Complicated case underscores need for care, preparation

Take-home: Routine cataract surgery easily can become complex. Therefore, surgeons must pay meticulous attention to technique to minimize the risk of complications, but at the same time, be prepared to handle adverse events and to revise their surgical plan.

A case of cataract surgery with planned presbyopia-correcting IOL implantation– complicated by posterior capsule rupture and a postoperative refractive surprise– reinforced important lessons and provided a new revelation to one experienced surgeon.

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Thomas Kohnen, MD, the operating surgeon, outlined a case that reminded him to always be careful and to have a back-up plan because there is a risk for complications during routine procedures. In addition, Dr. Kohnen found after this case that a patient can achieve a satisfactory visual outcome when implanted with a bifocal IOL in one eye and a trifocal IOL contralaterally.

Dr. Kohnen is professor and chairman, department of ophthalmology, Goethe University, Frankfurt, Germany.

The patient was a 90-year-old woman who was slightly hyperopic (+1.75 -0.50 @140° OD; +0.75 -2.5 @154° OS) and she wanted to be spectacle independent after cataract surgery. She had an incipient cortical cataract in her right eye and mature cortical cataract in her left eye.

The initial plan

Dr. Kohnen decided to perform femtosecond laser-assisted cataract surgery (FLACS) and implanted a single-piece, trifocal IOL (AT Lisa tri839MP, Carl Zeiss Meditec) bilaterally, operating first on the eye with the cataract and soon after on the fellow eye.

“A study we conducted that was recently published in the American Journal of Ophthalmology showed that patients who underwent bilateral implantation with this trifocal IOL achieved good visual acuity (VA) at far, intermediate, and near distances, as well as high rates of spectacle independence and satisfaction,” Dr. Kohnen said.

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The first eye surgery was performed uneventfully, and two days later, the patient returned for her second procedure. The femtosecond laser steps were completed successfully, but during lens removal, the posterior capsule ruptured, followed by loss of cortex and nucleus into the vitreous. The femtosecond laser-created anterior capsulotomy remained intact.

“Removal of the lens is facilitated after pretreatment with the femtosecond laser, but the surgeon still needs to be careful,” Dr. Kohnen said. “When the plan is to implant an advanced technology presbyopia-correcting IOL, it is important to have a back-up solution in the event of an intraoperative complication that precludes adhering to the original IOL plan,”

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Since the posterior capsule rupture was too large, Dr. Kohnen expected he could not implant the single-piece trifocal IOL in the capsular bag. The alternatives were to leave the patient aphakic and subsequently implant a three-piece multifocal IOL in the bag or sulcus, a three-piece monofocal IOL, or an anterior chamber or iris claw IOL.

The back-up plan

The back-up plan

His decision was a three-piece bifocal IOL (AT Lisa 802, Carl Zeiss Meditec) and place it with an optic capture technique.

“The trifocal IOL I had planned to use has a plate haptic design and would not fit well into the sulcus,” Dr. Kohnen explained. “Therefore, I ordered a bifocal IOL with a three-piece design for implantation with optic capture.”

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The dropped lens material was removed from the vitreous through 23-gauge pars plana vitrectomy, and the bifocal IOL implanted in the sulcus through a slightly enlarged incision with a posterior optic capture technique.

On the first day after surgery, the patient had significant corneal edema and distance uncorrected visual acuity (UCVA) was only 0.1. On day 4, she had slight corneal edema and distance UCVA was still only 0.3.

On day 14, UCVA at distance, intermediate and near was 0.2, 1.0, and 0.63, respectively. However, distance best-corrected visual acuity (BCVA) was 1.0, and refractive error was the cause for the unsatisfactory uncorrected vision. The patient’s refraction was -2.0 -1.0 @103°, and on examination at the slit-lamp after pupil dilation, the cause was determined to be loss of the optic capture.

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“The patient was quite unhappy because she had a perfect refractive and functional outcome in the first eye,” Dr. Kohnen said.

Considering the patient desired spectacle independence, she was taken back to the operating room for a reattempt at optic capture, which was completed successfully.  At 1 week after the revision, the patient had only slight residual myopia in both eyes (-0.25 D). Her UCVA at distance, intermediate, and near in the right eye was 1.0, 0.63 and 0.8, respectively.

“I learned from this case that the combination of a bifocal and a trifocal IOL can work well, and I have used it with success in a subsequent patient,” Dr. Kohnen added.

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Thomas Kohnen, MD

E: kohnen@em.uni-frankfurt.de

Dr. Kohnen consults, lectures for, and receives research support from Carl Zeiss Meditec and other companies that market IOLs and femtosecond lasers for cataract surgery.