▪ This 48-year-old patient has a traumatic cortical mature cataract, vitreous in the anterior chamber, iridodialysis, posterior synechias, and zonular dialysis for at least 120 degrees, along with a traumatic mydriasis.
I would first consider performing the surgery under general anesthesia, providing a peaceful environment for the physician and the patient, as this might be a difficult and long procedure. I would also consider giving 150 cc of intravenous mannitol 20% about 1 hour before actual surgery begins.
The incision should be performed in a meridian in which the zonules are considered to be intact. This leaves the options of an inferior nasal, inferior, or an inferior temporal incision. As a right-handed surgeon, I would probably choose the 7 o'clock position for a clear corneal 2.5 mm incision made with the 3-dimensional diamond knife. Before that, I would make a paracentesis with a 15 degree blade at about the 9 o'clock position and inject a low-cohesive, highly dispersive viscoelastic material. After the incision is made, further injection of the viscoelastic material will determine the need for a dry vitrectomy, which appears likely in this eye.
Gentle release of the posterior synechias would be done with a Barraquer spatula. The dry vitrectomy would be performed with the Legacy 20,000 unit with the A-vit cutter set at a rate of 400/min, with no irrigation, and a vacuum set at 200 to 250 mm Hg as required when using the high-vacuum cassette/tubing of the unit. The vitrectomy is slow, but it will prevent further vitreous herniation. I would tamponade the area with more viscoelastic material.
Next, I would attempt to perform a continuous curvilinear capsulorhexis (CCC). The difficulty in performing a CCC in this case arises from 2 major factors: poor visibility and raised intracapsular pressure.1 If I were uncomfortable performing the CCC with high illumination and high magnification, I would consider staining with gentian violet 0.3% solution placed over the anterior capsule. A faint violet coloration will be seen but no capsular staining. The liquefied lens cortex will ooze out immediately after the initial puncture and can then be aspirated. A gentle CCC is then performed with the capsulorhexis forceps, viewing the stained epithelial cells under the anterior capsule. I would aim for a relatively small CCC as the intracapsular pressure will tend to extend the capsulorhexis to the periphery.
I would not consider hydrodissection as lens removal should not pose any special problems. Aspiration would then be performed gently. At this stage, I would consider inserting a Morcher endocapsular ring (type 14) with the Geuder injector and then completing the removal of the lens contents with irrigation and aspiration (I/A). Capsular expansion will prevent vitreous prolapse and facilitate safer cortex removal. If posterior capsule plaque were present, I would probably leave it alone for a future neodymium:YAG capsulotomy.
If the CCC were two small, I would consider enlarging it (2-stage CCC).2 Implantation of the capsular ring will only enlarge the bag and stabilize it for cataract removal. Permanent repair of the zonular dialysis would be accomplished by suturing the capsule to the sclera (risk of tearing the capsule) or by inserting a Cionni endocapsular ring to recenter and reinforce the capsular bag for endocapsular intraocular lens (IOL) implantation. (RJ Cionni, RH Osher, KD Solomon, “Zonular Instability: In Pursuit of a Surgical Solution,” video presented at the Symposium on Cataract, IOL and Refractive Surgery,” San Diego, California, USA, April 1998). I would prefer the latter after filling the capsular bag with a cohesive viscoelastic material.
A double-armed 10-0 polypropylene suture with a CIF4 needle would be used for the fixation. A limbalbased conjunctival flap would be performed at the 11 o'clock position. The needle is passed through the eyelet of the ring and then the sclera. The other needle is passed gently through the sclera and then the ring inserted and gently dialed toward the area of zonular weakness with a Sinskey hook and slight suture tension. The sutures are tightened and the knot rotated into the sclera. A type 2L with 2 Cionni extensions has recently become available, which would be a better choice in such a case (personal communication, Y. Tokuda).
My preference for the IOL would be an MA60BM acrylic lens inserted through a 3.75 mm incision after the capsular bag is filled with a cohesive viscoelastic material. Careful viscoelastic aspiration is then performed. The wound could be left unsutured if the incision architecture were considered appropriate.
Finally, I would not consider iridodialysis repair as eventual peripheral capsule opacification should prevent monocular diplopia. The repair of traumatic mydriasis by Osher's variation of the pupillary circlage technique of Pius Bucher, MD, would be considered if the patient reports severe glare and edge-related symptoms.
1. Vasavada AR, Claros JA, Singh R. Phacoemulsification in intumescent and rock hard cataracts. In: Lu LW, Fine IH, eds, Phacoemulsification in Difficult and Challenging Cases. New York, NY, Thieme, 1999; 111-119
2. Gimbel HV. Two-stage capsulorhexis for endocapsular phacoemulsification. J Cataract Refract Surg 1990; 16: 245-249