Stop complications is advice to young ophthalmologists

“A poorly designed incision can make your life very difficult throughout the whole procedure,” according to Mercé Morral MD, PhD, Barcelona, Spain. Dr Morral spoke to delegates attending the Young Ophthalmologists Session entitled “How to Prevent Complications: What Not to Do During Phaco”, at the XXXIII Congress of the ESCRS in Barcelona.

The auditorium was full for this session, suggesting that the subject of cataract surgery complications, how to avoid them and what to do if they occur, is on the minds of many young surgeons.

“Smaller incisions are generally better, as they are usually more watertight, leading to better intraoperative fluidics. However, make sure to match the incision size with your instruments. If it is too tight, incision burns can occur, which delay wound healing,” she advised.

Regarding tunnel shape, the longer the tunnel is, the more self-sealing it is. Nevertheless, if the incision is too long, distortion of the cornea will occur, as well as restricted movement and potential overheating of the phaco tip, she cautioned.

Dr Morral next addressed the capsulorhexis, which is considered by many young ophthalmologists to be the most challenging step of the procedure. “To achieve a good red reflex and to maintain sufficient positive pressure is essential in preventing a rhexis run to the periphery. And if the rhexis does run outwards, re-grasp the flap and pull straight towards the centre, the so-called Little’s manoeuvre,” she said.

The session featured six speakers, who progressed chronologically through the steps of a cataract operation, highlighting potentially dangerous moments in the procedure.

Khiun Tjia MD, Isala Klinieken, the Netherlands, said many young surgeons seem tempted to move on to fragmentation despite an incomplete hydrodissection, but he added that this increases the risk of problems such as zonulolysis and posterior capsular rupture.

ANTERIOR WAVE

“Everyone knows to obtain a posterior fluid wave, but what is often overlooked is the importance of an anterior wave, which is necessary to separate lens adhesions from the anterior capsule,” he said.

Dr Tjia showed a video that demonstrated the use of pressure on opposite sides to the anterior mid-periphery of the lens, in order to generate this anterior wave circumferentially.

“In the following step, fragmentation, failing to generate fully mobile lens fragments can lead to the same complications as with a poor hydrodissection. Turning large nucleus fragments can overstretch the posterior capsule and zonules. A very simple but often overlooked trick is to turn the nucleus a little sideways in order to gain easy entrance for the second instrument to the bottom of the groove. This will lead to much more effective and easier cracking,” said Dr Tjia.

Capsular rupture happens more frequently during irrigation/aspiration than during the phaco step, said Oliver Findl MD, of the Vienna Institute for Research in Ocular Surgery, Austria.

“If this occurs, maintain the pressure in the anterior chamber, make sure to thoroughly tamponade with your ophthalmic viscosurgical device, and attempt to convert the hole into a posterior continuous curvilinear capsulorhexis,” said Dr Findl.

Once the eye is ready for implantation of the intraocular lens (IOL), complications can still occur.

“When young surgeons get the IOL stuck in the incision, most will try to pull it back out, which can be very difficult and traumatic for the eye. Instead, I always suggest slightly enlarging the incision to mobilise the IOL,” said Dr Findl.

Richard Packard MD, Windsor, England, then
discussed complications involving the iris, the pupil and the intraocular pressure. “For beginning surgeons, iris prolapse is a dreaded complication. Many beginners will try to immediately push the iris back into the eye, but what works better is to first decompress the globe by letting some anterior chamber fluid out of a different incision. The iris is then more likely to re-enter the eye rather than continue to prolapse,” explained Dr Packard.

Dr Packard also offered tricks to enlarge the pupil size early in the procedure, including a high-viscosity viscoelastic, non-preserved lidocaine one per cent, followed by non-preserved phenylephrine 2.5 per cent.

RISK FACTORS

Subsequent videos of disastrous complications such as expulsive haemorrhage and lens-iris diaphragm retropulsion syndrome were met with obvious discomfort in the audience, as each delegate hoped to avoid similar iatrogenic dramas.

Roberto Bellucci MD, University Hospital of Verona, Italy, addressed the cornea during phaco. “Phacoemulsification is safe for the cornea, although definite risk factors for endothelial cell loss are a low initial endothelial cell count, particularly hard cataract, an inexperienced surgeon, and an intraoperative complication,” said Dr Bellucci.

“The most important point is maintaining a safe distance between phaco tip and endothelium. It has not yet been proven that ‘bevel-up’ is worse for the endothelium than ‘bevel-down’ surgery,” added Dr Bellucci.

The final speaker was Luis Cordovés MD, a retinal surgeon at the Hospital Universitario de Canarias, Tenerife, Spain. He reminded delegates that one of the most important things they should remember regarding vitreoretinal complications after cataract surgery was to be sure that there is no vitreous left in the corneal wounds at the conclusion of the surgery.

He also told the audience about how the use of intracameral cefuroxime has become standard in care for endophthalmitis prophylaxis in cataract surgery, and the lack of sound scientific evidence for the use of perioperative topical antibiotics.

Merce Morral: merce.morral@gmail.com

Oliver Findl: oliver@findl.at

Richard Packard: mail@eyequack.vossnet.co.uk

Khiun Tjia: kftjia@gmail.com

Roberto Bellucci: robbell@tin.it

Luis Cordovés: luis.cordoves@hotmail.es