|LETTER TO THE EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 215
Expert's comments to “Unexpected mishap for a beginner surgeon”
Cataract and Glaucoma Services, Chakrabarti Eye Care Centre, Thiruvananthapuram, Kerala, India
|Date of Submission||22-Jun-2020|
|Date of Acceptance||23-Jun-2020|
|Date of Web Publication||25-Aug-2020|
Dr. Arup Chakrabarti
Cataract and Glaucoma Services, Chakrabarti Eye Care Centre, Thiruvananthapuram, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chakrabarti A. Expert's comments to “Unexpected mishap for a beginner surgeon”. Kerala J Ophthalmol 2020;32:215
Thank you for the opportunity to go through the very interesting letter to the editor.
I have the following comments to offer in this connection.
It is always a good idea to include the “Maximum Mydriatic Test” in the battery of tests when evaluating a patient for cataract surgery. In the event the pupil does not dilate, we need to look into the etiology of the small or mid-dilated pupil. The management strategy of a small pupil is governed by its etiology to a large extent. If the pupil is found to be unsafe for uneventful phacoemulsification, a pupillary dilating device should be used at early stages of the surgery. It could be iris hooks or any pupillary expander of the surgeon's choice. The surgeon can also deploy the dilating device intraoperatively should the pupil come down further. In that case, the surgeon has to take care not to inadvertently engage the rhexis margin with the device, which may jeopardize the integrity of the bag. In the given case, it appears that the capsulorhexis was disproportionately small in the presence of a moderately sized small pupil (5 mm) to start with. Use of iris hooks/expansion devices would have permitted the surgeon to do a proper capsulorhexis. Viscomydriasis with a heavy ophthalmic viscosurgical device would also enable the surgeon to do a relatively larger rhexis and then proceed with safe capsulorhexis, nucleus disassembly, and cortex aspiration., Use of a rhexis marker is not likely to add additional benefits in small pupil situations. Small pupil surgery is usually associated with excessive tissue handling (resulting in exaggerated postoperative inflammation), increased chance of posterior capsular compromise, and other complications.
There may be multiple causes of deep anterior chamber during cataract surgery. The phaco parameter settings might have to be adjusted to create a comfortable working environment. Reverse pupillary capture might contribute to intraoperative deep anterior chamber and an appropriate strategy will have to be adopted in such a situation.
The situations where an exaggerated anterior capsular fibrosis is expected have been well enumerated by the author. In such cases, it is paramount to remove as much cortex as possible and polish the anterior subcapsular lens epithelial cells. A single piece hydrophobic acrylic intraocular lens (IOL) is the preferred IOL in these situations. The rhexis size in such situations should be between 5 and 5.5 mm.
In summary, the postoperative complications could have perhaps been avoided using appropriate pupillary dilatation devices that would have rendered rhexis, nucleus disassembly, cortex removal and IOL implantation safer.
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Conflicts of interest
There are no conflicts of interest.
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