Techniques and Principles of Surgical Management for the Traumatic Cataract

Cataract Surgery, 3rd Edition

PART V – Special Techniques for Cataract Extraction

Chapter 30 – Techniques and Principles of Surgical Management for the Traumatic Cataract

Michael E. Snyder, MD,
Robert H. Osher, MD

Contents

	•	Introduction
	•	Clinical Evaluation
	•	History of the Injury
	•	Examination
	•	Cataract Surgery in the Acutely Traumatized Globe
	•	Cataract Surgery and the Acute Operative Intervention
	•	Surgical Planning and Technique
	•	Demonstrative Cases
	•	Conclusion

CHAPTER HIGHLIGHTS

	≫	Preoperative assessment and surgical planning
	≫	Modifications in surgical technique
	≫	Use of hooks, rings, and segments
	≫	Case studies

Introduction

Management of the patient with a traumatized anterior segment often poses challenges both at initial evaluation and in the operating room. Traumatic cataract commonly occurs with severe penetrating ocular trauma, but may also result from blunt injury by, for example, snowballs, waterballoons,^[1] and airbags.^[2] Athletic events and other seemingly harmless everyday activities may also give rise to traumatic cataracts. In a particularly peculiar case, a golfer sustained a large corneal laceration teeing off when a bird flew into his eye! Traumatic injuries are thus, by their very nature, highly variable and the extent of damage can be difficult to determine at the initial presentation. The anterior segment injury may appear either much less or much greater than it actually is. Furthermore, concurrent posterior segment damage may require vitreo-retinal intervention which may precede, follow or be concurrent with the cataract operation, necessitating communication and coordination with the vitreoretinal surgeon. Traumatic cataracts are among the most technically demanding cases that the anterior segment surgeon may face. As with all surgeries, preparation and planning for any anticipated or unanticipated intraoperative events will serve to maximize both the patient's outcome and the surgeon's comfort with the operative procedure.

In acute, severe injuries, preparation may include delving a bit into the psyche of the injured patient, allowing the surgeon to provide appropriate counseling, emphasizing the unpredictable nature of these cases and the reasonable short-term and long-term expectations. The patient began with “normal vision” and may anticipate returning to pre-injury status; however, this may or may not be possible in any given case. While it is important to offer reasonable hope, the authors would advocate the “underpromise and overdeliver” philosophy.

The goal of this chapter is to outline a careful, systematic approach to surgery for traumatic cataract and to describe several surgical techniques which may be helpful in these challenging settings.

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Clinical evaluation

Careful preoperative evaluation of the patient with a traumatic cataract is essential in gaining a complete understanding of the disrupted ocular anatomy and for anticipating events which may occur in the operating room. The goal of the preoperative evaluation is to assess the degree of ocular damage, formulate an operative plan, and determine all potentially needed instruments, equipment, sutures, and implants in advance. Careful preoperative planning should reduce the number and degree of intraoperative surprises, thereby enhancing the surgeon's comfort with the operation and maximizing patient's visual outcome.

History of the injury

In the acute setting, the preoperative evaluation should include a careful history of how the injury occurred. The force and mechanism of the injury may give clues as to whether an occult perforation or intraocular foreign body may exist or whether coexisting posterior segment damage should be anticipated. Metal-on-metal injuries should raise suspicions of an iron-containing intraocular foreign body. In cases of an open globe, inquiry about the environment where the injury occurred may provide clues as to the presence of potentially infectious or inflammatory material. Keep in mind that the history of events surrounding the injury may be unreliable when provided by children. In our experience, children and adolescents may not be entirely forthright initially and often the real story is not disclosed for weeks or months. The implication for the clinician is the need to maintain a high degree of vigilance and refrain from eliminating any possibilities based on the history provided by a child.

Some cases of traumatic cataract will present months, years, or even decades after the injury; the patient may have long forgotten the details or even the occurrence of the injury and may remember details only after the surgeon has posed several probing questions.

Examination

This section will review those components of the ophthalmic examination that are particularly relevant to cases of traumatic cataract.

Assessing visual function

The examination should, of course, always begin with an assessment of visual acuity. Ideally, this will be a best-corrected Snellen visual acuity tested in the controlled setting of the office environment. Of course in acute trauma this ideal situation may not present itself. When testing reveals hand motions or light perception vision, the ability to identify colored light gives some prognostic information about macular function. Confrontational visual fields give very helpful information, but are not possible in eyes with mature cataracts. The patient's response to the Purkinje phenomenon may provide indirect evidence about whether the retina is attached or detached or if glaucomatous or visual field loss may be present. The authors once examined a patient with a mature cataract who noted the Purkinje phenomenon only in the nasal visual field. An MRI disclosed an otherwise asymtomatic pituitary tumor! Simlarly, Carp et. al. reported a patient who presented 3 months after an ocular injury with a monocular nasal hemianopia confirmed by Humphrey 24-2 testing. The hemianopia resolved completely following extraction of a posterior subcapsular cataract.^[3] Purkinje testing is contraindicated in the presence of an open penetrating wound.

For evaluations performed in the emergency room formal Snellen assessments may not be possible. It is possible, however, to document light perception, hand motions, count fingers … all the way up to “recognizes faces” or even “reads 14 point print on hospital consent form.” Though visual acuity measurements can underestimate visual potential in the setting of acute penetrating trauma, proper documentation and patient/family counseling may protect the surgeon from inaccuracies in a patient's or family's subsequent recollections of the severity of the initial injury.

As the only objective measure of visual function, assessment for an afferent pupillary defect should always be ascertained. While assessment of the pupillary response can be extremely helpful in predicting prognosis, it is not always easily performed in the acute setting on an anxious patient with an open globe. Since traumatic mydriasis, miosis, and frank iris tears or incarceration may limit the function of the involved pupil, the ophthalmologist should always remember that visualization of only one pupil is required to determine the presence or absence of an afferent pupillary defect. Significant efforts to simultaneously open both lids should be avoided if it is likely to result in the patient squeezing them closed.

Biomicroscopy

Slit-lamp biomicroscopy provides extremely helpful information for the operative intervention. First, the anterior chamber may be studied for possible vitreous prolapse or retained intraocular foreign body. The presence and degree of iris damage or loss can be assessed and, of course, the crystalline lens can be scrutinized. In fact, the traumatic origin of cataract is sometimes revealed by noting the subtle findings of a gap between the iris margin and lens surface or decentration of the Y-sutures relative to the pupil center. Phacodonesis, frank decentration, and zonular loss should be carefully documented in both location and degree. When the lens capsule is visibly damaged, the extent of a tear should be carefully delineated and recorded. A corrugated appearance to the lens capsule may indicate compromised capsular or zonular integrity. The anterior lens capsule can be ruptured even in cases of blunt (non-penetrating) trauma.^[4] The surgeon should already be thinking about how a capsulorrhexis might be able to incorporate the defect. An anterior capsule tear will typically enlarge as the lens material swells. Therefore, if a defect is near the margin to which it could be incorporated into a capsulorrhexis, intervention might be expedited. Posterior capsular breaks can, similarly, occur with either penetrating or blunt trauma;^[5] though this may not be apparent on clinical exam, since cataract formation may limit the examiner's view.

Some biomicroscopic findings may be fairly obvious in some cases. Netland and colleagues describe a case of dislocation of the crystalline lens into the anterior chamber following blunt injury.^[6]

In the setting of an open corneoscleral laceration, careful preoperative evaluation at the slit lamp may be either impractical or impossible, making surgical planning much more challenging.

Ophthalmoscopy

Funduscopic evaluation (when view permits) should include an evaluation for retinal holes, tears, or commotio. Subretinal or suprachoroidal hemorrhage may portend a more guarded prognosis. When any suprachoroidal hemorrhage is present, the surgeon should expect positive posterior pressure in surgery.

Special testing

When a “mature,” opaque cataract is present, B-scan ultrasonography is instrumental in the surgical planning. First, the B-scan can provide crucial information about the status of the posterior lens capsule. In one case of mature cataract following penetrating injury, B-scan ultrasonography confirmed a displaced rupture of the posterior lens capsule (Figure 30-1). In addition to confirming the posterior segment status, B-scan information may alter the surgeon's approach to removing the cataract. When a suprachoroidal hemorrhage is detected, for example, the anterior segment surgeon should exercise caution in considering a pars plana approach for anterior vitrectomy. If possible, intervention should be delayed until the hemorrhage has resolved. If a large suprachoroidal hemorrhage is present, vitreoretinal consultation is recommended, since drainage may be required. Though the drainage procedure is not particularly difficult, subsequent retinal detachment may occur as the choroidal mounds flatten. Ultrasound testing can also demonstrate vital features in the anterior segment. Sathish and colleagues reported a patient who sustained an anterior scleral rupture with ultrasound-documented dislocation of the crystalline lens into the subconjunctival space.^[7]



Figure 30-1 This B-scan ultrasound demonstrates a full thickness laceration of the lens with discontinuity of the two hemispheres. This case is described in detail in Demonstrative case number one at the end of the chapter.

If the surgeon suspects an intraocular or intraorbital foreign body, CT scan imaging of the orbits with thin slices is indicated. CT scanning may have some role in diagnosing traumatic cataract in the setting of acute trauma. One study reports that a low attenuation of the lens is diagnositic of current or near-term development of visually significant cataract.^[8] In that study, no patients with normal attenuation developed cataract within 1 year. The ophthalmologist should be aware of another study which demonstrated that an intumescent cataract may appear invisible on CT scan, giving a false impression of traumatic aphakia.^[9] MRI scanning is not particularly helpful in the management of the traumatic cataract patient and could cause serious damage if a ferromagnetic foreign body is present in the eye or orbit.

Cataract surgery in the acutely traumatized globe

While some articles advocate primary cataract extraction at the time of an open globe repair,^[10] there are advantages to a staged approach. First, there are many instances where corneal clarity, anterior chamber hyphema, clot or disorganization of the anatomy may obscure the view of anterior segment structures and may lead to unanticipated complications. Further examination and testing after repair of the primary laceration can lead to more accurate surgical planning. Second, at the time of an open globe injury, keratometry and biometry of the affected eye are virtually impossible, and usually the patient is unable to cooperate maximally for accurate A-scan and keratometry measurements of the contralateral eye. This may lead to a greater likelihood of significant ammetropia or anisometropia in what might be an otherwise optimal visual result.

Occasionally, the degree of injury to the lens may appear greater at the initial presentation, but, in fact, it may not require cataract extraction. One patient presented emergently to the authors with a full-thickness central corneal laceration that penetrated the anterior capsule of the lens. The cornea was closed primarily and cataract extraction was not performed. The lens capsule sealed over and developed only a small, focal cataract. The patient retained 20/20 vision and was asymptomatic. Pieramici and colleagues reported five cases in which peripheral lens perforation occurred and lens clarity was maintained using a lens-sparing approach for intraocular foreign body removal.^[11] They noted that some inert (glass) foreign bodies were well tolerated without removal. Conversely, any potentially iron-containing foreign body should be removed since an iron-containing intralenticular foreign body may result in ocular siderosis with potentially devastating visual consequences.^[12]

Cataract surgery and the acute operative intervention

There are, of course, certain occasions where cataract surgery at the time of primary open-globe repair is absolutely indicated. First, when traumatic cataract obscures the view for removal of a known intraocular foreign body, cataract extraction should be immediate, particularly when the foreign body may carry vegetable or other contaminated material. Delayed treatment of an intraocular foreign body significantly reduces the chances of a favorable outcome.^[13] If the foreign body is in the posterior segment, the anterior segment surgeon should work in combination with a vitreoretinal surgeon. Preferably, the traumatic cataract should be removed using an anterior approach. Pars plana lensectomy leads to more capsular damage and may commit the patient to aphakia unnecessarily or result in the need for a sutured posterior chamber intraocular lens (PC IOL). If the posterior segment surgeon feels strongly that a pars plana approach lensectomy is required for vitreoretinal reasons, efforts should be made to retain as much capsular support as possible.

Also, some patients may have medical conditions which may significantly increase their anesthetic risks, making a single general anesthetic episode more desirable. In these instances an expeditious primary extraction is appropriate, though the surgeon should remember that the alternative of a secondary procedure may often be performed under regional anesthesia with a lesser anesthetic risk.

Preoperative patient counselling should be directed at setting realistic expectations based on the available prognostic information.

Surgical planning and technique

Ideally, the surgeon should be able to plan the case well in advance so that the operative procedure is one that has been mentally rehearsed. This means anticipating each surgical step to the best degree possible preoperatively. The first decision in any operative plan is the selection of the anesthetic approach. In traumatic cataract cases, the surgeon will usually be choosing between general and local anesthesia. For open-globe situations, general anesthesia usually provides greater safety. In the setting of a secure globe, the decision about regional or general anesthesia may be based on factors relating to the patient's ability to cooperate and the anticipated length of the procedure. Topical anesthesia should be reserved for only the most straightforward traumatic cataract cases. If significant posterior pressure is anticipated, intravenous mannitol administered in the holding room may be helpful. Though some informal, anecdotal teachings suggested a link between intravenous mannitol and suprachoroidal hemorrhage, formal studies have not identified mannitol as an independant risk factor. Traumatic eye injury, though, is a well-documented risk for suprachoroidal hemorrhage.^[14,][15]

Selection of wound location

Once anesthetic concerns have been addressed, the surgeon needs to select the planned location of the scleral or corneal wound. The wound should preferably be positioned in the area of the most normal anterior segment anatomy. A cataract incision placed over a zonular dialysis will make scleral suturing of a modified, Cionni capsular tension ring or sutured posterior chamber implant unneccessarily more difficult. Furthermore, the surgeon will be working directly over an exposed hyaloid face, increasing the chances of disturbing the vitreous. Sometimes a steep orbital rim will mandate a temporal approach, though if the traumatic wound crosses the temporal limbus, this area should be strictly avoided for the cataract incision. In such a case, an inferior incision may be considered. If the factors described above do not limit the surgeon's choices of wound location, then astigmatic considerations may be taken into account. The planned wound location will usually dictate the most appropriate orientation of the surgeon's operating position.

Managing the conjunctiva

Often in traumatic cases, the additional strength of a scleral tunnel wound is preferable, since a larger incision may be required if the surgeon has selected a polymethylmethacrylate (PMMA) implant. While the conjunctival incision is not the most glamorous part of the procedure, careful consideration should be given to the location and extent of the peritomy. The conjunctival openings should allow ample access to the planned scleral tunnel wound sites and, additionally, should include access for a pars plana sclerotomy or a site for scleral suturing of a PC IOL or modified, Cionni capsular tension ring. While adequate access is of vital importance, uninvolved conjunctiva should be respected, since several traumatic cataract cases may find themselves seeing a glaucoma specialist at some point in the future.

Viscoelastic options

Selection of the viscoelastic agent for a traumatic cataract case depends on several factors. In some cases more than one agent may be appropriate. When the intact hyaloid face is partly exposed, a dispersive viscoelastic agent such as Viscoat (Alcon, Fort Worth, Texas) or Healon D (AMO, California) may tamponade the vitreous and keep it back^[16] (Figure 30-2). The highly retentive agents are also excellent endothelial protectants. This may be particularly relevant to cases in which the endothelial cell density has been reduced by the trauma.^[17] The space-retaining qualities and ease of removal typical of highly cohesive viscoelastic agents, such as Healon GV and Healon 5 (AMO, California), make these agents more facile for the lens implantation stage of a procedure. In some cases one may choose the “soft shell” technique,^[18] which combines the added endothelial protection of a highly dispersive agent with the space-maintaining abilities, ease of removal, and clarity of the cohesive agents. The “soft shell” is created by loosely filling the corneal dome with a dispersive viscoelastic, then instilling a cohesive viscoelastic just in front of the crystalline lens. This presses the dispersive agent against the corneal endothelium, creating a thin protective layer. The soft shell approach should be used cautiously when vitreous tamponade is desired since the cohesive agent may thin or displace the protective “plug” in front of the vitreous.



Figure 30-2 A dispersive viscoelastic can create a “plug” to protect an exposed hyaloid face.

Some surgeons prefer a “pseudoplastic” agent such as Healon 5 with outstanding space-maintaining properties. At higher aspiration flow rates, the cohesive agent sheers, providing properties similar to the dispersive materials. Healon 5 holds promise for use in traumatic cataracts; however, the authors’ experience in this setting is still in the early stages and any surgeon should be alerted to the possibility of greater intraocular pressure elevation if any agent remains in the globe at the completion of the procedure.

DisCoVisc ® (Alocn, Fort Worth, Texas) has recently been added to the authors’ ophthalmic viscosurgical device (OVD) armamentarium. This agent contains a mixture of hyaluronic acid and chondroitin sulfate and, accordingly, maintains significant dispersive and cohesive properties of each.

When “dry” lens material aspiration under viscoelastic is anticipated,^[19] highly dispersive viscoelastics tend to clog the cannula for manual aspiration techniques while Healon GV and Healon 5 tend to follow into the tip of the cannula preferentially to the lens material and, in fact, can inhibit aspiration of cortex. In this setting, Healon, Provisc, and Discovisc may be more suitable.

The capsulotomy

The anterior capsulotomy often determines the ease or difficulty of the cataract removal. Sometimes, the traumatic injury may have caused either an anterior capsular defect either from a blunt rupture or a sharp laceration. The opening may provide direct access to the lens material, yet every effort should be made to convert the capsular tear into an intact capsulorrhexis. A complete capsulorrhexis has far superior mechanical integrity to either a can-opener capsulotomy or a partial capsulorrhexis^[20] and will improve the safety of each subsequent step of the operative procedure.

Microinstrumentation 23- and 25-gauge forceps are available in both reusable and disposable formats, and can be very helpful in completing a capsulorrhexis through a paracentesis, perhaps placed in an area of particularly tough or thickened capsule.

Occasionally, a vitrector may be useful in creating an anterior capsular opening. This type of capsulotomy has a greater structural integrity than a can-opener, but is not as desirable as a complete capsulorrhexis.^[21] The vitrectorrhexis technique can be less facile in practice than in theory since the lens capsule is not always easily aspirated to the cutting port. Moreover, when the capsule is engaged in the port, marginal zonules may be compromised.

Visualization for the capsulorrhexis may be much more difficult in cases of traumatic cataract, particularly when the capsule is torn or the cortex is opaque. Several dyes have been recommended to aid in visualization of the anterior capsule, including fluorescein,^[22] methylene blue, gentian violet,^[23] crystal violet, trypan blue,^[24] and indocyanine green (ICG).^[25]Clinically, ICG (IC Green, Akorn, NJ) and trypan blue (Vision Blue, Dutch Ophthalmic Research Corporation, Netherlands) are extremely helpful and have acceptable safety profiles^[26](Figure 30-3). The initial descriptions of ICG recommended instillation under air. However, the authors have found that when the capsule is intact, gently painting a drop of ICG or trypan blue across the anterior capsule under viscoelastic is equally effective. The “three step” technique stains the capsule by creating a fluid layer of BSS over the capsule and under the OVD-filled anterior chamber.^[27] The stain may even delineate the edges of a torn capsule. Trypan blue has an impressive safety profile and may be directly irrigated into the anterior chamber, then diluted with balanced salt solution (BSS). In the presence of a zonular dialysis, however, trypan blue entrance into the vitreous cavity can reduce or eliminate the red reflex. Focal placement of DisCoVisc over the dialysis can create a “plug” and prevent inadvertent migration of the dye into the posterior segment. Fluorescein has a high index of safety, but stains the capsule only weakly and tends to cause a diffuse yellow appearance of the operative field which may limit visualization of subsequent steps. Methylene blue and gentian violet have a known cytotoxicity.^[28]



Figure 30-3 Indocyanin green (ICG) (left) or trypan blue (right) can be used to stain the anterior capsule for greater visibility in the white cataract.

Tangential illumination of the anterior capsule using a sterile endoilluminator probe may also facilitate visualization for capsulotomy with a white lens. Metz^[29] and, subsequently, Gimbel and Willerscheidt^[30] reported aspirating liquified, white cortical material through a tiny, central capsular opening to decompress the capsular bag in cases of intumescent white cataract. This may decrease the tendancy for peripheral extension by lowering the endocapsular pressure.

The surgeon should exercise meticulous technique in creating a capsular tear in traumatized lenses. Zonular countertraction may not be uniform so the physics of creating the tear are slightly different to the usual case. The surgeon should make special efforts to have the leading edge of the capsular flap folded over in order to control the path of the tear more predictably (Figure 30-4).



Figure 30-4 If the anterior capsular flap is folded over, the surgeon will have greater control over the direction of the capsular tear. Indocyanin green (ICG) was used in this case to better demonstrate the capsular flap. In this case, the ICG was administered under viscoelastic and some residual dye is visible within the viscoelastic material.

If significant zonular instability is present, the surgeon may use a side port instrument to stabilize the lens nucleus during capsulorrhexis. A “pincushion” appearance of the anterior capsule noted before the cystotome penetrates through the capsule is an indicator of diffuse zonular laxity. The anterior capsulorrhexis in children with traumatic cataract may be even more challenging than their adult counterparts since the pediatric lens capsule has a stronger and more elastic consistency. For these patients it may be easier to plan to make the capsulorrhexis smaller initially and enlarge it later if needed, since these capsules have a greater tendency toward peripheral extension of the circular tear.

Nucleus removal

Removal of the lens nucleus can be addressed by a number of different techniques, each of which has potential advantages and disadvantages, depending on the setting. In a young patient the nucleus is usually very soft and is amenable to many different options. For a patient with an intact capsulorrhexis, phaco-aspiration of the nucleus is typically safe and expeditious. If an anterior or posterior capsular tear is present, then manual aspiration with a Simcoe-style cannula affords greater control (Figure 30-5). “Dry” aspiration of the soft nucleus under viscoelastic material offers exquisite control, especially in the most complicated cases.^[15]



Figure 30-5 The remaining white cortical material within the capsular bag is aspirated manually with a 27-gauge cannula in a “dry” fashion. Viscoelastic material protects the exposed hyaloid face in an area of pre-existing posterior capsular tear seen just up and to the left of the cannula tip.

Since the nucleus is denser in older patients, its removal will require a more challenging disassembly. The superior control of a small incision, closed-system approach to nucleus removal shines particularly brightly in cases with distorted anatomy and potentially weakened zonules. Since traumatized eyes are at greater risk for suprachoroidal hemorrhage, maintaining a closed system reduces the chances of the catastrophic expulsive consequences. Furthermore, a closed system allows compartmentalization within the anterior segment. If the posterior capsule is broken or if a zonular dehiscence is present, viscoelastic tamponade of the vitreous can be best maintained in the setting of a closed system. Manual extracapsular cataract extraction and manual phacosection techniques require an open wound and thereby compromise an important degree of control over the intraocular environment.

The technique of phacoemulsification may vary somewhat depending on the surgeon's usual approach, though some important principles should be incorporated into these special traumatic cases. A cautious respect for the zonular support in the traumatic cataract should guide the surgeon away from choosing a “phaco-flip,” “chip-and-flip” or other technique which may exert trampoline-like pressure to the zonular apparatus, even when no frank zonulodialysis is detected preoperatively. Many variations of gentle divide and conquer techniques or phaco-chop techniques can be modified to incorporate the principles of “slow motion phaco.”^[31]

Phacoemulsification in the presence of zonular compromise

In some patients with very weak zonules, grooving for a divide and conquer, and other endocapsular manipulations, may stress the already compromised capsular support. A relatively large capsulorrhexis will facilitate viscoexpression of the nucleus into the anterior chamber. Alternatively, a very gentle chopping procedure is protective to the remaining intact zonules since all applied forces are borne by the chopper instrument, the nucleus, and the countertraction of the phacoemulsification handpiece.

When severe zonular damage is present, the surgeon can use a capsular tension ring to help stabilize the lens nucleus before phacoemulsification begins. In order to facilitate endocapasular ring placement, cortical cleaving viscodissection will create the potential space for the ring to pass into the capsular bag. When more than 4 clock hours of zonular damage is present, the modified Cionni capsular tension ring (Morcher, Germany) adds suture fixation to the area of greatest zonular weakness^[32] (Figure 30-6). The authors have found that it is easiest to load the suture through the fixation eyelet prior to ring implantation, then to pass the transcleral sutures in an ab-interno fashion once the fixation element has been guided into the proper meridion. Suture fixation improves the lens stability for the remainder of the case. If the lens nucleus is particularly large and dense, it may be difficult or impossible to place the endocapsular ring prior to phacoemulsification. In such cases the surgeon can temporarily augment the native zonular support with flexible nylon “iris” retractors placed through a limbal incision to engage the capsulorrhexis margin (Figure 30-7). The retractor can be placed through a paracentesis tract, though a pathway may be created with a curved S-14 spatula needle placed perpendicular at the conjunctival insertion, entering the anterior chamber just above the iris insertion. This method of placement creates less anterior movement of the lens–capsular complex, thereby providing a deeper anterior chamber to work in. The tract of an S-14 needle is self-sealing. Once the nucleus is emulsified, the endocapsular ring may be placed with greater ease.



Figure 30-6 A, A modified (Cionni) capsular tension ring in situ within the capsular bag. The fixation eyelet courses in front of the capsulorrhexis margin. The sutures have not yet been passed through the sclera. B, The position of the fixation element is seen after the fixation sutures have been tightened. The second light reflex is the second Purkinje-Sanson image from the front surface of the well centered intraocular lens. C, The appearance of the eye at the end of the procedure.



Figure 30-7 Flexible “iris” retractors can be placed to stabilize the capsular bag for phacoemulsification when zonular support is compromised. After the phacemulsification, the capsular tension ring can be more easily inserted.

Though not yet available in the United States, the Ahmed segment (Morcher GmbH, Germany) is an excellent approach to stabilize the loose lens either prior to or after the phacoemulsification of the nucleus.^[33,][34] The Ahmed segment has the same fixation element as the Cionni CTRs, but is only a 120° arc instead of a complete ring. Its smaller size makes it more facile to insert into the capsular bag, particularly when the bag still contains nuclear material.

Theoretically, the capsular tension ring could be inserted after a posterior capsular break if both an intact anterior and posterior capsulorrhexis were present. Capsular tension ring placement should not be considered with any other setting of anterior or posterior capsular break. If a capsular tear or break were to occur with the endocapsular ring in situ, the device should be promptly retrieved from the anterior segment since its stability is no longer guaranteed.

Cortical removal

Once the lens nucleus has been successfully removed, the capsular bag should be inspected carefully for integrity. Isolated posterior capsule rupture has been reported as a result of blunt injury.^[35–38] When the capsular bag and zonular apparatus are intact, cortical removal can be routine, but when zonular damage is present, the cortex is best removed by a very gentle, controlled technique. Some of the principles discussed above for soft nuclei apply particularly well to cortical removal and will be reviewed in more detail here. If cortical cleaving hydrodissection was performed at the beginning of the case, this step may be much easier. If hydrodissection was incomplete or not performed, viscodissection can gently separate cortical material from the capsular bag^[39] (Figure 30-8). When an automated irrigation–aspiration method is used, teasing the cortical strands parallel to the zonular dialysis will be less likely to cause the intact zonules to unzip. The same principle applies to manual aspiration with a Simcoe-type cannula, which offers a greater degree of control within a stable chamber. If a posterior capsular break is present, a viscoelastic tamponade of the intact hyaloid face, combined with a manual “dry” aspiration with a 25- or 27-gauge cannula on a 3cc syringe in a chamber filled with viscoelastic material, can facilitate complete cortical removal without vitreous loss. The exquisite control of the dry aspiration technique offsets the more tedious and time-consuming nature of this approach.^[23]



Figure 30-8 Cortical cleaving “viscodissection” can separate the lens material from the capsular bag, making the cortex easier to remove.

Removal of lens material with vitreous prolapse

Vitreous in the anterior segment alone or admixed within the lens material increases the risk of posterior segment complications. It is not uncommon for penetrating injuries to go through the lens and into the vitreous. If the penetrating object is withdrawn, vitreous may be pulled into or through the lacerated crystalline lens. The surgeon should always try to avoid aspirating any vitreous material. Any traction on the firm attachments of the anterior vitreous to the vitreous base can create a retinal break and subsequent retinal detachment. If there is extensive loss of zonular support and the capsular remnants are severely lacerated, a pars plana lensectomy with vitrectomy may be the most appropriate course.

When vitreous is identified within the lens material but the lens support and peripheral lens anatomy are relatively intact, some special anterior segment approaches are indicated. First, any vitreous which has prolapsed through the laceration or surgical wound should be removed with an automated vitreous cutter. A dry vitrectomy can be performed at the wound site by placing the cutting port against the scleral or corneal opening. This will effectively remove any external vitreous without creating traction. The machine settings should have relatively low flow and low vacuum.

Next, the vitreous cutter can be placed into the anterior chamber and a gentle anterior vitrectomy can be performed to remove the vitreous material from the anterior segment and sever any incarcerations or attachments to the anterior segment wounds. Coaxial irrigation on the vitrector handpiece can blow the vitreous away from the cutting port and thus cause unneccessary flow through the anterior chamber. Bimanual or split infusion via a separate paracentesis site is preferable using a 21-guage butterfly or blunt cannula to allow control of the direction of the irrigation stream.

When the anterior chamber is clear of vitreous, attention is turned to the removal of the lens material. When the lens material is soft, it may be aspirated via the vitrector handpiece on “I/A cutter” settings so that the instrument behaves as an I/A device until foot position three, in which cutting action is engaged. Use of the vitrector handpiece adds additional safety when vitreous may be admixed with lens material since, if an errant strand of vitreous finds its way to the aspiration port, cutting may be immediately initiated, thereby releasing vitreous traction.

Dry cortical aspiration

If zonular damage is present and exquisite control is required, a “dry “aspiration technique under a chamber filled with viscoelastic can be carefully performed. A moderately cohesive viscoelastic agent can be injected to deepen the chamber. Special caution should be used to place the viscoelastic agent at the wound first and not to overfill the chamber. If too much viscoelastic material is injected, the increase in the intraocular pressure may cause vitreous to prolapse through the wound during instillation. The aspiration is most effective introducing a 25- or 27-gauge cannula into the soft lens material with the cannula tip placed as far from the capsular break as possible. The lens material can be carefully stripped and aspirated, working from the area most distal to the capsular break. If vitreous is engaged at any point it must be immediately released and additional vitrectomy is performed.

Dense capsular plaques

Not infrequently, capsular plaques may line either the posterior capsule or, occasionally, the entire internal circumference of the capsular bag. Once an edge of the plaque is elevated, viscodissection, blunt dissection, and peeling of the plaque may result in a clear posterior capsule and clean capsular bag (Figure 30-9). Other times, a posterior capsulorrhexis may be created or, alternatively, YAG laser capsulotomy may be performed after surgery.



Figure 30-9 A, A dense capsular plaque is viscodissected from the capsular bag. The plaque encompasses the entire internal lining of the intact bag. B, Once the tightest adhesins have been lysed, the plaque can be peeled away from the capsule. C, The plaque is removed en bloc, leaving an intact and clear capsular bag.

Dense nucleus and an open posterior capsule

In the presence of dense cataractous lens material, phacoemulsification may be required. If the anterior segment has been entirely cleared of vitreous, an anterior chamber phaco over a bed of dispersive viscoelastic or a Sheets glide may be cautiously considered. In this setting, a side-port instrument should be used to support the lens material. Sheets glide placement technique should be meticulous, since inaccurate insertion can engage or tear remaining capsular support. The surgeon should consider that a Sheets glide can be very difficult to place from a clear corneal wound.

Preferentially, if a complete anterior capsulorrhexis can be achieved, slightly smaller than the IOL optic, then the nuclear fragments can be placed on the iris leaflet anteriorly, the cortex can be manually aspirated in a “dry” fashion, and the IOL can be placed in the ciliary sulcus. With posterior capture of the implant optic through the capsulorrhexis, the barrier between the anterior and posterior segments has been reestablished and anterior chamber phaco can be performed without concern for posterior dislocation of lens fragments (Figure 30-10).



Figure 30-10 A, A posterior capsular break (outlined in yellow) becomes evident as the last large nuclear fragment is held at the phacoemusification tip. The anterior chamber and bag were filled with viscoelastic material, tamponading the hyaloid face. The fragment was placed on the iris leaflet. B,The posterior chamber intraocular lens (PC IOL) was inserted into the ciliary sulcus. C, The optic was captured into the capsulorhexis reestablishing a barrier between the anterior segment and the vitreous. D, The nuclear fragment is safely emulsified without risk of posterior dislocation.

Kelman has proposed a technique which he calls “posterior assisted levitation” in which nuclear material is supported from behind via a second instrument placed through the pars plana.^[40] With this technique the surgeon should be vigilant in watching for vitreous at the port of the phacoemulsification handpiece. The surgeon should always avoid manual manipulation of the vitreous gel, since traction on the anterior vitreous base may lead to serious retinal sequellae.

Anterior segment clean-up

Once the lens material is removed, careful re-evaluation of the anterior segment for any anteriorly displaced vitreous should be carried out. If vitreous is identified, further vitrectomy should be performed. Once the anterior segment media permits a view through the pupillary space, vitrectomy through a pars plana incision, again with a split, anterior infusion can be utilized. The vitrector handpiece is placed through a sclerotomy created 3mm posterior to the limbus by a 20-gauge V-lance blade (Figure 30-11). Some 25-gauge vitreous cutters utilize a trocar system with equal effectiveness. The pars plana approach has several advantages over limbal vitrectomy. First, the vitreous material is aspirated posteriorly away from the anterior segment wounds. With anterior–irrigation and posteriorly placed vitrector aspiration, a localized pressure gradient occurs creating a flow from anterior to posterior, as desired. Pulling the vitreous back into the vitreous cavity creates less traction on the vitreous base and allows better access to subincisional vitreous, which may be coursing around the iris margin.^[41] Furthermore, when the vitrector handpiece is placed through the cataract incision, the corneal dome is more likely to be distorted, leading to suboptimal visualization. With the pars plana approach, the view through the cornea is excellent. Once an adequate vitrectomy has been completed, the 20-gauge sclerotomy should be cleaned externally (as described above) and then closed with a suture, for example, a figure of eight, 7-0 vicryl suture. Although the 25-gauge trocar opening can be left unsutured, but may result in transient undesired hypotony in a globe with at least one risk factor (trauma) for suprachoroidal hemorrhage.



Figure 30-11 Anterior vitrectomy is achieved via a pars plana approach. The automated vitrector is placed through a 20-gauge opening 3mm posterior to the limbus. Irrigation fluid is infused (blue arrows) through a 21-gauge butterfly needle placed through a corneal paracentesis tract. The prolapsed vitreous material is pulled back into the vitreous cavity and removed with the automated cutting device (open white arrows).

Managing the compromised capsule

When all lens material and any offending vitreous have been safely removed, the surgeon can breathe only a brief sigh of relief; they must then move on to assessing the degree of zonular and capsular support that remains. After filling the anterior segment with viscoelastic, the surgeon may gently retract the iris in order to directly visualize the underlying anatomy. When the anterior capsulorrhexis is intact, but a posterior capsular break is present, a few different options exist. Ideally, if the posterior capsular tear is small, some viscoelastic can be placed through the opening to retroplace the vitreous and the posterior tear may be converted into a posterior capsulorrhexis. This can preserve the capsular strength for endocapsular placement of a posterior chamber implant (Figure 30-12).



Figure 30-12 A three-piece acrylic posterior chamber intraocular lens (PC IOL) is placed wihin the capsular bag following posterior capsulorrhexis (PCCC). The anterior capsulorrhexis (black arrow) maintains its usual round appearance, while the PCCC (white arrow) becomes ovoid from the tension of the haptic on the fornices of the bag, inducing some striae (open white arrows) in the posterior capsule.

The experienced surgeon may be able to implant the IOL into the torn capsular bag even when the posterior tear cannot be safely converted to a capsulorrhexis, yet it may be safer to place the haptics of a three-piece posterior chamber implant into the ciliary sulcus. If the anterior capsulorrhexis is intact and measures 5mm or less, the lens optic can be prolapsed into the capsular bag, providing addition support and centration. In this setting, the implant power would be chosen as usually calculated. If both the optic and the haptics are in the plane of the ciliary sulcus, 0.5diopter should be subtracted from the calculated implant power. (Unpublished data presented at American Society of Cataract and Refractive Surgeons Annual Meeting, 1984.)

If significant capsular damage exists, a determination should be made as to whether there is enough support for the placement of a posterior chamber implant in the ciliary sulcus. The torn posterior capsular bag will often provide long-term fixation of an IOL, yet the surgeon must be capable of modifying the implantation technique in order to safely insert the lens without further damaging the capsular remnants. Special attention should be given to the inferior support since gravity may gradually rotate a horizontally oriented implant. When the lens is placed and found to be centered, the “Osher bounce test” can confirm stability. The optic is gently decentered toward each haptic, then released; the implant should spontaneously recenter. If capsular support is absent or deemed to be inadequate, the surgeon should consider scleral or iris suture fixation of one or both haptics of the posterior chamber implant. The techniques for this are covered in detail in Chapter 16.

Intraocular lens options

Once the cataract has been safely removed from the eye, the surgeon should consider the guidelines in the selection of an appropriate implant lens design and material. First, silicone-based lenses may increase the difficulty of future vitrectomy surgeries; therefore, they are a suboptimal choice if the injury has included the posterior segment.^[42,][43] Both PMMA and acrylic lenses are well tolerated by the eye and are preferred by the vitreoretinal surgeons.

Since traumatic cataracts are not uncommonly associated with some degree of traumatic mydriasis, a 6mm or larger diameter IOL optic seems prudent. Large optic diameters are also more forgiving in implant decentrations, which may be more likely in traumatic cataract cases.

When a sutured implant is required, a rigid, one-piece PMMA implant may provide additional stability and can be attached to the sclera with two- or four-point fixation, the latter decreasing the likelihood of tilt. A rigid implant, however, requires a larger incision. An implant with a fixation element on the apex of each haptic is preferable. Foldable acrylic lenses can be sutured to the ciliary sulcus as well, though with currently available implants only one suture can be affixed to each haptic, achieving just two points of fixation. An implant haptic and suture guard (patented by Michael E. Snyder, MD, Cincinnati, Ohio) will facilitate easier four-point fixation of a foldable PC IOL. This design has not yet been incorporated into a commercially available IOL.

One-piece acrylic lenses are suitable only for in-the-bag fixation. The surgeon should always consider the overall length of the IOL, since sulcus support cannot be predictably achieved using IOLs designed for endocapsular fixation, which have shorter overall lengths.

In cases where glaucoma is present and preservation of conjunctiva for an existing or future filtering bleb is paramount, the surgeon may consider an acrylic lens with a clear corneal incision.

Some experts discourage the use of anterior chamber implants, especially in the setting of a traumatized eye, since “modern” angle-fixated implants, even when perfectly positioned, will have some contact with the delicate uveal tissue of the ciliary body band and may induce a low-grade chronic cyclitis and, perhaps, cystoid macular edema. Moreover, the relationship to the trabecular meshwork is of concern when traumatic glaucoma is present. A recent study reported delayed-onset pupil deformity in 58% of patients with a Kelman-style anterior chamber implant.^[44] This may represent a chronic inflammatory or ischemic response. Furthermore, the anterior chamber implant lens optics may be smaller than the preferred 6mm or larger diameter. These angle-fixated lenses vault anteriorly in front of the iris plane, making the effective coverage of the entrance pupil even smaller yet, thereby accentuating the possibility of unwanted visual phenomena (such as halos, arcs, and edge glare). In some countries outside of the United States anterior chamber iris fixated “claw” lenses are popular (Artisan, Ophtec, Groningan, Netherlands).

The patient with a traumatic cataract who also has a reasonably good visual prognosis should not be dismissed from consideration for acrylic-based presbyopia-correcting IOLs.

Plate haptic silicone implants should be avoided in traumatic cataract patients. They are unforgiving in cases of capsular and zonular asymmetry, which may not be apparent at the time of surgery and, should YAG capsulotomy be required, the small size of the posterior capsule opening desired to prevent posterior dislocation^[45] may afford an inadequate view of the retinal periphery.

Intraocular lens placement

If the capsular bag retains its integrity, intracapsular placement of the implant is desirable. Even in the face of zonular damage, a few options exist for capsular fixation of the implant lens. As described previously, the capsular tension rings can be inserted at any stage of the procedure, providing that there is an intact anterior capsulorrhexis and the capsular bag is intact. If the ring is placed before complete cortical removal, special effort should be taken to avoid trapping cortical fibers in the fornix of the bag since they can be extremely difficult to remove. This is less problematic when the Ahmed segment is utilized, as the cortex can usually be stripped around either side of the 120° arc. If an endocapsular ring or segment is not available and only a small area of zonular dehiscence is present, one can orient the haptics of the implant along the axis of the weakness, unless it is obvious that the best centration is achieved in a different axis. Slowly unfolding the implant or gently placing a rigid lens will minimize the stress on the intact zonules.

Ciliary sulcus placement of a posterior chamber implant is still possible in the setting of a posterior capsular tear or zonular dialysis. If the anterior capsulorrhexis is intact, yet a severe posterior capsule break exists, the haptics should be placed in the sulcus and it may be possible to capture the lens optic posteriorly into the capsulorrhexis. This will provide adequate support and will prevent the lens from subsequently dislocating. If the capsulorrhexis is incompetent or larger than the implant optic then simple sulcus fixation with a large diameter implant can be utilized. If an inferior zonulolysis is present and capture within the rhexis is not possible, then suture fixation can add additional safety, since gravity may induce inferior lens migration over time (Figure 30-13).



Figure 30-13 The posterior chamber intraocular lens (PC IOL) optic is captured within the capsulorrhexis. The capsule was stained with indocyanin green (ICG). The lower haptic is fixated to the sclera by a suture. With this double fixation method the implant was well entered and secure.

Intraocular lenses and children

While many surgeons now commonly place intraocular lenses in children, the correction of aphakia in children remains somewhat controversial. Traumatic injuries typically affect only one eye and in uniocular aphakia, contact lens compliance may be even more poorly tolerated than in bilateral aphakes. Intraocular lenses can be safely tolerated in most children, even following trauma.^[46] Intraocular lens implantation may be significantly easier at the time of cataract extraction than at a later date, since iridocapsular adhesions and fusion of the anterior and posterior capsular flaps make a subsequent secondary implant procedure more challenging. In cases where the posterior capsule remains intact, the presence of an implant may reduce the risk of posterior capsular opacity^[47] and, should YAG laser capsulotomy be required, the implant will also prevent vitreous prolapse into the anterior segment. Furthermore, if we can extrapolate from the literature addressing implants in uveitic patients, an intraocular lens may decrease the chances of significant posterior synechiae.^[48]Scleral sutured posterior chamber implant lenses have been used successfully in children, although the long-term integrity of prolene sutures is still unknown.^[49] While the authors favor the use of implants in children, each surgeon must evaluate the merits of each implant option for each case. The informed consent discussion with the parent or guardian should include the fact that most intraocular lenses are still not approved by the FDA for use in children.

Some investigators in China have advocated the use of epikeratophakia for correction of pediatric aphakia following surgery for traumatic cataract. While they have had some promising successes, worldwide exprience with this approach is still limited. Epikeratophakia lenticules are currently not available in the United States.^[50] The authors feel that, currently, intraocular lenses remain the best option for the pediatric aphakia.

Iris repair and replacement

Unless the iris damage is extensive, preventing access to the lens or interfering with the operative procedure, the repair of iris defects can follow cataract extraction and lens implantation steps. The pseudophakos is significantly thinner than the intumescent cataract and, therefore, the anterior chamber is deeper allowing for more working space. Also, the long needles used for iris repair may inadvertentely engage lens capsule, cortex, or vitreous if the passes are placed early in the operative procedure. Gentle lysis of iridocapsular adhesions can be performed early; however, when the zonules are damaged, the iridocapsular adhesions may provide extra support during the capsulorrhexis and phacoemulsification.

Five types of iris injury can be present with trauma: holes, sphincter tears, iridodialyses, traumatic mydriasis, and partial or total loss of iris tissue. Repair of iris defects can be accomplished with transcameral 10-0 prolene sutures. A paracentesis location and orientation are selected so that passage of a long, curved needle can be easily directed toward the iris defect. The needle is gently wiggled into the paracentesis, taking care not to catch any stromal fibers. The tip of the needle engages one edge of the iris at the proximal margin of the tear. The tip then engages the distal iris leaflet (from the underside) and the needle is passed through the peripheral cornea. For iris sphincter tears, it is best to identify the cut margin at each side and to take a healthy bite of iris tissue (Figure 30-14). The suture can be tied within the anterior chamber with the sliding knot technique, as described by Steven Siepser, MD.^[51] Orientation of the suture ends is particularly important so that the suture will create a knot and not just a twist as the two ends are drawn together (Figure 30-15). We typically will use a double throw followed by a single throw. A locking knot can be achieved by alternate suture throw orientation.^[52] It is also possible to close an iris defect via a limbal incision using the basic technique described by McCannel.^[53]



Figure 30-14 The cut margin of the iris sphincter is identified. A, A 10-0 prolene suture on a long, curved needle is passed through the iris margin of each iris leaflet and then passed out the distal limbus. B, As the suture knot is secured, the pupil begins to return to a more normal shape.



Figure 30-15 Tying the sliding suture knot requires meticulous attention to suture orientation. First, the suture loops should be laid out on the globe as shown with the strand coming from the iris margin (iris strand) adjacent to the free (trailing strand) end. The free end of the trailing strand is passeddown through the retrieved loop (1), under the iris strand (2), down through the loop again (3), under the strand again (4), then over the trailing strand (5). The distal and proximal ends are pulled and the knot slides into the anterior chamber without causing any tension on the iris tissue. The knot is secured by a second retrieval and single or double throw.

Iridodialysis can be repaired by passing each needle of a double armed 10-0 prolene suture through the disinserted peripheral iris, then out the scleral wall at the iris root.^[54,][55] The knot can be tied externally and rotated internally (Figure 30-16).



Figure 30-16 A, A double-armed 10-0 prolene suture on a long, curved needle is passed via a corneal paracentesis through the disinserted peripheral iris at the junction between the middle and outer thirds, then out at the level of the iris insertion at the scleral wall. The white asterisk identified the site of the first suture pass; the yellow asterisk identifies the intended site of the second pass. Note that the peripheral iris anatomy is distorted by the needle during the suture pass. B, The second arm of the suture is similarly passed, a few milimeters from the first. C, As the suture ends are pulled, the suture loop is pulled into and across the anterior chamber. D, The suture is tied, achieving closure of the iridodialysis.

Traumatic mydriasis may result in postoperative glare from edge-related symptoms. A cerclage-type procedure can be performed to reduce the pupillary aperture.^[56,][57] While different techniques may be used to pass the suture through the iris tissue, each approach attempts to create either a segmental or circumferential purse-string of the iris margin.

When significant iris tissue has been lost, implantation of a diaphragm intraocular lens (Morcher and Ophtec), intracapsular iris rings (Morcher), occluding ring segments (Morcher), or the multipiece iris prosthetic system of Hermeking (Ophtec) should be considered. Details of iris supplements are beyond the scope of this chapter.

Membranous cataract and longstanding changes

Occasionally, a patient may present for evaluation of a white or brunescent cataract many years after a penetrating injury has occurred. In some of these cases, a significant portion of the lens material may have been resorbed; thus, leaving little separation between the anterior and posterior capsules. Special caution will prevent inadvertent entry into the vitreous cavity. The surgeon may occasionally encounter a fibrotic or calcified capsule or lens remnant requiring sharp incision and scissors dissection, and removal of the tough capsular material with the vitrector handpiece. Of benefit to the surgeon is the knowledge that longstanding traumatic capsular tears do not readily extend, as acute capsular tears tend to do.

Demonstrative cases

Case one

A 14-year-old boy accidentally struck his right eye while cutting a piece of rubber with a carpet knife. He had a corneoscleral laceration extending from the superior limbus through cornea, iris, and lens. The laceration deviated paracentrally 1.5mm around the corneal apex, severed the inferior limbus and ciliary body, and extended to just before the inferior rectus insertion. Vitreous was present at the limbus. The laceration was repaired primarily with automated vitrectomy performed at the scleral opening. Primary cataract extraction was not performed.

His clinical evaluation the next day revealed light perception vision with brisk identification of colored lights. The Purkinje phenomenon was present and no afferent defect was noted. The corneal wound was secure and the superior and inferior iris leaflets were bisected. A small amount of vitreous prolapse was noted at the inferior iris break. The anterior lens capsule was torn from the superior to inferior equatorial regions. B-scan ultrasonography showed a displaced rupture of the posterior crystalline lens (see Figure 30-1).

Problem list:

	•	Intumescent traumatic cataract
	•	Ruptured anterior capsule
	•	Ruptured posterior capsule
	•	Vitreous prolapse
	•	Lacerated iris
	•	Corneoscleral and ciliary body laceration (repaired).

The patient was brought back to the operating room 5 days later. A temporal wound site was chosen (the area of most normal anatomy). The corneal dome was filled with Viscoat Alcon, Fort Worth, Texas) and the anterior chamber was gently deepened with Healon (Pharmacia, Monrovia, California) in the “soft shell” technique. A 19-gauge cannula was placed via the superotemporal paracentesis site and the tip was placed into the peripheral lens material nasally where the lens anatomy was not damaged. Manual aspiration of lens material was undertaken in a “dry” fashion. Additional Healon was added serially to maintain the anterior chamber. The peripheral lens material was similarly removed from the temporal area via a nasal paracentesis. Viscoat was used to tamponade the anterior hyaloid centrally, allowing aspiration of the remaining central lens material. In this young boy, the soft lens nucleus was easily aspirated with a cannula alone. The area inferiorly around the prolapsed vitreous was carefully avoided. An inferotemporal pars plana sclerotomy was created and an automated vitrectomy was performed locally using irrigation via the superior paracentesis site. The small knuckle of vitreous was pulled back posteriorly and removed with the cutter device. The small bit of lens material in this region was removed with the vitrector handpiece. An acrylic foldable lens (MA60BM Acrysof, Alcon, Fort Worth, Texas) was placed into the ciliary sulcus, oriented horizontally, with excellent support. The iris was then repaired in a “closed chamber” sliding-knot technique. The viscoelastic was removed with the vitrector handpiece. Postoperative uncorrected visual acuity improved to 20/40.

Case two

A 25-year-old man presented with light perception vision in his left eye after hammering a nail that hit his left eye. Examination showed vague light perception vision and a questionable afferent pupillary defect. Testing was limited by poor cooperation. Brief glimpses at the slit lamp showed a central corneal full-thickness laceration. The anterior chamber was deep with an admixture of fibrin, heme, and, possibly, vitreous. The pupillary outline was irregular, but central. The status of the lens could not be ascertained.

Problem list:

	•	Central corneal laceration
	•	Vitreous prolapse?
	•	Lens status?
	•	Status of anterior choroid/pars plana?

The patient was brought to the operating room and the corneal wound was closed under general anesthesia. Vitreous was present outside the corneal wound and was carefully removed at the level of the laceration with the automated cutter. The lens was not removed.

The following day, vision was counting fingers and the corneal wound was secure. Vitreous streamed through the inferior portion of the lens to the back of the cornea. Condensing fibrin filled the anterior chamber. The crystalline lens was obviously lacerated and was starting to turn white. B-scan showed a clear vitreous, an attached retina, and no suprachoroidal hemorrhage. Steroids, cycloplegics, and antibiotics were administered. A-scan ultrasonography was performed on each eye and keratometry readings were obtained.

Problem list:

	•	Repaired central corneal laceration
	•	Vitreous through lens to posterior cornea
	•	Traumatic, lacerated cataract.

On post-injury day 4 the patient was brought to the operating room for cataract extraction, PC IOL implantation, and vitrectomy. A supero-temporal wound site was selected. The anterior segment anatomy was most normal superiorly and, additionally, a superotemporal incision would best offset the probability of future induced astigmatism from the corneal wound. (Typically, the steep axis will be perpendicular to the sutured laceration.) Two paracenteses were created, one superonasally and the other temporally. A bimanual (split irrigation) anterior vitrectomy was performed via these two sites to sever the bands of vitreous going to the corneal wound and to clear the vitreous from the anterior chamber. Healon GV was used to maintain the anterior chamber and for endothelial protection. The cataract material in the area of the lens laceration was removed with the vitrector handpiece on irrigation–aspiration cutter mode. This successfully cleared a view through the pupillary space. A pars plana sclerotomy was then created 3mm posterior to the limbus and the remaining vitreous material was cleared from the pupillary and retropupillary space. The remaining lens material was removed with the vitrector on irrigation–aspiration cutter mode. Examination of the capsular remains showed no support inferiorly and inferonasally. It was elected to suture a 6mm optic, single piece, PMMA posteror chamber implant to the ciliary sulcus. Miochol was instilled. The vitrector was used to remove the viscoelastic material from the anterior chamber.

The postoperative course was unremarkable and the patient achieved a suture-out 20/25 result with a −3.25+3.25 × 090 correction, despite the central, apical corneal laceration. Topographic astigmatism was regular. Neither corneal transplant nor contact lens was required.

Case three

A 66-year-old man sustained a blunt injury when a softball struck his right eye 2 years prior to evaluation. At his initial presentation, his right eye vision was counting fingers at 6 feet and his intraocular pressure was elevated to 36mmHg. An afferent pupillary defect was present. The slit-lamp finding showed a subluxated dense nuclear, cortical, and PSC cataract with obvious phacodonesis. Zonules were absent from 10 o'clock to 4 o'clock positions. Vitreous was prolapsed anteriorly around the lens equator and into the anterior chamber. A fundus exam showed a pale optic nerve head with no posterior segment details. Gonioscopy revealed 7 clock-hours of angle recession.

Problem list:

	•	Subluxated, dense traumatic cataract
	•	Vitreous prolapse
	•	Angle recession glaucoma.

The patient chose to undergo cataract extraction with endocapsular ring placement, IOL implantation, pars plana approach anterior vitrectomy, and trabeculectomy. First, the trabeculectomy site was prepared with a fornix-based flap. A superonasal paracentesis was created for anterior–irrigation. A pars plana sclerotomy was performed 3mm posterior to the 10:30 limbus. The prolapsed vitreous material was removed with the automated vitrector, pulling the vitreous back into the vitreous cavity (Figure 30-17). Viscoat (Alcon, Fort Worth, Texas) was placed to tamponade the remaining vitreous posterior to the lens. A capsulorrhexis was then performed and the lens nucleus was meticulously emulsified with a phaco-chop technique. The cortical material was aspirated with a Simcoe cannula and dry cortical stripping was performed. An endocapsular ring was placed. This resulted in nice recentration of the capsular bag. An acrylic implant (Acrysof MA60BM, Alcon, Fort Worth, Texas) was placed intracapsularly. The scleral tunnel was then pedunculated to create a scleral flap and several punches were taken from the posterior scleral rim. The flap was secured with releasable sutures and conjuctiva was closed. The final postoperative vision was 20/20 and intraocular pressure was 16mmHg. The patient retained this result at 2 year follow-up.



Figure 30-17 In this case of traumatic cataract, vitreous is prolapsed around the lens equator and into the anterior chamber. Asterisks outline pigment clumps along the edge of the prolapsed knuckle of vitreous anterior to the crystalline lens. The vitrector is placed behind the lens and the vitreous is pulled posteriorly out of the anterior chamber and removed with the cutter device. Folds in the lens capsule are not uncommon in cases of traumatic cataract.

Conclusion

Traumatic cataracts vary widely in nature, presentation, and degree of ocular comorbidity. With careful clinical evaluation and meticulous attention to surgical technique, these cases can often yield excellent visual, functional and cosmetic results. In fact, rehabilitation of these challenging cases can often be among the most gratifying services provided to patients.

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