However easy or however difficult the surgery, the threat of a complication is always present, and, as surgery becomes arduous, the surgeon must diligently address those factors that may destabilize the operation. Unavailability of the right instruments is one such factor. To echo a recent paper, there should be micrograspers and microscissors to hand when operating on uveitic cataract.
In their review, the authors described the methods for managing the small pupil and the fibrosed pupil. With the requisite instruments and hand-skill, a scarred and constricted pupil yields to surgical effort, but a rarity arises when the nest of fibrosis at the pupil is too adherent and extensive. The pupil cannot be freed, and there may be concern about tearing of the anterior capsule. On facing this peculiar pupil, the way to progress the operation is to make a peripheral iridectomy and inject viscoelastic below the iris. Sub-iris viscodissection is combined with a sweeping of the cannula, a sub-iris motion whose aim is to uproot the fibrosed, stuck pupil from the anterior surface of the lens.
Advancing into the eye, rarely the surgeon can find a uveitic cataract that is so calcified that a capsulorhexis is not possible. The capsule is literally too tough. One solution is a can-opener capsulotomy, but it makes the surgery less controlled, the capsular opening, a ragged circle, at risk of tearing out into the equator. It is safer to manually cut out a capsulorhexis with microscissors. To wield these scissors, multiple paracenteses are made at the corneal limbus, via which the scissors are passed, moving stepwise around the corneal periphery, thus cutting out a disc of capsule from the hardened anterior capsule. Additionally, one should avoid the fashioning of a small rhexis when there is the intraocular milieu of inflammation.
A small rhexis is liable to contracting down after surgery. Other factors that cause rhexis shrinkage are active simmering uveitis, and zonular fragility in the uveitic eye. A phimosed rhexis not only blocks the visual axis, but the resulting large anterior capsule will allow capsule-to-iris adhesions, which, at worst, lead to pupil block and iris bombe. The precipitant of this type of pupil block is marked or sustained uveitis over the postoperative course.
A patient who exemplifies the travails of uveitic cataract surgery is one that is Human Leukocyte Antigen B27+ve, suffers from severe spondylitis and a chronic anterior uveitis. In such a high-risk eye, a large enough rhexis (6–7 mm) plus the use of a capsule tension ring negates the risk of capsular phimosis. Moreover, a high-activity eye may sprout a fibrotic membrane that clogs the pupil, or densely spreads over an endocapsular lens implant.
The avoidance of these troubles is dependent on the strict elimination of clinical uveitis--of inflammatory cells--from the anterior chamber. Attention is redirected here toward the attainment of a quiet eye for 3 months before surgery, followed by a total suppression of the anterior uveitis into the ensuing months. Uveitic eyes respond unpredictably to surgical stress and, after taking precautions, the clinician must be ready to manage postoperative inflammatory sequelae. Eyes of moderate-to-high risk should undergo scrutiny soon after the intraocular procedure to detect and prevent major complications.
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