Expecting the unexpected – experts offer rescue strategies

“Expect the unexpected” should be the guiding mantra of every cataract surgeon

Dermot McGrath

Posted: Friday, October 9, 2020

Boris Malyugin MD, PhD

“Expect the unexpected” should be the guiding mantra of every cataract surgeon who presumes that each procedure will inevitably proceed in a smooth and controlled manner. That was the clear message to emerge from the symposium “What to do when the unexpected happens” co-chaired by David Spalton MD, FRCS, and Ype Henry MD.

From intraoperative issues such as a shallowing anterior chamber, zonular dialysis, and posterior capsule rupture through to postoperative concerns such as refractive surprise and suspected endophthalmitis, a panel of vastly experienced cataract surgeons shared various strategies and techniques to deal with each scenario and increase the chances of a successful outcome.

“The only surgeon who doesn’t encounter complications is one who doesn’t operate at all. The overall message is not to panic when things go wrong and to realise that there are possible solutions,” Dr Spalton said in his opening remarks.

For surgeons encountering a shallowing anterior chamber, Miguel Teus MD advised checking the IOP intraoperatively. “For a soft eye, we can raise the bottle, suture the incision or perform a new incision, or switch to bimanual technique. In a hard eye we need to check the red reflex.

“Anticipating problems before they occur is always the best solution,” he said.

In patients with zonular dialysis, Boris Malyugin MD, PhD, said that there are two major surgical goals: to preserve the capsule and the capsular bag, and to avoid late capsular bag and IOL dislocation. He discussed the use of capsular tension rings (CTR), hooks and other devices that can be used to support the zonules and enable surgery to proceed smoothly.

“We need to be prepared for a much longer surgical time in patients with zonular deficiency.

For zonular defects up to 90 degrees, I advise using a conventional CTR, and a modified CTR in bigger defects for scleral fixation,” he said.For posterior capsular rupture, Richard Packard MD, FRCOphth, emphasised the importance of having a clear strategy in place. “We generally do not lose vitreous and we usually know where it has gone but just don’t like to admit it. However, we need to remember that most of the time in phaco a broken capsule does not necessarily equate to vitreous loss,” he said.

In the absence of capsular support, Abhay Vasavada FRCS discussed various options such as transscleral or intrascleral fixation or iris-claw IOLs that may be employed to obtain a satisfactory outcome in these complex cases. He stressed the importance of patient counselling and co-management with retinal colleagues to ensure the best possible results whatever strategy is selected.