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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Peripheral Firestorm: The Ischemic Retina

Proliferative disease may still be progressing despite good vision.

Apoorva Jadhav, MBBS, DNB; Unnikrishnan Nair, MS, FRCS, FMRF; and Manoj Soman, DNB, FICO, FRCS

Retina Today

A 62-year-old man with a history of diabetes for the past 10 years presented with complaints of bilateral blurred vision for 2 months with a BCVA of 20/30 OU. Findings on color fundus photography were suggestive of proliferative diabetic retinopathy with fibrovascular proliferation around the optic disc and along the vascular arcades (Figure 1). Widefield OCT demonstrated mild alteration of the foveal contour with minimal parafoveal cystic spaces (Figure 2). The left eye also showed internal limiting membrane folds with vitreomacular adhesion. No significant macular edema was noted. Figure 1 Figure 2 Widefield OCT angiography (OCTA) demonstrated extensive peripheral microvascular alterations consistent with a severe ischemic retinopathy (Figure 3). The most striking feature was the presence of large areas of capillary nonperfusion involving the mid- and far-peripheral retina bilaterally. These regions appeared as well-demarcated flow voids on widefield OCTA, indicating significant capillary dropout and retinal ischemia. At the junction of perfusion and nonperfusion, there were multiple abnormal vascular proliferations visualized as bright, irregular, high-flow networks. These frond-like vascular complexes exhibited disorganized branching and looping patterns, characteristic of neovascularization elsewhere.