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March 2013

Experts Tackle Cataract Complications, Part 2
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At last November’s Spotlight Session, audience members voted on video case studies highlighting myriad clinical challenges, including IOL exchanges, traumatic cataracts, and surgery in patients with chronic uveitis. Here, the experts weigh in with additional perspectives.


Case 3: White Lens Plus Uveitis


Q  This 16-year-old patient has a three-year history of chronic iridocyclitis. What is your preferred capsulotomy method in a young patient with a white lens?

Retentive ophthalmic viscosurgical device (OVD) and forceps


Irrigating cystotome


I use a sharp needle to first aspirate cortex


Femtosecond laser


I would refer this patient


Bob Osher  There are different types of white lenses. Although they share in common poor visibility of the anterior capsule requiring staining, each calls for a different approach.

Either a needle or a forceps will work fine with a hard white cataract, while a morgagnian cataract requires a puncture followed by refilling the bag with retentive OVD and the use of a forceps. It is the intumescent cataract in the younger patient that is at great risk for the “Argentinean Flag.” Carlos G. Figueiredo recently published the ideal approach to managing this cataract,1 which is characterized by a nuclear block within the lens, whereby liquefaction has raised the pressure within both the anterior and posterior cortical compartments. Simply decompressing the anterior compartment with a needle does nothing for the posterior compartment, and spontaneous extension of the anterior capsular tear may occur.

After the anterior capsule has been stained and a retentive OVD (such as Healon 5) compresses the lens, a small capsulorrhexis is initiated by a puncture followed by downward force (ballotting) on the lens. This breaks the nuclear block, allowing the posterior cortical compartment to decompress. Once this occurs, the risk of capsular extension diminishes, and the surgeon may proceed with his or her preferred needle or forceps technique. A safer strategy is to plan a small rhexis, which can then be enlarged. By combining these measures, the rhexis can be safely accomplished.

Remember that the capsulorrhexis is like the alphabet: If A goes Awry, then B is Bad, C is Catastrophic, and D is a Disaster!


1 Figueiredo CG et al. J Cataract Refract Surg. 2012;38(9):1531-1536.


Q  Which IOL material is your preference for eyes with chronic uveitis?

Hydrophobic acrylic


Hydrophilic acrylic








Randy Olson  The audience response is about what I would expect and follows the generally held concept that silicone is bad and hydrophobic acrylic is the lens of choice. While earlier plate-haptic silicone and PMMA IOLs did have a marked increase in signs of inflammation (giant cell deposits and synechiae), later-generation silicone IOLs did not show this. Thus, PMMA and plate-haptic silicone IOLs are contraindicated, but all the other IOLs listed in the survey do not have peer-reviewed evidence that they are contraindicated.

Theoretically, the greatest uveal biocompatibility would be with hydrophilic IOLs (hydrophilic acrylic and collamer). However, in the capsular bag in uncomplicated surgery, the two hydrophobic alternatives (hydrophobic acrylic and later-generation silicone IOLs) have stood the test of time and do fine.


Q  During the capsulotomy, one side of the tear abruptly splits radially. What would you do next?

Initiate phaco and/or I&A


Attempt to rescue one side of the capsulotomy


Convert to a can-opener capsulotomy


Make radial relaxing incisions in the two edges


I would refer this patient elsewhere


Bob Cionni  The intumescent cataract is more likely to develop a radial tear in the anterior capsule during capsulorrhexis due to the inherent intralenticular pressure. The best way to manage this occurrence is to prevent it. Use of the femtosecond laser to perform the capsulotomy has been quite successful.

If performing the capsulotomy manually, one should stain the capsule with trypan blue and then, using a highly retentive OVD, deepen the anterior chamber until the anterior capsule flattens. The capsulotomy should be initiated more centrally than is typical; and, using a 27-gauge cannula, the surgeon should aspirate the liquefied cortex to decompress the lens and prevent the intralenticular pressure from pushing the tear peripherally. These steps will usually prevent a radial tear.

However, if a radial tear develops, the case can still be saved. To begin, deepen the chamber with a highly retentive OVD. If the edge of the tear can still be seen, one can rescue the tear as described by Brian Little: The edge is folded under and redirected by pulling centrally. The tear should move centrally instead of continuing peripherally. If the tear has extended beyond the pupil margin, inject a highly retentive OVD, make an incision circumferentially in the edge of the radial tear, and, using capsulotomy forceps, restart a new tear, basically ignoring the radial extension.

Whenever the capsulotomy is not continuous, one must be extremely careful and gentle for the remainder of the case. Do not hydrodissect, as doing so would only encourage the tear to extend further, perhaps all the way to the posterior capsule. Instead, begin phacoemulsification; the intumescent lens should be removable without issues. Careful cortical aspiration begins away from the radial tear, and great care should be taken when removing cortex from the area near the tear. The bag is then filled, but not overfilled, with a cohesive OVD before implanting the IOL. A single-piece acrylic IOL with low expansile force haptics, such as the AcrySof IOL (Alcon), is placed with the haptics oriented perpendicular to the tear to decrease the risk of tear extension (versus a three-piece IOL with more rigid haptics). The OVD can be removed as usual; to prevent the chamber from collapsing, inject balanced salt solution (BSS) when withdrawing the I&A tip.


Q  Preoperatively, this uveitis patient had decided on a toric IOL for 1.5 D astigmatism. With a single radial capsulorrhexis tear, what IOL would you implant?

Single-piece acrylic monofocal IOL in bag


Single-piece acrylic toric IOL in bag


Three-piece IOL in bag


Three-piece IOL in sulcus


I would refer him elsewhere



Q  The toric IOL is implanted into the capsular bag. How would you try to prevent posterior synechiae from forming to the anterior capsule in this eye?

Topical atropine postoperatively


Topical pilocarpine postoperatively


Make a can-opener capsulotomy or radial capsulorrhexis cuts


Secondary enlargement of the capsulorrhexis


I would not change my routine


J.P. Dunn  In the first scenario, assuming that the nucleus and cortex have been successfully removed so that the only issue is the IOL, the first step is to determine the extent of the capsulorrhexis tear. The eye should be gently filled with a dispersive viscoelastic, and the iris manipulated peripherally with a Lester IOL Manipulator (Katena) or a similar instrument to see if the tear has extended to the equator or  beyond. (Many such anterior radial tears do not continue past the equator.) 

It is not usually a problem to place a toric IOL in the capsular bag in these situations unless the tear extends posteriorly; however, it is very important that the haptics are well seated in the capsular bag. Moreover, if the axis of the tear is in the same meridian as the desired axis of the toric IOL, it becomes much more likely that the haptic will push through the capsular tear, thereby causing significant IOL decentration. In this situation, it may be safer to implant either a single-piece or a three-piece IOL in the bag and deal with the astigmatism later with astigmatic keratotomy. One time-consuming but generally safe method to test these options is to place the toric IOL, gently remove the viscoelastic, and check the alignment of the IOL. If it is properly positioned at this point, it is unlikely to move significantly in the postoperative period. If the alignment is unstable, the toric IOL should be removed and a monofocal IOL placed.

In the second scenario, the most important means of preventing posterior synechiae (iridocapsular adhesions) from forming is to aggressively control postoperative inflammation with potent topical corticosteroids, especially if some residual cortex was left behind at the end of surgery. Occasionally, it is necessary to employ a periocular corticosteroid injection and/or a short course of oral corticosteroids. Posterior synechiae will often form following cataract surgery as long as the uveitis is active, regardless of whether the capsular opening is intact (continuous capsulorrhexis) or has been modified with radial cuts or converted to a can-opener type. Pilocarpine is proinflammatory and should not be used in patients with uveitis either to induce miosis or decrease IOP. In addition to aggressive control of the uveitis, dilating drops can be helpful, but the goal is to keep the iris moving, rather than keeping it fully dilated. Use of atropine once or twice a day at the most will usually allow movement of the pupil on a diurnal basis (dilation followed by slow return to normal size) and prevent or minimize synechiae formation. More frequent dilation will simply cause the synechiae to form with a dilated pupil to the edge of the rhexis, especially if it has been enlarged. Be aware that it is now difficult to obtain homatropine, so if a shorter-acting cycloplegic agent is desired, cyclopentolate 1 percent is a reasonable choice, although it stings much more than either homatropine or atropine.


Case 4: Rock-Hard Nucleus Plus Fixed Small Pupil


Q  What is your usual approach for an ultrabrunescent cataract in a 90-year-old patient?



Manual ECCE (large incision)


Manual ECCE (small incision)


Comfortable with either phaco or ECCE—it depends on the patient


I would refer this patient


Dick Lindstrom  For me, as a 65-year-old ophthalmologist who has done several thousand planned ECCE procedures, this patient is best managed with manual large-incision ECCE. The nucleus will be very dense, the endothelial cell count low from natural aging, the capsule weak, and the zonules less resilient than in a younger patient. 

If the patient is not on anticoagulants, I do a peribulbar block, use a large continuous tear anterior capsulotomy, hydrodissect the nucleus until it tilts out of the bag, and remove it with an irrigating vectis. I like to preplace three sutures and tie the central one with a temporary bow. I&A is routine, and a 6.5- to 7-mm all-PMMA aspheric monofocal IOL is my implant lens preference. The patient with this approach will have a crystal-clear cornea and good vision on day one. 

If I believe a small-incision procedure is indicated—for example, with a patient who is on anticoagulants and has a history of a choroidal hemorrhage in the other eye—then I make a few adjustments to my phaco technique. If the patient is not on anticoagulants, I will consider a peribulbar block in case conversion to an unplanned ECCE or even ICCE is required. I use a dispersive and cohesive viscoelastic in the Arshinoff soft-shell technique, make a larger continuous tear anterior capsulotomy, and hydrodissect the nucleus until it is freely mobile. I then also place some dispersive viscoelastic under the nucleus. Next, I debulk the nucleus with phacoemulsification, using a duty cycle in pulse or ultrapulse and energy level that is low enough to avoid a wound burn, in the posterior chamber, removing as much material as possible. I do not hesitate to place extra dispersive viscoelastic two or three times during the  nuclear removal. While chopping and divide and conquer work well, I like a modified supracapsular phaco technique called tilt and tumble. Once the nucleus is just a thin shell, I hydrodissect or viscodissect it out of the bag and remove the final nuclear remnants using a bevel-down technique. This eliminates any problem with a leathery posterior plate, and keeps the posterior capsule well protected.

In countries where manual ECCE skills are high, almost no surgeon would elect phacoemulsification in a 90-year-old with an ultrabrunescent cataract. In the United States, where most younger surgeons are far more comfortable with phaco than any form of ECCE, it is not surprising that 53 percent preferred this approach. With a high skill level and careful surgery, phaco can be done safely in these eyes, but for those skilled in the art, ECCE is a nice alternative.

R.D. Ravindran  It is interesting to see that nearly 70 percent of the audience members would consider phacoemulsification. This shows the level of competence and the confidence of the members in the reliability of technology. With phaco, vertical or direct chop is the preferred technique. With any phaco technique, using a dispersive viscoelastic to coat the corneal endothelium is critical, as the emulsification process tends to be longer in these cases, generating significant levels of heat. Using a chopper tip that is long and pointed is important to create the division in the posterior plates of the hard cataract. Creating a complete initial crack with breakage of the posterior plate and bisecting the nucleus completely is the most important step. Creating at least six to eight fragments before removing each of these fragments is preferred. Extra caution should be taken while emulsifying the fragments, especially the last few, as these cases will not have any protective epinuclear cushion.

Given this patient’s history [see below], large-incision ECCE should be done with all precautions. If ECCE is planned, doing it with preplaced sutures is preferred.

Even though it is preferred by only a small percentage of the audience, manual small-incision ECCE is an ideal technique in such cases, performed through a 6.5-mm to 7-mm incision. A large rhexis of 5.5 to 6 mm is essential with the nucleus delivered from the bag using a Sinskey hook. Here again, good use of a dispersive OVD is required. With this technique, the surgical complications are fewer compared with phaco, and the corneal clarity is much better on day one. Placing the incision on the steep axis will help in achieving better uncorrected visual acuity.


Q  Two years ago, this 90-year-old patient lost her right eye due to a suprachoroidal hemorrhage during phaco. Her left eye is bare hand motions with an ultrabrunescent cataract and fixed secluded pupil. She is very scared about the possibility of surgical complications in this eye. What would you advise?

I would discourage surgery or tell her to postpone it as long as possible


I would encourage surgery and perform it for her


I would encourage surgery but refer her


I would be neutral and totally leave it up to her


I would refer her for a second opinion


Kevin Miller  With a bare hand-motions cataract, this patient has little to lose. She is already bilaterally blind. Under the worst of circumstances, she might wind up with a blind and painful left eye instead of just a blind eye. It is heartening to see that only 1.1 percent of the audience members would discourage her from undergoing cataract surgery.

Most patients who experience bad outcomes in one eye are reluctant to undergo surgery in the second eye. This is understandable. These patients appreciate that, while you are well intentioned and well trained, you cannot control everything that happens in the operating room. You cannot guarantee an uncomplicated outcome.

It is under these circumstances that a second opinion is very helpful. You can almost never go wrong by recommending that a patient obtain a second opinion, as long as the person rendering it is competent. Whenever you refer a patient for a second opinion, you take the ego risk that the patient will decide to have their surgery performed by the other ophthalmologist, but that is life. We are here to serve our patients.

I would not be neutral and leave it completely to the patient to decide, as was the response of 35.4 percent of the audience. This patient needs a paternalistic approach. Gentle and reassuring but firm pressure should be applied to get the patient to look at the situation less emotionally. Let’s imagine a related scenario. Wouldn’t a cardiologist who is caring for an asymptomatic patient with 95 percent blockages of the left circumflex, left anterior descending, and right coronary arteries be ethically obliged to strongly recommend immediate surgical intervention? Would it not be inappropriate for the cardiologist to follow the patient’s inclination for continued observation? Neither would it be appropriate, in my opinion, for this blind patient to choose continued blindness without significant resistance from the ophthalmologist. She is understandably scared, but she also wants to see. She is reaching out for reassurance. While, ultimately, the decision rests with her, the ophthalmologist has the ethical obligation to encourage surgery and make sure it is done in a way that will ensure the best odds of a successful outcome.

This will be a difficult case, even without her history of suprachoroidal hemorrhage in the fellow eye. Ophthalmologists who do not routinely perform surgery on dense brunescent cataracts would appropriately refer this patient to someone with more experience. This was the response of 11.4 percent in the audience.

A little less than half of the audience would have encouraged this patient to undergo cataract surgery, and they would have performed it themselves. I belong to this group. If we look at the published literature, we find that complications following cataract surgery on monocularly sighted patients are acceptably low, and visual outcomes are almost uniformly good.1,2 We would expect the same for this patient.


1 Bergwerk KL, Miller KM. J Cataract Refract Surg. 2000;26(11):1631-1637.

2 Trotter WL, Miller KM. J Cataract Refract Surg. 2002;28(8):1348-1354.


Q  After dissecting free the pupil margin and inserting a Malyugin ring, you notice a large tear in the dye-stained anterior capsule. What would you do next?

Convert to a can-opener capsulotomy, then commence phaco


Try to tear a partial continuous curvilinear capsulotomy (CCC), then phaco


Convert to a can-opener capsulotomy and an ECCE


Abort surgery and refer the patient


I would refer her elsewhere for surgery


Steve Arshinoff  It always adds a bit of humor to note that a small percentage of the audience says that the patient should have been referred elsewhere, thus allowing them to avoid the problem and the patient and get to the golf course earlier.

It is, however, interesting to note that one-third of the audience would have simply given up and converted to ECCE and a can-opener capsulotomy. I think that before we do that we should recall the potential complications of such actions. A ragged capsulotomy often leads to a piece of inverted capsule adhering to the posterior aspect of the iris, causing a bound-down decentered pupil and chronic inflammation. Furthermore, there is a high likelihood of having only one foot of the IOL in the bag and one in the sulcus, no matter where you intend to place them. If a single-piece acrylic had been chosen, chronic inflammation and uveitis-glaucoma-hyphema syndrome may result. Even with a three-piece IOL, the IOL may be decentered. Long-term inflammation and glaucoma are much more likely in these cases. So, perhaps bailing out to a can-opener capsulotomy and ECCE should not be the next step.

I tend to agree with the majority, over half of the audience, who proposed to attempt to make the capsulotomy as good as possible and to try to complete the phaco. As a first step, I would add a viscous OVD to increase the pressurization of the anterior chamber. This tends to make the capsule want to tear inward rather than outward. I would place an aliquot of a combination of intracameral xylocaine and phenylephrine below the OVD to get maximal pupil dilation to enhance visualization. Then I would try either to continue the capsulorrhexis in the direction opposite to where the tear occurred, or to pull the tear back inward using the Little tear-out rescue technique, if the tear and its termination can be visualized. The fact that the capsule has been stained here with trypan blue aids in the rescue of the capsulorrhexis, as trypan blue decreases the elasticity of the capsule, thus making tearing in the desired direction in a pressured anterior chamber much easier.

Usually, a surprisingly good rhexis can be fashioned and the phaco can be completed. I would use lower flow and turbulence techniques to keep everything stable as the case progressed. It may take a little longer, but the result is better. Sometimes, if the rhexis is not completely intact but is large, the nucleus will prolapse into the anterior chamber, thus making phaco safe with respect to the capsule. A slow, gentle phaco is still advised. I&A is routine, leaving the area of the tear for last. I would prefer a single-piece acrylic IOL in this case, if a reasonable rhexis to contain it is present at the end of I&A. I would also place the haptics 90 degrees away from the tear because the gentle unfolding of single-piece acrylic IOLs makes their positioning in a potentially unstable capsular bag less risky.

Terry Kim  First of all, I’m very pleased with the low number of responders who would either abort surgery or refer the patient. To me, this response reflects how valuable teaching efforts like this session have proved in instructing the audience how to handle these complications.

Otherwise, the majority of the audience decided to either perform a partial CCC (then commence with phaco) or convert to a can-opener capsulotomy (with greater preference to then commence with ECCE rather than phaco). In this particular case, based on the size, shape, and location of the anterior capsular tear, I would agree with the majority response and attempt a partial CCC and then, presuming successful completion of the CCC and adequate access to the lens, commence with phaco. To me, this approach would avoid the sometimes unexpected behavior of a can-opener capsulotomy as well as the much larger incision required for an ECCE.

I would use a dispersive viscoelastic to flatten the anterior capsule during the partial CCC to prevent further radialization of the current capsular tear as well as to prevent the partial CCC from heading out peripherally. I would then recommend removing this dense lens with a vertical or horizontal phaco chop technique to minimize stress to the capsule and zonules. During I&A of the cortex, I try to remove as much of the cortex as possible, saving the cortex near the anterior capsular tear for last. Finally, if the anterior capsular tear has not extended to the posterior capsule, it is reasonable to place a single-piece acrylic IOL in the bag or a three-piece acrylic IOL in the sulcus, with the haptics  oriented away from the area of the anterior capsular tear.

Despite all of these potential bumps in the road, many of these patients can achieve an excellent anatomic and visual outcome.


Q  With a large radial anterior capsular tear, what IOL would you implant?

Single-piece acrylic IOL in bag


Single-piece acrylic IOL in sulcus


Three-piece IOL in bag


Three-piece IOL in sulcus


Would refer elsewhere for surgery


Walter Stark  With a large radial tear in the capsule, the main considerations are to avoid having the tear extend posteriorly and to prevent decentration or dislocation of the IOL. My favorite lens to use in these cases is the MA50BM acrylic (Alcon), which is a three-piece IOL. This lens has a 6.5-mm optic diameter and can be placed in the bag or the sulcus, whereas a single-piece acrylic IOL should never be placed in the ciliary sulcus. Also, this lens is not aspheric. Slight decentration of an aspheric lens causes more visual aberrations than a nonaspheric IOL.

If the tear does not extend posteriorly—past the equator of the nucleus—I would gently place the IOL loops in the bag. If the tear extends posterior to the equator, I would place the three-piece IOL loops in the ciliary sulcus. If the lens was not stable, I would constrict the pupil, obtain optic capture by the iris, and perform a modified McCannel suture of the IOL loop to the iris superiorly and possibly inferiorly using a 10-0 Prolene suture on a CTC-6 needle (Ethicon).


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