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OCULAR SURGERY NEWS 5/15/2006
Endoscopic probe assists in performing cataract
surgery through cloudy cornea
Corneal scarring or clouding may jeopardize the safety of routine cataract surgery.
Steven M. Silverstein, MD, FACS; Kelsey Kleinsasser, OD; Kevin Pikey, DO; Kevin R. Skelsey, MD
Patients requiring cataract extraction or other intraocular
procedures often have cloudy corneas from a variety of causes.
The surgeon’s view in these cases is limited, heightening the risk of
complication or anterior or posterior segment injury. This article
reports our use of an endoscopic probe for visualization during
cataract surgery in a patient with a cloudy cornea.
Scarring, corneal dystrophy and other problems may limit the
surgeon’s view through the operating microscope (although
preoperatively, the oblique light beam at the slit lamp may provide
a better perspective). Most of these patients do not have corneal
pathology significant enough to require lamellar or full thickness
corneal transplantation.
We have been performing endocyclo-photocoagulation (ECP)
using the Endo Optiks Uram E2 laser endoscope in our surgery
center for several years. The endoscopic view on the video monitor
is remarkable, allowing direct visualization of all intraocular tissues.
Guided by this visualization, ECP is performed in selected
glaucoma patients, allowing laser ablation directly to the ciliary
processes. Previous reports describe use of the ECP probe for
confirming haptic placement and assisting with sutured IOLs.
Case report
A 70-year-old woman presented with complaints of gradually
diminished vision in each eye, affecting her ability to read and drive
her car. She had been told in the past that she has “corneal
dystrophy” in both eyes. The patient reported no prior injury,
infection (ocular or systemic), severe visual loss during childhood, chemical burn or known family history of ocular disease.
Medical history was significant for breast cancer (2001, currently in remission), vertigo and a blood clot in 1997.
Examination revealed a best corrected Snellen visual acuity of 20/50 in the right eye and 20/30 in the left eye, decreasing to
20/200 in each eye with standard glare testing. IOPs measured 17 Hg mm in each eye. Biomicroscopy demonstrated
midstromal corneal cloudiness limited to the central two-thirds of the corneal diameter, with a peripheral clear zone consistent
with central cloudy cornea of Francois (Figure 1). Moderate nuclear sclerotic cataracts were noted bilaterally and the posterior
segment was normal.
Biomicroscopy demonstrated
midstromal corneal cloudiness
limited to the central two-thirds of the
corneal diameter, with a peripheral
clear zone consistent with central
cloudy cornea of Francois.
ECP probe placed through the
paracentesis in order to produce an
internal view of the anterior segment
on the video monitor.
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Images: Silverstein SM
Surgical technique
Under topical anesthesia (2% Xylocaine jelly; lidocaine HCl, AstraZeneca) a Leiberman lid speculum was used to hold the lids
apart, and a 2.75 mm temporal clear corneal incision was created using a diamond blade. The anterior chamber was reformed
with Ocucoat (hydroxypropylmethylcellulose 2%, Bausch & Lomb), and a paracentesis was made 3 clock hours away from the
primary corneal incision. A 5.5 mm continuous tear curvilinear capsulorrhexis was created using capsulorrhexis forceps and
hydrodissection was performed employing an irrigating J cannula until the lens rotated freely.
At this point, the ECP probe was introduced through the paracentesis in order to produce an internal view of the anterior
segment on the video monitor (Figure 2). Using both the operating microscopic and the endoscopic views, the cataract was
safely and completely removed using a divide-and-conquer technique. A small piece of residual nucleus – partially beneath the
iris and not visible through the operating microscope – was easily visualized and removed guided by the ECP probe. The
probe was also quite helpful during cortical cleanup.
A silicone lens (LI-61U, Bausch & Lomb) was injected into the capsular bag using a small-incision injector, and the viscoelastic
was removed with irrigation and aspiration. The wound was hydrated and checked for watertightness.
Postoperatively, the patient has done quite well, placed on our standard regimen of Pred Forte (prednisolone acetate
ophthalmic suspension 1%, Allergan) and Zymar (gatifloxacin ophthalmic solution 0.3%, Allergan) four times a day, and is
happy to have avoided corneal transplantation.
Discussion
If corneal pathology is not severe and most of the patient’s visual loss is thought to be due to cataract formation, it is
preferable to proceed with cataract extraction alone, rather than in conjunction with corneal transplantation. At times, corneal
scarring or clouding is significant enough to jeopardize the safety of routine cataract surgery, making it difficult for the surgeon
and possibly dangerous for the patient, risking an unsuccessful postoperative outcome. Endoscopically assisted surgery is
simple to perform, and raises the safety margin considerably. Until recently, such visualization was not possible. We highly
recommend using this technology for similarly appropriate patients.
For more information:
Steven M. Silverstein, MD, FACS, Kelsey Kleinsasser, OD, Kevin Pikey, DO, and Kevin R. Skelsey,
MD, can be reached at the Silverstein Eye Centers, Suite 1000, 4240 Blue Ridge Road, Kansas City,
MO 64133; 816-358-3600.
EndoOptiks, makers of the Uram E2 laser, can be reached at 39 Sycamore Ave., Little Silver, NJ
07739; 800-756-3636.
Copyright ®2006 SLACK Incorporated. All rights reserved.
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