Aspheric Macular Lens for Complication in Cataract Surgery

Cataract surgery stands as the prevailing surgical procedure in the USA. However, these procedures come with inherent risks, and one of the most prevalent is posterior capsular rupture (PCR), which represents the most commonly encountered sight-threatening complication requiring intraoperative management. When coupled with vitreous prolapse, PCR elevates the complexity of the surgery and is estimated to occur in approximately 1.4%–3.2% of cases [1].

In instances where a PCR is coupled with the descent of the lens into the vitreous, specific measures are necessary. These include performing a vitrectomy and potentially removing any remaining cortex. To achieve this, visualizing the posterior segment becomes imperative, typically facilitated by the utilization of BIOM posterior viewing system [2, 3]. If the BIOM posterior viewing system is unavailable or a more concentrated viewing field is needed, an alternative option is to utilize an aspheric macular lens either instead of or in conjunction with the BIOM system [4].

In this illustration, we demonstrate the utilization of the Grieshaber aspheric macular lens (Alcon) as the sole visual instrument in a complex cataract surgery. The lens was employed for visualizing the posterior segment and conducting pars plana vitrectomy, followed by the subsequent extraction of cortical lens remnants. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000539820).

A 70-year-old female patient presented at her local ophthalmologist with concerns about declining vision and was subsequently referred to our clinic. Her medical history revealed type 2 diabetes mellitus managed with sitagliptin/metformin, hypercholesterolemia treated with atorvastatin, and gastroesophageal reflux disease addressed with famotidine. She also had a known sensitivity to metamizole. Her ocular history did not indicate any prior eye conditions. Upon preoperative examination, the patient exhibited uncorrected visual acuity of 6/60 and 6/30 in her right eye (RE) and left eye, respectively. The best corrected visual acuity was 6/20 in both eyes. Refraction for the RE revealed −2.25 D with a cylinder of −1.25 D, while the left eye showed −2.00 D with a cylinder of −1.00 D. Intraocular pressure measured 15 mm Hg in both eyes. Additionally, the anterior segment examination revealed a deep and clear anterior chamber, a round and wide iris under pharmacological dilation (5 mm), nuclear cataract +3 in both eyes, and an intact posterior segment. The patient was recommended to undergo a RE cataract surgery.

The procedure was conducted through superior access, utilizing two incisions and a separate opening for a maintainer, consistent with the standard protocol observed at the medical center where the surgery took place, using Stellaris (Bausch & Lomb, Rochester, NY, USA) [5]. During the intraoperative phase, PCR was monitored by identifying the “pupil snap sign” distinguished by two clinical indicators: sudden pupillary constriction and a tilted lens (online suppl. Video 1) [6]. Following that step, the surgeons performed posterior-assisted levitation, anterior segment phacoemulsification, and anterior segment vitrectomy. Owing to the insufficient availability of operating rooms equipped with the BIOM posterior viewing system, an aspheric macular lens (Grieshaber, Alcon) was placed on the patient’s eye, followed by PPV and the removal of cortical material from the vitreous, using 23-gauge vitrector. The procedure concluded with the insertion of a 3-piece acrylic intraocular lens (AcrySof MA60AC) and the closure of all incisions through suturing (online suppl. Video 2).

Three weeks post-surgery, a refraction evaluation of the operated eye indicated uncorrected visual acuity and best corrected visual acuity of 6/8.5, with an intraocular pressure measuring 10 mm Hg. Subsequent exam revealed a clear cornea displaying Descemet folds +1. Minimal cortical remnants were observed in the vitreous, and examination of the retina detected no tears or signs of inflammation. Furthermore, optical coherence tomography scans revealed an intact retina without any signs of edema (Fig. 1).

PCR represents a significant complication in cataract surgical interventions, necessitating immediate and targeted interventions [1, 7]. In cases where PCR results in the descent of the lens toward the posterior segment, performing posterior vitrectomy is imperative. Additionally, if deemed necessary, the extraction of residual lens material should be carried out.

These measurements ought to be conducted by qualified surgeons, preferably vitreoretinal specialists, utilizing appropriate tools for visualizing the posterior segment. These assessments are crucial due to the significant risks of iatrogenic retinal tears that may arise if unplanned posterior vitrectomy is performed [8].

In most cases, measurements taken following a PCR complication are visualized using the BIOM posterior viewing system. This system boasts a wide field of view and does not include the need for direct contact with the patients’ eyes [3]. When a more concentrated and clearer visual field is required, or if the BIOM posterior viewing system is not accessible in the operating room, an alternative is to use an aspheric macular lens. This type of lens, such as the Grieshaber (Alcon) lens, is more readily available than the BIOM posterior viewing system. The 59 D lens magnifies by a factor of 1.15, has six legs, and functions as a hands-free and self-retaining contact lens [9].

To the best of our knowledge, the utilization of an aspheric macular lens in posterior segment procedures has previously been documented solely in conjunction with the BIOM posterior viewing system or comparable systems [10]. This marks the initial account, to our awareness, of employing an aspheric macular lens as the sole visual instrument for visualizing the posterior segment during procedures like PPV.

This could prove valuable for cataract surgeons in facilities lacking the BIOM posterior viewing system, enabling them to conduct posterior segment procedures if necessary. However, it necessitates proper training to ensure they can navigate the procedure adeptly and avoid inadvertent damage to the retina.

In conclusion, this marks the novel utilization involving the exclusive application of an aspheric macular lens for performing posterior segment procedures following complications in cataract surgery. Opting for an aspheric macular lens alone presents several advantages, such as its cost-effectiveness and accessibility, even in operating rooms lacking a BIOM posterior viewing system. However, it comes with drawbacks, including a limited visual field and the necessity to make contact with the patient’s eye. We believe that this innovative perspective could prove advantageous for cataract surgeons globally, especially in medical settings where the conventional posterior viewing systems may not be accessible.

Ethical approval is not required for this study in accordance with local or national guidelines. Written informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images.

The authors have no conflicts of interest to declare.

The research presented in this scientific article did not receive financial support or funding from any external sources or organizations.

Nadav Shemesh wrote the article and edited the videos. Avi Ohayon performed the surgery and edited the article. Eliya Levinger edited the article. Asaf Achiron performed the surgery and edited the article.

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.