Cataract Surgery in Patients with Corneal Opacities

When the view through the cornea is poor, adjustments in illumination, capsular staining, and pupil expansion can help.

Boris Malyugin, MD, PhD

Cataract and Refractive Surgery Today

KEY TAKEAWAYS Corneal opacities can compromise visualization during cataract surgery, but microscope illumination adjustments and supplemental light can improve the surgical view Transcorneal, intracameral, or pars plana chandelier illumination can enhance lens visualization by using reflected retinal light when coaxial light is insufficient Capsular staining, posterior capsule–safe phaco technique, and pupil expansion with a Malyugin Ring 2.0 or iris hooks can further improve control In eyes with corneal opacities, visualization of the capsule and lens can be challenging. The degree of difficulty depends on the density and location of the opacity. When cataract surgery alone, rather than a combined corneal and cataract procedure, is planned, several techniques can improve visualization. OPTIMIZING VISUALIZATION The first technique to improve visualization is to adjust the intensity of the operating microscope light and the balance between the coaxial and paraxial illumination. The second is to add supplemental illumination. A light pipe borrowed from a vitreoretinal setup can be positioned on the cornea near the limbus for transcorneal illumination or introduced into the anterior chamber through a paracentesis incision for intracameral illumination. Pars plana chandelier illumination can be useful in these cases. This technique was first described by Oshima et al in 2007.1 The approach is illustrated in Figures 1 and 2. When the coaxial microscope light is turned off and the chandelier illuminator is turned on, light reflects off the retina and improves visualization of the lens structures.

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A Rare Case of Choroidal Vitiligo

Recognize this uncommon sign of varicella-zoster reactivation.

Tina Tang, MD, and Nauman Chaudhry, MD

Retina Today

A 66-year-old immunocompetent woman with a history of recurrent cutaneous lesions was referred for evaluation of retinal lesions in the left eye noted during a routine examination. Her cutaneous lesions were characterized as discrete erythematous macules and small papules on her lower back. Her BCVA was 20/20 OU with normal IOPs and anterior segment examination. Dilated fundus examination of her left eye showed irregular yellowish choroidal lesions temporal to the macula and focal areas of hypopigmentation nasal to the disc (Figure 1). OCT of her left eye showed trace epiretinal membrane with no definite mass lesion (Figure 1, Inset). Fundus autofluorescence revealed hyperautofluorescence corresponding to the yellow lesions, along with hyperfluorescent changes on fluorescein angiography. ICG angiography of the left eye revealed early blocked cyanescence in the area of the lesions temporal to the macula (Figure 2A) with late foci of hyperfluorescence nasal and temporal to the disc (Figure 2B). Work-up revealed positive varicella-zoster virus (VZV) immunoglobulin G, but immunoglobulin M was negative. The ocular oncology service ruled out ocular lymphoma. Her choroidal lesions slowly enlarged over the next 6 years with regular monitoring and no definite mass on OCT (Figure 3).