Case Reports

Two-steps cataract surgery in an eye with high myopia and silicone oil post-vitrectomy – unexpected situations demand intraoperative changing of strategy

Case Report Details

First Author: O.Moraru ROMANIA

Co Author(s):    C. Moraru                    

Abstract Details

Purpose:

When reliable biometry can’t be obtained due to associated pathology, cataract surgery can be done initially without intra-ocular lens (IOL) implantation, which will follow later, as a second procedure. But, sometimes, the latter can evolve different than expected. Our purpose is to present a stepwise modality of operating a cataract in a high myopic vitrectomized eye (for previous retinal detachment), in which no reliable biometry could be achieved, probably due to the presence of silicone oil in the vitreous cavity. We want to highlight the way the surgeon can face and solve possible unexpected issues in such cases.

Setting:

Oculus Eye Clinic – Bucharest, Romania

Report of Case:

We report a case of a high myopic eye of a 42 years old male patient, with history of retinal detachment operated with silicone oil tamponade, which presented with advanced cataract. We planned for a combined procedure: standard phacoemulsification with posterior-chamber intraocular lens (PC-IOL) implantation and silicone oil extraction (in the same surgery). Preoperatively, the biometry could not be performed, although attempted with three devices (no axial length displayed), most probably due to high myopia and presence of silicone oil. Consequently, we decided at this point for phacoemulsification and silicone extraction only and, later on, reliable biometry and secondary PC-IOL implantation were to be accomplished. During the first surgery, apart from the need to detach the pre-existing iris-lens synechia, the presence of an unexpected floppy-iris syndrome - which significantly constricted the pupil - and the moderate anterior chamber fluctuations (not surprising in high myopic and vitrectomized eye), no other issues were encountered and the whole combined procedure was overall uneventful. Few days postoperatively we could perform biometry (in aphakic mode) and we scheduled the patient for secondary in-the-bag one-piece hydrophobic IOL implantation, which took place eight days after the cataract extraction and silicone-oil removal. During the second surgery, extreme pupil constriction produced from the very beginning of the procedure necessitated this time enlargement with iris hooks. Moreover, significative opacification, fibrosis and complete fusion of both anterior and posterior capsule were noted. These capsular changes, surprisingly developed so early after cataract extraction, required manual central posterior capsulotomy and changing of the selected IOL with a more appropriate one - respectively, for sulcus position (a 3-pieces acrylic PC-IOL). The postoperative follow-up was favorable, the corrected distance visual acuity was 0,9 (Snellen) at one month and the targeted refraction was acquired. Retina remained attached and long-term follow-up is uneventful.

Conclusion/Take Home Message:

This is a cataract case in an eye with associated pathology, which posed several challenges: biometry issues led to the decision for two-step procedure; high myopia and previous vitrectomy with presence of silicone oil determined a more challenging phacoemulsification surgery; during the second procedure, the sudden extreme pupil constriction from the beginning and, the central fibrotic opacity and - most of all - the unexpected early complete fusion of the lens capsules determined the surgeon to quickly adapt his surgical strategy. To prevent postoperative refractive surprises, two-step procedure is desirable, instead of a single one. Secondary PC-IOL implantation should be performed as soon as possible after cataract extraction, in order to avoid capsular fusion, which could jeopardize the in-the-bag positioning of the IOL. If this can’t be avoided, mastering the posterior rhexis on fibrotic capsule and having several types of IOLs at surgeon’s disposal, are mandatory in these cases.

Financial Disclosure:

None