Pride and fear
The voice inside my head helps keep me alert when the going gets tough, says Leigh Spielberg MD
He was going blind in both eyes, and I had only a few days to help him before the light slipped away forever. But how to proceed? Each plan I came up with had a significant chance of at least one serious complication.
The patient was a 60-something male with 60-something IOP bilaterally. The cause: angle closure in the context of extreme hypermetropia. +11 dioptres. The anterior chambers had disappeared: 100% of the corneal endothelium had contact with either lens or iris. The eyes didn’t look like eyes, but rather like poorly made glass prosthetics, with too little glass to make an anterior chamber.
He had been referred to us after peripheral laser iridotomies and intravenous mannitol had been unsuccessful. Now it was my turn to try, but what should I do? There’s no consensus on how to treat this problem.
Something needed to be removed from the eye, but what was the safest option? Simple lens removal would be the best-case scenario. However, there was no safe way to enter the virtual space of what used to be the anterior chamber. There was far too much posterior pressure. Under these conditions, I wouldn’t be able to get any viscoelastic into the anterior chamber, never mind a phaco tip. And once inside, how would I prevent the iris from popping out of the incisions? A capsulorhexis would be impossible
Neither my own knowledge, my books nor PubMed offered any clear solution. So, I did what I do when I want to discuss a case: I pitched the problem into our colleague group on WhatsApp. I described the situation, and then added: “The solution will be surgical: either regular phaco or vitrectomy with lensectomy.” I specifically directed the question to our glaucoma specialist, Koen Vermorgen.
“I’d suggest a core vitrectomy + phaco,” he replied within minutes. The core vitrectomy, he elaborated, would decrease the posterior pressure and allow activity in the anterior chamber.
I walked to the operating room with a sense of pride for taking on such a challenging case. I had, in collaboration with my colleagues, come up with a legitimate plan that had a reasonable chance of success. However, this sense of pride was tinged by a sense of fear of the consequences of my intervention. And yet, as I scrubbed in, I told myself that this was the reason that I had chosen this subspecialty.
But the voice inside my head was not impressed. “So what? You chose vitreoretinal surgery, big deal. This isn’t even VR, it’s glaucoma and lens. You’re about to pierce a little marble of an eye with a 23G incision and you’re going to see the vitreous squeeze through the trocar, pop off the valve and drag the retina right on out. The pressure will drop and you’ll have effusion until the choroids kiss. Good luck,” it said, and then it was gone.
The voice inside my head helps keep me alert when the going gets tough. But I don’t always appreciate its presence in my mind, especially when I’ve made the decision to go for it. I walked into the operating room and tried to think only happy thoughts.
The sharp tip of the bevelled trocar inserter cut through the pressurised sclera like butter. I placed the inferotemporal trocar and then immediately inserted the vitrector for a core vitrectomy. It was too dangerous to remove the valve to place the infusion line. My devil’s advocate was right: the vitreous would come right out.
I removed some vitreous and got the IOP down to a reasonable level before placing the infusion line and the two superior trocars. There was of course no PVD, and I didn’t have much room to manoeuvre, so I shifted my attention to the anterior chamber. It was time.
One option was lensectomy with the vitrector via the pars plana, leaving the anterior face of the lens capsule intact. But I didn’t like the idea of placing a sulcus lens – especially a thick, 35-diopter lens – into the sulcus of a 19.5mm eye. So, I started creating some space between the cornea and the iris without allowing the iris to dance on out of the eye. Despite the reduction of posterior segment pressure, the anterior chamber still didn’t exist, so I injected a dispersive viscoelastic using a 27G needle, which creates a hole that’s too small for any tissue to creep through.
This worked well. As I filled the anterior chamber, the posterior segment’s pressure rapidly increased, so I went back and removed more vitreous before proceeding. The cornea started to clear a bit and I carefully proceeded with phaco, always mindful of the iris, which had suffered ischemia due to the high IOP, and could not be trusted…
To be continued…
Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent University Hospital in Belgium