Treating Cataract Complications

E. Parikakis1 – E. Gotzaridis2

1“Ophthalmiatreio” Eye Hospital, Athens, Greece2 Vitreoretinal Surgeon, OMMA, Athens, Greece

1. Capsular rupture & Vitreous loss

2. Dropped nucleus / fragments

3. IOL dislocation

4. Endophthalmitis

5. Iris trauma / aphakia

6. Need for IOL exchange / IOL opacification (open posterior capsule)

Common Cataract Complications

Treating Cataract Complications

1. Control the environment (consider subtenon anesthesia)2. Do not let AC collapse. Use OVD to prevent vitreous

prolapse. 3. Try to maintain the rest of the capsule4. Always work in a close environment5. Keep fluidic stability, use AC maintainer6. Use separate incisions for vitrectomy. Remove the vitreous

using a 25ga sclerotomy and a high-speed cut vitrector7. Use the side ports (consider bimanual irrigation/aspiration)

Pearls for Capsular ruprure / Vitreous loss

Treating Cataract Complications

1. Remove the nucleus with the vitrector (± PFCL ±forceps) (25/23 gauge technique)

2. Use the phacofragmatome (20 gauge technique)

3. Fill with PFCL and bring the lens to anterior segment (AC procedure)

4. Other method (Ozil phaco probe?)

Dropped nucleus/ fragments

Treating Cataract Complications

Treatment Modalities

Dropped nucleus Dropped nucleus –– Other ?Other ?

Dropped nucleus / fragmentsDropped nucleus / fragments((OZil versus FragmatomeOZil versus Fragmatome))

Convetional Convetional 2020--gauge fragmatomegauge fragmatome

OZil torsional OZil torsional handpiece without handpiece without

silicone sleevesilicone sleeve

22,5 mm22,5 mm

OZil torsional phaco OZil torsional phaco handpiecehandpiece

20,5 mm20,5 mm

IOL Repositioning

Assessment whether is sufficient capsular support Makes the refraction 0,5 – 1 diopter more myopic Single-piece acrylic lens are designed for in-the-bag

implantation & can lead to dislocation, iris inflammation Better option: three-piece acrylic lens, (PMMA with holes)

Ciliary Sulcus repositioning

1. Posterior Capsule Defect

Management of IOL Dislocation

A. Anterior (limbal) approach

If the IOL is still supported by the capsular remnants

B. Posterior (pars plana) approach

More complete and controlled vitreous removal Better access to the vitreous cavity Ability to treat potential intraoperative complications

(tear, hemmorrhage, IOL vitreous dislocation)

IOL Repositioning

The Posterior Segment Approach Useful maneuver to bring 1 haptic into the AC The IOL to be rotated before placing the 2nd haptic

Ciliary Sulcus repositioning

1. Posterior Capsule Defect

IOL Repositioning - Posterior (p. p.) approach

Αύξηση IOP για έλεγχο αιμορραγίας

Dislocated IOL & RD

PFCL useful to stabilize the retina and to float the IOL

anteriorly and to manipulate the IOL into the sulcus

IOL Vitreous Dislocation – IOL Exchange – Iris-claw IOL

The Posterior Segment Approach

ΕVS – Treatment modalitiesVITRECTOMY: 3port ppv, 0.2-0.5 cc undiluted vitreous

core vitrectomy (do not force for PVD, target: gel removal > 50%)

ΤΑP: 0.1-0.3cc vitreous, βελόνη 22-25g or portable vitrector

Intravitreal: Vancomycin (1mg/0.1cc) + Amikacin (0.4mg/0.1cc)

S/Conj: Vancomycin (25mg/0.5cc) + Ceftazidime (100mg/0.5cc)+ Dexamethasone (6mg/0.25cc)

Fortified drops: Vancomycin (50mg/ml) + Amikacin (20mg/ml) + cyclo + predn

P.O. ?: Prednisone 30mg bid , Moxifloxacin

VA<ΗΜ 60cm → 25g VIT + iVIT vanco, ceftazidime, (dexamethasone)

VA>HM 60cm (diabetics) or rapid progression/pain →VIT + …

VA>HM 60cm → TAP + iVIT vanco, ceftazidime, (dexamethasone)

+ PO moxifloxacin, prednisone (not in diabetics)

+ fortified drops, dexamethazone, cyclo

Treating Cataract Complications -Endophthalmitis

Vitreous biopsy with a needle or cutting/aspirating probe

(Parabulbar anesthesia may be necessary) Povidone-iodine 5% solution -rinsed thoroughly with

sterile BSS or normal saline to remove residual antiseptic from the ocular surface

Surgical drape, lid speculum, (operating microscope) 30-gauge needle attached to a tuberculin syringe is

inserted through the limbus into the anterior chamberand through the pp into the vitreous cavity

Vitrectomy probe attached to a tuberculin syringe is inserted into the vitreous cavity through a sclerotomy incision

Approximately 0.1–0.3 ml of vitreous is removed Automated cutting mechanism of the probe and

slow, manual aspiration into the syringe

Treating Cataract Complications –Iris trauma - Aphakia

PPV & Iris Reconstuction & Artisan/Verisyse AC

Treating Cataract Complications

1. Control the environment (consider anesthesia)2. Maintain the integrity of the capsular bag and remove the

old lens from the capsular bag to the AC (consider haptic ampulation)

3. Use OVD to prevent vitreous prolapse, to protect the capsule & the cornea & to dissect

4. Insert the new lens before removing the old one

5. Use a new wire loop snare

6. Dissect slowly or cut the lens > 50%

7. Choose a 3 –piece acrylic lens for sulcus implantation

Pearls for IOL exchange in Open Posterior Capsule

Treating Cataract Complications -Need for IOL Exchange

IOL Exchange in Open Posterior Capsule

Treating Cataract Complications

E. Parikakis1 – E. Gotzaridis2

1“Ophthalmiatreio” Eye Hospital, Athens, Greece2 Vitreoretinal Surgeon, OMMA, Athens, Greece

Time for Practice!