Surgery: Phacoemulsification of a Dense Cataract with Synechiolysis and Fibrotic Anterior Capsule

Dr. Barber: This is a case of a 31-year-old African-American female, who was a type I diabetic for over 25 years. Who had proliferative diabetic retinopathy, which required two part plan a vitrectomy for the repair of tractional retinal detachments. She post-operatively developed chronic inflammation. As you can see here, there’s significant posterior synechiae and a dense white cataract.

So we’re using trypan blue, we did inject the trypan blue underneath the iris to try and cover as much of the anterior surface of the lens as possible. But now I’m doing a gentle synechiolysis by injecting viscoelastic between the iris and the capsule and then gently lifting up. Carefully being attentive to not tearing the anterior capsule.

As you can see, the eye is soft, despite viscoelastic placement. So again, synechiolysis is performed, the synechiae are being broken by injecting viscoelastic doing a visco-dissection and then also lifting anteriorly. Again, being cautious to protect the capsule and not tear it.

Despite the synechiolysis, we only have a two to three millimeter pupil diameter.
Therefore, I elected to use a Malyugin Pupil Expansion Ring. Again being careful to not damage the anterior capsule, inserting all four of the eyelets of the Malyugin ring onto the iris during insertion. And then repositioning the Malyugin ring into a central location.

You’ll notice that the anterior capsule has a dense fibrotic plaque, which will further complicate the ability to make a capsulorhexis. So I’m starting centrally, lifting up, I notice that the entire anterior capsule feels very tough and fibrotic, and is not tearing normally.

I choose to go clockwise, carefully watching the capsulorhexis until it hits this fibrotic plaque and becomes very difficult to tear the capsule from this subcapsular plaque. Therefore, I use a cystone to go back to the 6 o’clock position and attempt to make a nick in the capsule, to creating a flap. And will now try a counter-clockwise approach. Continue to place more viscoelastic, keep the chamber as stable and as filled as possible. This point I’m tearing the plaque with the capsule, and the anterior capsule tends to run out peripherally, so I place the flap back down and then pull it centrally. And this is the technique I prefer to use to save a capsulorhexis that is wanting to run out peripherally. The capsulorhexis did go out underneath the iris for just a millimeter or two, but we were able to safely bring it back to the center.

Now using a Chang cannula to provide hydrodissection. There are multiple adhesions with this lens to the capsule, despite fairly aggressive hydrodissection. Using a push and pull technique to loosen the nucleus from the capsule is much as possible.

We’ll now begin phacoemulsification. Start with a central groove.

Cracking the nucleus into two hemispheres. We’ll then use the Connor wand, going posterior to the nucleus and elevating it up vertically and then I will use a back chop technique to phaco the nucleus at the iris plane.

At the conclusion of the nucleus removal, you’ll notice there’s not much of a red reflex, that it is blue. At this point, I noticed that the trypan blue capsular staining dye, not only stained the capsule but also migrated posteriorly into the vitreous. Remember this eye has had two vitrectomies, therefore there is a liquid-based vitreous that the trypan blue quickly discolored. This made cortex removal slightly more challenging as we don’t have a good red reflex.

The cortex is also quite sticky and adherent to the capsule, so therefore I go slow and take my time, being careful not to cause any unneeded stress on the zonules or the capsule. This is also a deep chamber due to the prior vitrectomized state.

Again, carefully bringing the cortex towards the center, but noticing that the cortex has significant density to it. There is a fibrotic plaque on the posterior capsule that was not amenable to capsular polishing. Therefore, I elected to simply insert the lens, expecting to do a YAG posterior capsulotomy in the proceeding months.

Fortunately the capsule and the zonules are in good shape and this lens centers nicely. You can see the red reflex is slowly starting to form as the trypan blue dissipates. This is the Tri-Moxi, a triamcinolone and moxifloxacin injection. And I’m administering transzonularly into the anterior vitreous. And you can see the retinal reflex change in its color and nature.

And now disinserting the Malyugin ring, the eyelets from the iris. And then we will disinsert the Malyugin ring with a quick pull technique. Irrigation/aspiration is then used to remove all of the viscoelastic. And the wounds will then be hydrated and sealed.

This concludes a case of a dense cataract with a synechiae and a dense capsular fibrotic plaque. Thank you for watching.