Query NO: 438 - Post OP shallow AC

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admin:
I  have seen some cases developing air behind pupil - glaucoma on first post operative day if I use air to reform AC. In all cases i use air  to insert iol into the bag and no viscoelastic is used. ( VISCOELASTICS   used only during rhexis and nucleus delivery). The bag is also inflated with air only to let the iol go into the bag only. At the end air is kept in the AC only and no ringer is used to reform the AC. This is done to avoid hyphema ( I do not do cautery at all). This procedure is done in my high volume camp cases. I need suggestions how to avoid this problem

Dr. Harjeet Singh,
Kolkata. 

Responses:

No:1

Dear Sir,
Prescribe tropicamide with phenylephrine drops and advice to put it twice daily till air get absorbed from AC.

Dr Nilesh.

No:2

We are using air since 27years. But we see that we keep RL also in AC from side port & reduce the size of airbubble. Our idea to use air not to allow hypotony in eye so that conjnctival fluid do not get absorbed in AC & act like temponade. Fluid from AC easily leaks out but Air remains inside to maintain AC. We also use Antibiotic drops after finishing surgery before putting Pad. Waterjetting procedure is good if you use viscoelastics for removam of the same. Remember when you use Visco, inject only as much as ou need  which you can remov easily & also only in the bag not in sulcus. A sit is difficult to remove from sulcus & will give rise tored eye postoperative & may be TASS.

Thanks,
Dr. J K Shah,
Mumbai

No:3

Dear Dr. Harpreet Singh
Avoid hyper inflating the eye. Use a little bit of fluid also to form the chamber.  Even rhexis can also be done under air. Regards,

Dr. Vinod Arora
Navjyoti Eye Hospital & Dehradun Wavelasik Centre,
Dehradun.

No:4

Dear Dr.Harjeet,
I think you can do reforming of A/C with smaller quantity of air and keep ringer as well so that it would serve your dual purpose of avoiding hyphaema as well as avoiding air-pupil block glaucoma instead of fully forming the A/C with air alone.
 
Best wishes,
Dr.N.Jayanth Rao
Shimoga.

No:5

Dear Dr Harjeet Singh,
First i should congratulate you for doing high volume cataract surgery and we definitely need surgerons like you to help out the underprivleged masses who cannot afford the high cost (quality) cataract surgery.
But, quality should never be compromised running after numbers. It seems like you are cutting down on a lot of steps just to do a few more cases at the end of the day. And I would like to point out one more point, you are doing this only to your HIGH VOLUME CAMP CASES. This sort of an appraoch is dangerous on the long run and was proved to be wrong repeatedly.
Let us learn from our predecesors mistakes. Please do not comproise on any step and the quality of the surgery, be it your high paying case or your high volume case. Just 1 % (an example) complication rate on your statistics chart is good to look at but for that patient it is 100% morbidity and he has to live with it for the rest of his / her life. Please take this in the right sense and develop a quality conscious attitude. There is no substitute to quality and u can achieve quality with no new complitions only when you do  all the steps completely.
 
DR G RAJESH
SUDARSANI EYE HOSPITAL,
GUNTUR. 

No:6

Dear Dr Harjeet Singh,
There is no need to use air to insert IOL in the bag. Air may cause either approximation of anterior and posterior capsule or entrapment of air in bag behind IOL. Please use visco to inflate bag to avoid this situation. Injection of air is to reform A.C. is also unnecesssary. Good wound closure takes care of post op shallow AC and hyphaema if any.

Regards,
Dr. U S Tiwari
Gwalior.

No:7

After you have inserted the i o l inject some b s s from side port and leave half of a c filled with air, you will never have air bihind pupil  and enjoy all other benefits of free air and pt will have better vision on 1st post op day.

Thanks,
Dr.Balbir Singh

Comment:

Many Thanks for the suggestions. I  want to point out that using air is not to cut down the expense. It is convenient step so that you don't have to wash out the visco in the end. Many experts have advocated putting IOL in Ringer/BSS only as the eye is crystal clear on the first day. There are less chances of getting TASS also.  I do this even in my private cases to get the better results. In camps this has been done for the last 2 years with no complications. Rather case of hyphema have reduced. But some few cases of air behind were worrying me. Putting tropicacyl or drosyn at the end of surgery(as suggested will rather increase the incidence and is to be done only to bring the air bubble into the AC immediately on the postop day only . We  have seen and done many of these in those intracapsular days.Dictum-- Do not leave the patient till air is in ac only).  I will definitely try using some amount of ringer and less amount of air to balance and avoid  both the complications.

Thanks & regards,
Dr. Harjeet Singh  

Expert Comment:

Dear Dr Harjeet Singh,
I  know you are excellent surgeon. The problem of air behind the pupil happen some time. It is best to put small air bubble into anterior chamber and reform rest of AC with BSS plus or Ringer lactate. Once this problem occur i.e air behind pupil and IOL, dilate pupil with phenyl ephirine and tropicamide eye drops about twice a day.

Kind regards,
Dr Jagat Ram., Professor,
Advanced Eye Centre,
PGIMER, Chandigarh.

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