfoliation technique as published in the Masters Techniques in Cataract Surgery textbook.

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Case #071

2 mm PUPIL WITH POSTERIOR ADHESIONS AND PUPILLARY EXPANSION

This patient was particularly challenging because she had posterior adhesions which needed to be lysed, fairly dense cataract, and pupil that continually remained in about the 2-3 mm range throughout the entire surgery. This case is illustrative of proper management in a low-flow system maintaining segmental expansion of the pupil as necessary without using iris hooks.  We avoid aspirating the iris.  Once iris ultrasound fragmentation takes place, it is very difficult to prevent the tissue from jumping into the aspiration port of the phacoemulsifier constantly.

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Case #069

This is a patient with a 5+ cataract and a previous history of uveitis. He has a 1 mm bound down pupil with posterior adhesions. Patient is using Flomax.  He has had several iridotomies to treat a pupillary block.  A pupil expansion and lysis of posterior adhesions was performed.  The cataract was literally 5+, exceptionally dense. The posterior adhesions were cleared and the pupil was expanded and the surgery was performed with a posterior chamber lens and a small 2.4 mm incision. This procedure is not pretty but it is an excellent example of the different manipulations required for low flow and careful tissue manipulation as well as hydro-dissection in the presence of the inability to see essential structures. Hydrodissection was used for the separation and prolapsing of the nucleus and the maintenance of the anterior chamber was important so as not to have sharp nuclear fragments cut through the posterior capsule or damage the cornea if an AC collapse would occur.

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Case #068

This is a normal toric lens implant case where the implant was noted to be scratched right down the optical center. The IOL was cut into two pieces and removed and replaced with another IOL. The interesting thing here is how the implant replacement was managed without damaging the internal structures.  The incision was enlarged from 2.4 to 3.2 mm to enable the IOL extraction maintaining  an excellent seal of the incision. 

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Case #066

“Difficult Small Pupil Cataract Case”

This is a very difficult cataract procedure with a small pupil due to Flomax and longstanding glaucoma. There is a peripheral iridectomy present; which allows fluid to flow posteriorly, causing the iris to prolapse even though the eye is pressurized. The small pupil makes it particularly difficult, and it was managed relatively cleanly. This is a good example showing hydrodissection and generalized low flow to manage such a case. 

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Case #065

“Routine Crystalens™ Refractive Lens Exchange”

This is fairly routine refractive lens exchange procedure using the Crystalens™ AO. This is a very soft cataract, managed with segmental hydrodissection first freeing the nucleus then the cortex and then the epicortex from the lens capsule. Generally we do not use sutures with the Crystalens™ procedure, but in this case, a 10-0 nylon suture was placed for additional safety because of the patient’s level of activity.

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Case #064

Choroidal hemorrhage during removal and replacement of lens implant

This is a patient with a subluxated lens implant years after surgery. There is a history of pseudoexfoliation.  In this case, the implant is removed in a fairly conventional manner, removing the capsule bag and a significant amount of residual cortex. Leaving so much cortex in the periphery makes the capsule bag heavier and may contribute to dislocation of the lens implant. The implant is removed relatively routinely and a subtotal vitrectomy is performed. A peripheral iridotomy was done.  The new implant is inserted into the anterior chamber. While the 10-0 nylon suture is being placed, the patient reported pain in the eye. You can see the gradual loss of the red reflex with a choroidal hemorrhage beginning to be noted coming in from the right side posteriorly. Fortunately there was time to put in three 8-0 silk sutures before any iris or other structures were prolapsed. The 10-0 nylon sutures would have burst open and iris, vitreous and then retina would have been expulsed. But with the 8-0 silk sutures closing the wound securely, the pressure in the eye could build up to counter the blood pressure in the choroidal hemorrhage acting as a tamponade, stopping progression of the choroidal hemorrhage.  A scleral incision could have been considered but since the situation appeared to be under control, observation was elected and an hour later the hemorrhage had not progressed and there was a deep anterior chamber. The wound remained intact. The pressure normalized at 25.  Of course, she will need to be watched carefully. This represents a good moderate rapid response to the situation.  If any iris material had presented in the wound, it would have been very difficult to get this to seal if possible at all.  Had conjunctival cut down been done, and a sclerotomy performed, this could also have made this much more complicated. Sometimes the decision is difficult and the decision is not always right, however in this case the results will likely be optimal.

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Case #061

Difficult Removal and Replacement of Lens Implant in Patient with Previous Radial Keratotomy.

This is an edited case. The patient had old radial keratotomy and the lens implant needed to be exchanged because of the patient’s dissatisfaction with the focusing power. This case shows how carefully the Viscoelastic dissection of the implant from the posterior capsule can be effected. There was a four, month interval from the time of the cataract surgery until the time of the implant replacement and yet the implant can be easily freed from the capsule structure. The removal of the implant was performed by cutting it into four pieces. This is a 28 diopter very thick TECNIS™ implant and the wound was limited by the radial keratotomy incisions. Despite the best efforts, one radial keratotomy incision did separate. The surgery was completed and Viscoelastic was placed in the eye and the new implant inserted. The radial keratotomy incision was sutured back into its original position with four interrupted 10-0 nylon sutures. A safety suture was placed for the original cataract incision to assure wound closure. Much Viscoat was left in the eye and the pressure was managed with short term Diamox after the surgery.

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Case #057

This is a 63 year old woman with bilateral subluxated lenses and glaucoma. The procedure performed involves as little traction on the vitreous as possible. This was performed through clear cornea under the Rand-Stein anesthesia protocol (Alfentanil and Propofol). The wound is enlarged sufficiently to remove the lens in one piece. An irrigating vectis is utilized to raise the nucleus into the anterior chamber and remove it from the eye with minimal vitreous disruption.  A vitrectomy was performed with the intent of removing all possible formed vitreous with as little vitreoretinal traction as possible. An anterior chamber lens was utilized and the wound is closed with a 10-0 nylon anti-torque suture and reinforced with four traditional interrupted 10-0 nylon sutures. In the past we have done pars plana lensectomies with two 1 mm incisions but the wound still needed to be open for the IOL and the cataract itself was not soft. This way avoids fragments of lens material falling posteriorly.  

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Case #056

Preoperative zonular dialysis traumatic. 
This is an interesting case with preoperative history of trauma and a 90° temporal zonular dialysis.  The case is well handled with Trypan blue in the beginning and careful manipulation of the lens material with hydrodissection.  All of the cataract material was removed without tearing or disinserting the capsular bag.  No vitreous was encountered and a posterior chamber lens was placed in the bag with a haptic in the area of the weakest zonules in order to reinforce the capsule in that area. There is a thin sheet of cortex, which entered the posterior chamber through the area of zonular dialysis.  It was elected to leave it intact since it will absorb.  Since there is no nucleus involved, it would be unlikely to cause an inflammatory response.  To pursue this cortex would almost certainly involve disinsertion of the remaining zonular conversion to an anterior chamber lens and vitrectomy. 

Ten days later, the cortex migrated into the anterior chamber and was aspirated at the slit lamp. Vision was 20/30 plano. 

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Case #054

This is a good example of routine pupil expansion procedure with sequential equatorial reduction in a 93-year-old woman with 4+ cataract.  The pupil is approximately 3-4 mm in size and did not require sphincterotomy.  It is important to note that at no time does the equator of the nucleus pass the midline until sufficient equatorial reduction is accomplished.  This avoids traumatizing the posterior capsule which is not visualized during surgery. 

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Case #053

This a patient who is +7.00 in both eyes prior to surgery. His other eye was done a week ago and now sees 20/20 near and far with a ReStor™ 3 multifocal lens implant with refraction of plano -0.25 x 90.  This eye has a very tight anterior chamber with very little space to work in and the zonules are somewhat fragile and the chamber cannot be deepened significantly to permit an easy capsulotomy. The capsulotomy tended to flare outward and when it got to the 11 o’clock position, it appeared that it would not be controllable and would tear into the area of the zonules.  Additional administration of small amounts of Viscoelastic could not overcome this  tendency to tear towards the zonules. Attention was shifted to the other side. There was not enough anterior chamber depth to start a circular capsulorrhexis. A can-opener technique was utilized which successfully opened the capsule bringing it to the area where it ended at 11 o’clock.  The two areas were joined and the procedure continued routinely. With removal of the nuclear material, the chamber  deepened and was more easy to work with.  The ReStor™ multifocal lens was inserted into the eye and fixated 90 degrees away from the weakest part of the capsulotomy resulting in a 20/20 near/far result. 

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Case #034

No zonules. Tecnis placed inside bag after a vitrectomy.

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Case #032

1st Eye. Post adhesions. Pupil expansion. Psuedoexfoliation. Hoya IOL was used.

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2nd Eye. Floppy iris. Pupil expansion. LOPA psuedoexfoliation. The Hoya IOL fractured into 3 pieces. Had to remove and replace the lens.

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Case #031

Patient moved constantly. Had to adapt to the uncooperative patient.

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Case #030

Post adhesions, pupil expansion. Old PI present. Very high hyperopic with weak zonules and a shallow anterior chamber.

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Case #028

Toric IOL. 7.5 cyl surprise. Axis correct! Capsule reopened 2 months later. Exchange without Toric 2mm incision.

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Case #020

Hoya IOL Damaged. IOL was cut into 3 pieces.

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Case #017

Parkinson's patient that constantly moved. Pseudoexfoliation.

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Case #016

Very large rock hard cataract. Rhexis tear. Toric IOL was used.

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Case #013

The capsule was wide open without any vitreous loss.

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Case #012

6+ Cataract with weak zonules. Sensar IOL was used.

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Case #010

Neurological patient. Very uncooperative and moved the entire time. No medications or lidocaine were used.

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