COVER FEATURE Complex cataract cases Considerations in long and short eyes by Ellen Stodola EyeWorld Staff Writer A small eye with a very shallow anterior chamber undergoing cataract surgery. Even a small error in predicted effective lens position could result in a large relative refractive error, Dr. Zavodni said, noting that he prefers to use the Holladay 2 and Dr. Raju said patients with short eyes should be positioned in a way that will not add to positive pressure. During the exam, Dr. Zavodni said he looks closely at the extent of anterior segment crowding. Additionally, lens exchange can also lower the risk of angle closure, and it’s a relatively predictable procedure compared with LASIK.He offers a few surgical tips in these challenging eyes: Use Healon 5 to maintain the chamber, a needle rhexis, and maintain perfect fluidics to avoid leakage. But Dr. Haigis has a few recommendations to help.Ultrasound axial length determination is frequently more difficult compared to normal eyes because these eyes have distorted geometries which make it difficult to get a good-quality A-scan. In addition, even a maximum power IOL (i.e., 40 D) might not fully correct the refractive error. The rhexis can be more difficult to control because of ergonomic adjustments necessary to accommodate the crowded anterior chamber and because these lenses often have increased anterior capsule convexity, which will steer a rhexis tear peripherally.” To prevent iris prolapse, Dr. Raju said she might create a scleral tunnel versus a clear corneal incision. Zachary Zavodni, MD, The Eye Institute, Salt Lake City, said that patients with extremely short axial lengths (less than 20 mm) and small white-to-white measurements (less than 11 mm) may be at higher risk for suprachoroidal hemorrhage, which should be discussed.
“If I still have shallowing after the viscoelastic is placed, I will consider a vitreous tap or dry vitrectomy,” she said. No Financial Interests. Dr. Zavodni said he might also use preoperative IV mannitol to soften the globe and allow the anterior chamber to deepen. A pars plana vitreous tap is an option for extreme cases as well. She also said she’d consider using iris hooks if the anterior chamber is shallow, although she noted that just because an eye is short does not mean it has a shallow chamber.
But we have to assure them we have a plan in place in case the surgery varies a little from the standard operation,” Dr. Raju said.
Small eyes have a shorter axial length, typically less than 22 mm, and accompanying hyperopia of +3 D or more.
Clinical Associate Professor of Ophthalmology Oregon Health & Science University. Noted by Dr. Ken Hoffer some 30 years ago, short eyes with high hyperopia continue to present a special challenge with regard to biometry and IOL calculation, said Wolfgang Haigis, MS, PhD, at the 2013 Congress of the European Society of Cataract and Refractive Surgeons.
Dr. Zavodni said in eyes with cataract and narrow angles, he would go straight to cataract surgery, rather than a laser peripheral iridotomy, unless the patient was describing relative block symptoms and couldn’t have cataract surgery in the near future, or if he didn’t think they were safe to dilate for cataract surgery. She would avoid retrobulbar anesthesia in favor of peribulbar or topical anesthesia, both of which she said could avoid surgeon-created posterior pressure.
In these cases, Dr. Zavodni said he tells patients they may still need to wear glasses or perhaps consider a piggyback IOL in the future.
Source: Uday Devgan, MD Its important to be aware of Measurement errors, IOL manufacturing tolerances and uncertainties regarding effective lens position all affect short eyes much more than medium or long eyes.
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