Issue: July 2021
Disclosures: Devgan reports he owns CataractCoach.com, which is a free teaching website.
July 21, 2021
3 min read
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Cataract surgery after lens trauma from intravitreal injections

Issue: July 2021
Disclosures: Devgan reports he owns CataractCoach.com, which is a free teaching website.
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The most common ophthalmic procedure is an intravitreal injection, with more than 10 million per year performed in the U.S.

These injections of anti-VEGF and corticosteroid medications are helpful in treating retinal disease and inflammation. For the vast majority of patients, these intravitreal injections are easy, painless and beneficial; however, there can be rare complications, such as infection. Another potential complication is iatrogenic damage to the crystalline lens capsule during the injection.

Uday Devgan
Uday Devgan

During the cataract consultation, patients with a history of intravitreal injections should have a careful examination of the posterior capsule, using the red reflex of retroillumination to highlight any defects or opacities. Penetration of the lens capsule by an intravitreal injection will cause either a total white cataract due to liquefaction of the cortex or a small focal defect. A history of developing a total white cataract within a week or two of an intravitreal injection is very suspicious for extensive posterior capsule damage.

Case presentation

A patient had multiple prior intravitreal injections for macular disease and now presents for cataract surgery. Upon examination, there is moderate nuclear sclerosis and another small focal lens opacity (Figure 1). This is the site where the needle penetrated the lens capsule. Cataract surgery in this case will be very high risk because the posterior capsule has this weak spot that will easily break. The cataract lens material may fall into the vitreous cavity and require a pars plana vitrectomy surgery as well.

puncture site
Figure 1. The lens capsule puncture site can be easily seen in the red reflex from the operating microscope. The safest way to proceed is to treat this like a posterior polar cataract, which also has a defect in the posterior capsule.

Source: Uday Devgan, MD

The best approach to this case is to treat it like a posterior polar case. This means avoiding hydrodissection because that would cause pressure that would blow out the posterior capsule. Instead, do just hydrodelineation and remove the lens endonucleus, then use a dispersive viscoelastic to perform viscodissection. This slow wave of dispersive viscoelastic will slowly dissect the epinucleus and cortex from the capsule and will tamponade any break in the posterior capsule.

In this case, standard hydrodissection was performed, immediately revealing the needle tract within the crystalline lens (Figure 2). This happens so quickly that it is easy to miss. Continued hydrodissection pressurizes the capsular bag and the posterior capsule splits wide open from the force (Figure 3). Now this cataract is in danger of falling into the vitreous due to the infusion pressure once the phaco probe is placed in the anterior chamber.

needle path
Figure 2. At the beginning of hydrodissection, the needle path within the crystalline lens is highlighted. At this point, further hydrodissection should be avoided. Hydrodelineation and viscodissection are still possible and lower risk.
posterior capsule split
Figure 3. Continued hydrodissection has caused the posterior capsule to split wide open, which now makes this a very high-risk case for retained lens material and vitreous prolapse.

Salvaging the case

This case can still be saved by bringing the nucleus up and out of the capsular bag. It can be brought up using a chopper or other second instrument, then additional viscoelastic can be placed under the nucleus to provide further support and to prevent vitreous prolapse. The nucleus can then be removed using a scaffold technique or a scleral tunnel can be made for manual nucleus extraction. The main incision will then need to be closed, and a bimanual approach can be used for cortex removal and anterior vitrectomy. A three-piece IOL can be placed securely with the haptics in the sulcus and the optic captured through the capsulorrhexis.

In this case, the anonymous surgeon did not perform these techniques because the capsule defect was not recognized ahead of time. When the surgeon placed the phaco probe in the eye and attempted to sculpt the nucleus, the entire lens dropped into the vitreous cavity. The patient was referred to a vitreoretinal surgeon who performed a pars plana vitrectomy and lensectomy and securely placed a sulcus IOL. Ultimately, the patient did well and recovered good vision.

With the high volume of intravitreal injections being performed every year, even a complication rate as low as one in 5,000 means that 2,000 patients per year will suffer a damaged lens capsule, and virtually every cataract surgeon will encounter this condition. Fortunately, we can spot this damage in most cases ahead of time and then take precautions to help ensure a good outcome.

See full video of this case at cataractcoach.com.