Intraoperative Capture of Descemet Membrane Detachment During Cataract Surgery

Hisato Ohno, MD

Eyetube

This video captures the exact intraoperative onset of a Descemet membrane detachment during cataract surgery. Surgical footage, anterior segment OCT findings, treatment, and clinical outcome are presented, providing valuable insight into the mechanism, diagnosis, and management of this uncommon complication.

The Essential Role of Capsule Retractors

These instruments provide temporary zonular support that can help surgeons safely remove the lens and plan for permanent capsular stabilization.

Beeran Meghpara, MD

Cataract and Refractive Surgery Today

KEY TAKEAWAYS Capsule retractors act as temporary artificial zonules, centering the capsular bag and preventing posterior displacement, anterior vitreous prolapse, and phaco-tip aspiration Early placement after continuous curvilinear capsulorhexis and before hydrodissection stabilizes eyes with phacodonesis, flaccid lens behavior, or significant zonular compromise Unlike iris hooks, capsule retractors provide equatorial support; after lens removal, permanent support requires a capsular tension ring or scleral-fixated segment Managing profound zonular compromise is one of the most demanding challenges in anterior segment surgery—one that tests the surgeon’s composure and technical acumen. Whether caused by pseudoexfoliation syndrome, prior ocular trauma, Marfan syndrome, or advanced age-related changes, generalized or localized zonulopathy threatens the stability of the capsular bag. The primary surgical goal in these cases is to remove the lens without damaging the capsule or allowing lens fragments to become posteriorly displaced into the vitreous. One useful tool in this setting is the capsule retractor; it is designed to provide atraumatic support and centration of the capsular bag throughout cataract extraction. These instruments feature an elongated nylon shaft and a broad, blunt terminal paddle or loop that cradles the capsular equator without causing iatrogenic trauma. A sliding silicone element on the shaft rests externally against the limbus and allows the surgeon to adjust the amount of tension required. Although retractors can be placed as a rescue maneuver when unexpected zonular dialysis becomes apparent during phacoemulsification or cortical aspiration, the instruments are most effective when used prophylactically. WHEN TO DEPLOY CAPSULE RETRACTORS The timing of capsule retractor deployment is critical to preventing progressive capsular instability. If significant phacodonesis is observed at the slit lamp preoperatively or if the lens appears flaccid during initial capsulorhexis creation, early intervention is warranted. Ideally, capsule retractors are inserted immediately after completion of the continuous curvilinear capsulorhexis and before hydrodissection or any manipulation of the nucleus.

Choroidal Nevus Growth Into Melanoma in a Young Patient

Know the clinical risk factors for the development of malignancy.

Henry M. Nguyen, BS; Aruba Zafar, MD; Robert J. Medina, BA; and Carol L. Shields, MD

Retina Today

KEY TAKEAWAYS Uveal melanoma (UM) is the most common primary intraocular cancer in adults, with an annual incidence of 5.1 cases per 1 million individuals in the United States. The three strongest predictors of transformation of a choroidal nevus into UM were found to be tumor thickness > 2 mm on ultrasonography, subretinal fluid on OCT, and orange pigment on fundus autofluorescence. The risk for transformation of a nevus into UM increases sharply with age, becoming nearly 75-times more likely by the eighth decade of life; still, careful monitoring must be guided by objective criteria rather than age alone. Uveal melanoma (UM) is the most common primary intraocular cancer in adults, with an annual incidence of 5.1 cases per 1 million individuals in the United States and a propensity to affect individuals with more lightly pigmented skin.1,2 UM mainly presents in the choroid (90%), with fewer tumors arising in the ciliary body (6%) and iris (4%).3,4 Prognosis worsens when the ciliary body is involved, owing to the greater tumor thickness, greater risk for cytogenetic abnormalities, and higher metastatic potential.5 In one series of 1,059 patients tested for genetic abnormalities, ciliary body tumors demonstrated the highest odds ratio (OR) for chromosome 3 monosomy (OR = 8.17, P < .001) and chromosome 8q gain (OR = 102.87, P = .001), two alterations that are strongly predictive of metastasis.5 Despite advances in local control of UM, approximately 50% of patients develop metastasis, mainly to the liver via hematogenous spread.4,6,7 This persistent risk for systemic spread underscores the need for early detection and structured, risk-based monitoring to improve long-term outcomes. While risk-assessment tools have been published and apply across all ages, nevus transformation into melanoma remains rare in patients under 30 years of age.8-10 In this article, we describe a case of melanocytic growth of a choroidal nevus in a 28-year-old patient, our treatment approach, and the importance of balancing vigilance with measured follow-up in patients of all ages. RISK FACTORS FOR CHOROIDAL NEVUS TRANSFORMATION INTO MELANOMA  Careful monitoring must be guided by objective criteria rather than age alone. One widely used framework to standardize the criteria for nevus transformation to melanoma is the mnemonic “To Find Small Ocular Melanoma Doing Imaging” (ie, TFSOM-DIM):11 Thickness > 2 mm (by ultrasonography)  Fluid, subretinal (by OCT) Symptoms of VA loss to ≤ 20/50 (by Snellen acuity) Orange pigment (by fundus autofluorescence [FAF]) Melanoma showing acoustic hollowness (by ultrasonography) DIaMeter > 5 mm (by fundus photography) Previous analyses of 1,329 and 1,287 patients with small melanocytic choroidal tumors first highlighted these important features as key predictors of growth and occasional metastasis, with risks compounding when several of these factors were present.12,13 A larger subsequent series of 3,806 patients with choroidal nevus showed that the probability of transformation into melanoma increased when more risk factors were present at the time of diagnosis and over time.11 The 5-year Kaplan-Meier transformation rates were 1% with no factors, 11% with any one factor, 22% with two factors, 34% with three factors, and > 50% with at least four factors.11 The three strongest predictors of transformation of nevus into melanoma included tumor thickness > 2 mm on ultrasonography, subretinal fluid on OCT, and orange pigment on FAF. A smaller effect was noted for symptoms of visual acuity loss on Snellen acuity, melanoma acoustic hollowness on ultrasonography, and tumor diameter > 5 mm on fundus photography.11 In addition to TFSOM-DIM, the MOLES scoring system—Mushroom shape on ultrasonography, Orange pigment on fundus photography and FAF, Large size (≥ 3 disc diameters in base or thickness ≥ 1 mm), Enlarging tumor with growth, and Subretinal fluid on OCT—has been proposed for use by nonspecialists and communities with limited access to advanced imaging techniques in an effort to guide monitoring and referral.14 Despite its good specificity and sensitivity, the accuracy of the MOLES system diminishes for very small tumors.14 These predictive algorithms can help clinicians implement targeted surveillance and timely intervention for patients with one or more high-risk features. CASE REPORT  A 28-year-old White man with no ocular melanocytosis was observed with a choroidal nevus in his right eye for 6 years. Initial fundoscopic imaging elsewhere showed a flat pigmented lesion measuring 4 mm x 4 mm in diameter (Figure 1A, arrow) and demonstrated hypoautofluorescence (Figure 1B, arrow).