I had a 60 year old male patient for routine phaco with foldable surgery under topical anesthesia. Patient was 'normal' grade 2 cataract. No positive systemic history. After the phaco step was over the AC became shallow (not flat) and would not form either with air/visco/RL. The eyeball was slightly firm (not hard). I feared and expulsive hemorrhage. The glow was perfect and clear. The anesthetist gave fulsed etc and 200 ml of IV mannitol and waited for 30 minutes for the IOP to fall. The condition remained the same after 30 mins. All this time the glow was excellent. The patient was comfortable (no pain, discomfort). I had a telephonic discussion with 2 of our colleagues. I stopped the procedure, padded him and sent him for USG. His report was normal. I saw him again and the AC had become normal, though it was hazy (with the entire cortex floating around) and the eyeball felt normal to feel. I took him again to the OT, gave him 5ml of LA, did IA and put in the foldable IOL in the bag (uneventful). Next day and for a further 3 days the patient is doing very well and vision is 6/6 with normal IOP. Please give your valuable opinions for the same regarding the cause etc. and how to manage it.
Dr Manojkumar Agarwal
I had a similar situation in 3 of my cases and I presented this complication in the previous TNOA conference also. This complication can be called ' Intraoperative misdirection of the fluid or Malignant Glaucoma'. This happens when the irrigating bottle height is more than adequate- especially so when there is pseudo-exfoliation, zonular weakness and in cases of high myopia. This complication can be prevented by (1) lowering the bottle height, keeping it at a height that is good enough to maintain AC depth during all maneuvers and (2) to prevent any surge. The management is just the way you did - just remove all viscoelastics from the eye and try to form the AC with an air-bubble and post pone the surgery. Next day the eye will be soft and quiet and you can proceed with the surgery. Only this time you do not use methyl cellulose. Sodium Hyaluronate will let you finish the surgery and even prevent the complication from occurring once again. If you are in a hurry to finish the surgery at one go, you could even do a pars-plana vitrectomy with a single port and with the irrigation in the AC ‘on’. End point for vitrectomy is 'formation of the AC'. When you see the AC formed, withdraw the vitrectomy probe , close the pars plana entry wound with a single stitch and proceed with the cataract surgery.
Take home message:
1) Always check your bottle height before starting the procedure
2) When ever you suspect zonular weakness, use Sodium Hyaluronate. Inject this into the Posterior Chamber- just enough to plug the zonular area and not to balloon the Iris into the AC.
Dear Dr Maoj Kumar,
The patient may have had aqueous misdirection syndrome with infusion hydrating the vitreous by passing through defects in the zonular apparatus and ant vitreous. You have managed the patient excellently.
Dr. Ramesh D.
Intra-operative hard eye is a well recognized and a rare problem. Reverse circulation of aqueous humor or irrigating fluid is the suspect. You have managed the right way. TO STOP AND COMPLETE THE SURGERY on2nd or 3rd day. One will manage an uneventful surgery. The skill required is only to explain to the patient about your concern for safe surgery. Be careful for the fellow-eye surgery you may face same problem
DR PRASHANTH ISLOOR
Dear Dr. Manojkumar Agarwal,
While doing Phaco in vitrectomised eyes, you can encounter a similar situation due to Infusion Misdirection syndrome. The BSS passes through the zonules into the vitreous cavity of these vitrectomised eyes and causes a paradoxical shallowing of AC when you increase the bottle height. You have to lower the bottle height in these cases and look for the red glow (which you rightfully did). I had similar problems while forming the AC after PCIOL implant. The caveat is always maintain the bottle height low while doing Phaco in vitrectomised eyes and use lower parameters.
Dear Dr. Manoj Kumar,
The description you have given is of a fluid misdirection through the zonules into the anterior vitreous resulting in an intra operative hard eye. You have done the right thing by stopping the procedure and giving IOP lowering medications and doing a B scan( which can rule out a supra choroidal effusion or bleed). Usually it settles like what happened in your case and the post op results are good.
Dr. Minu M Mathen