Retro illumination-assisted surgery for cataract and dense vitreous hemorrhage

Author: Maria Concepcion Hernaez-Ortega (Spain)

Co-authors: Jimena Soto-Hernaez

Purpose

Combined cataract and pars plan vitrectomy (PPV) surgery is often performed. However, the absence of the red reflex still makes cataract surgery very challenging. We report the clinical presentation, surgical management, and outcomes of a patient with a cataract and dense vitreous hemorrhage, and demonstrate how to use retro-illumination to facilitate their removal.

Setting/Venue

Case report. A 58-year-old woman arrived at the hospital due to an acute vision loss of the right eye (RE) a month ago that does not allow seeing fundus details. Fundus examination of the left eye (LE) was normal. The patient did not report any previous ocular trauma, and had history of arterial hypertension.

Methods

A corrective surgical procedure in the RE was performed with 23G PPV along with 25G chandelier light (Alcon) that was placed into the nasal quadrant trocar. Cataract surgery started first positioning the light tip towards the posterior pole, thus providing a better definition of the crystalline lens by retroillumination. The anterior capsule was stained with Trypan blue solution to perform the capsulorhexis and then hydrodissection . At the beginning of the phacoemulsification of the nucleus, the position of the light was changed by horizontalizing the tip, allowing a better visualization of the nucleus and extraction of the lens cortex by irrigation-aspiration. Finally, posterior chamber intraocular lens (IOL) was placed. Due to insufficient mydriasis, a Malyugin Ring was placed and the PPV was performed using BIOM®5 (Oculus), that showed a very dense vitreous hemorrhage with adhered hyaloids. Central core and peripheral vitrectomy assisted with purified triamcinolone staining was then implemented. Since the bleeding was found to be caused by rupture of a retinal macroaneurysm, endophotocoagulation was applied and the vitreous cavity was filled with air. Visual acuity (VA), intraocular pressure (IOP), slit lamp biomicroscopy (SLB) and vitreoretinal findings were measured.

Results

The preoperative ophthalmological examination revealed VA of perception and light projection in the RE and 20/20 in the LE. The IOP was 16 mmHg in RE and 14 mmHg in LE. SLB revealed the presence of a sub-capsular and mild nuclear cataract. The fundus examination of the RE revealed a dense vitreous hemorrhage that made it impossible to see background details. Media transparency was achieved by retro illumination-assisted surgery and dense vitreous hemorrhage was solved. After 6 months of follow-up, the patient's RE VA was 20/25 and there was no rebleeding after vitrectomy.

Conlusions

This video demonstrates how to use retro illumination-assisted surgery to facilitate cataract removal in the presence of dense vitreous hemorrhage. The absence of the red reflex in these cases makes essential the use of retro-illumination with a Chandelier light to avoid possible complications in the cataract surgery.

Financial Disclosure

NONE