Author: Yassine Malek (Morocco)
Co-authors: Taoufik Abdellaoui, Said Chatoui, Shamil Louaya, Karim Reda, Abdelbarre Oubaaz
Purpose
To describe the failure of the attempt to manage a traditional lens couching with only a 23 gauge vitrectomy probe, which was successfully removed with a 23 gauge fragmatome.
Setting/Venue
Ophthalmology Department, Agadir Military Hospital, Agadir, Morocco.
Methods
In this video, we describe the case of a 73-year-old man, who underwent traditional lens couching, in a non-medical rural area, due to financial issues. Noticing that the visual acuity did not improve, the patient consulted an ophthalmologist who diagnosed him with a posterior lens luxation and referred him to our facility for adequate management. Preoperative assessment revealed vitreous strains in anterior chamber, complete posterior lens luxation in the vitreous cavity, without any retinal detachment or peripheral retinal breaks. Optic biometry was done to calculate iris-claw lens power.
Results
The patient underwent under local anesthesia, a 23-gauge 3 ports pars-plana vitrectomy. First, a core vitrectomy was done with 360 degrees liberation of vitreous adherences to the lens, until it became mobile in the vitreous cavity. Then, a first attempt of lens phacophagy was made, with a low cut rate of 1000 cut/min. However the center of the nucleus was too dense, resisting to several mechanical cracking maneuvers with both light and vitrectomy probes. 23 gauge fragmatome was inserted and permitted the phaco-fragmentation of the central dense nucleus. Then, anterior chamber vitrectomy with high cut rates was done to liberate the anterior chamber from vitreous strains. Peripheral vitrectomy was done with 360° degrees indentation and vitreous base shaving, looking for peripheral breaks or nucleus fragments. Acetylcholine was injected in anterior chamber and mechanical iris stimulation with sinskey hook was attempted to achieve adequate myosis for iris-claw lens fixation, but failed. Secondary-Lens Implantation was postponed.
Conlusions
Traditional Lens couching remains a burden for developing countries where access to cataract surgery is still insufficient. In our context, despite the democratization of phaco-emulsification, certain isolated rural regions remain at the mercy of charlatans who offer this technique which is not without risk: Endophthalmitis, phthisis and blindness are frequent complications. Our patient had the chance to benefit from an elegant but heavy, vitreo-retinal surgery, which allowed him after a secondary lens implantation to achieve descent BCVA, but at what cost? Certainly much more expensive than a simple phacoemulsification.
Financial Disclosure
I have No financial Interest
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