Archive for June, 2014 – Phaco Training

I overheard this very interesting conversation between different eye surgeons over the internet.

It is a great way to learn for all of us from a real case event

All of us, as eye surgeons, are bound to come across this scenario somewhere in our practice.

Most of it is self explanatory so I will leave out my own comments

I am taking out the names of all the doctors involved so as to preserve the anonymity.

This is a recent event having occurred somewhere around May 21st, 2014

Question

Dear Group members,

On Monday, at 3 pm. a colleague operated a case of Posterior Polar cataract by Phaco. There was the popping of the central Postwerior Capsule on eating away of the Nucleus core. So with the aid of Vitrectomy and minimal Vaccum Aspiration the entire cortical matter was aspirated and the case was beautifully completed by placing an Alcon IQ Lens on the Capsular bag, (which had a 4.5 mm ccc). Due to the unique situation some Viscoelastic would have entered the Posterior segment, and Pilocar was injected at end of case.

Bandage was Opened on Tuesday. Vision was more then 6/60. Fault on our part is we didnt check vision more thoroughly, as we were more relieved with the case having ben handled so well. Pupil was constricted, IOL was in place. Postoperative instructions, mainly of Prednisolone eye drops 6 times a day was given, amongst others.
On Tuesday at 9 pm, patient complained of bad vision. She isnt sure whether the vision dropped or it was so when bandage was opened in morning. When questioned thorougly , turned out the relatives had not put Prednisolone drops even once. A thin membrane was noted in Pupillary area which broke upon making her wait and dilatation. Vitritis Grade 2 was noted. She was Put on Prednisolone 1 hourly for Tuesday night.

On Wednesday morning, she complained of a further drop in vision. Anterior Segment was perfectly normal, Eye was quiet. Vitritis Grade 2.5-3 was noted. Glow was visible. Oral Steroids were started, Diamox BD and Timolol drops BD were added.

On Wednesday evening, the patient said she felt a marginal improvement in Vision. Rest all clinical signs were status quo. B Scan did not show any flocculent masses in the Posterior Segment. Yet to be on the safer side, we did give her IV Injection Fortified Cefotaxime and Oral Ciprofloxacillin with Fortified Antibiotic drops.

Still awaiting to see Patient this morning. Shall request your advice even after i add to this mail after we see her this morning.

Are we Missing something. DO we need to give Intravitreals. Can we wait?

Request all your opinions.

Opinion from 1st doctor

If a small nuclear fragment is in the vitreous, that may incite a significant reaction and may not be picked up on ultrasound. A dilated fundus exam is essential.

Of course in the presence of a complicated surgery, the risk of infection is higher as well. Hence if the dilated fundus exam fails to show lens material, need to treat it as endoph.

regards

Response from the primary surgeon

We did a dilated fundus exam

The Vitritis is grade 3 now.

We cannot appreciate anything besides the glow.

Today, there is a thin 1mm sterile hypopyon and flare and cells in AC. The IOP WAS 30 mm hg and the corneal edema didnt improve inspite of IV Mannitol.

I am thinking of injecting Antbiotics + Dexamethasone.

Would request your urgent reply on same.

Opinion from 1st doctor

Please treat it as endoph would in fact favour an early vitrectomy with intravitreal antibiotics considering the rapidity of progression despite one intravitreal, early presentation, own post-cataract surgery endop etc.,

regards

Repeat question from the primary surgeon

Request tips for doing Vitrectomy under a hazy cornea.

How do I go about it?.

Are you recommending just core vitrectomy or a complete vitrectomy.

If so how do I get a clear field through a hazy cornea?

I am ready for a Vitrectomy + re injection Intravitreals tomorrow morning. Dont want to do just a gesture, but a definitive treatment.

Opinion from 1st doctor

Rolling a dry cotton tip applicator on the cornea can help dry the edema. If not remove epithelium. A core vit should do as we do not want to risk a break and as it is early endoph core vit may be sufficient. I do prefer a complete vit if possible and this can be decided on the table. A complete vit if PVD is there or a core vit. Washing the ac is key to good visualisation.

Opinion from 2nd doctor

Was there retainted viscoelastic in the eye that can explain the raised IOP?
While treating this patient as bacterial endoph, we can hope its only a TASS like reaction.
Aravind endopth KIT is a nice single use pack that has all that we need for giving intravitreal Abx. All eye surgeons should stock one.

Opinion of 3rd doctor

Please consider viscoat in patients with an open PC where there is a chance for the viscoelastic to remain in the vit at end of surgery. The IOP raise in these eyes is less than with methylcellulose.

Best wishes with this patient

Opinion of 1st doctor

Retained visco will not explain vitritis. I also hope that it is just inflammation, but need to treat it as endoph

Regards

Response of the primary surgeon

Thankyou for all your inputs.

The patient is much improved today. AC reaction has disappeared. Glow is clear. Vitritis is grade 2. Vision is HMCF.

DO I STILL GO AHEAD WITH A CORE VITRECTOMY when I do a repeat Intravitreal this afternoon?

Would really appreciate urgent responses.

Thanking you.

Opinion of 1st doctor

If the patient is better, can withhold vitrectomy and repeat intravitreal antibiotic steroid.

regards

Response of the primary surgeon

Dear Everyone,

Thank you so much for your inputs.

They helped me a lot in crucial times.

It is clearly not a case of Endoph. But of severe Vitritis.

Now if we may have to take her for Vitrectomy for dense Vitritis, when would be ideal time ? How long should I 2ait?

Thanks once again.

Opinion of 1st doctor

Dear Dr.,

One can never be sure about it not being endophthalmitis good that it is getting better. Can wait for a week or so to see how the eye behaves. If only vitritis, it is likely clear by itself completely.

regards

Choo-Choo train in Elephanta Island Jan 2010

Elephanta Caves. Here Shiva is depicted to be performing the cosmic dance. It is supposed to herald the

destruction of the universe. The niche is 11 feet in height. It is one of the 2 shrines on the west wing. The caves

and sculptures have been dated to be around 6th to 8th century AD.

Dear Mahesh Sir,

We all of us face with this problem of non-responders..

My question to u is, when to decide on alternate option? can we change management plan if the pt does not respond to 1st injection of anti-VEGF itself, means the CMT has not resolved/ increased?( provided the systemic parameters are normal)

2) Why some subset of pts irrespective of good systemic control are non-responders/ poor responders? ( i make sure they are not taking pioglitazone group of drugs as well)

3) Do we need to treat OCT ?- cystic spaces in inner layers, if the pt is not very symptomatic?

Opinion of Dr. P. Mahesh Shanmugam on Rx. of Chronic cystic diabetic macular edema

I do look to see if there is any change at all after the first injection and may shift over if there is none. A few of us are currently working on guidelines for treating DME and the consensus amidst this group consisting of some of the leading retina specialists seemed to be wait for at least 2-3 injections.

The difference in affinity of the anti-VEGF agent to VEGF may play a larger role in diseases such as DME and vein occlusions as VEGF load is also higher in these diseases as compared to that of AMD.

Some patients do behave poorly I usually look at Hb, lipid profile, BP, microalbuminuria, HBA1c and for medicines that may worsen the edema to identify a cause. Some continue to have recurrent edema despite a good systemic status. In such I may consider a peripheral laser photocoagulation.

A cyst away from the fovea with a vision of 6/6 I would watch. If cyst is involving the fovea, I would treat.

In regards to another query about primary steroid studies (DRCR) have shown that in phakic patients, lucentis gave the best results and steroid fared poorly but then in pseudophakic patients it may have a role. Studies do have their strengths in number and methodology and hence we cannot brush them aside with our anecdotal reports. I also have a few patients who respond only to steroid and we would have to look at each patient with the strength of knowledge gained from the studies, tempered by our experience and decide on the treatment based on the patient characteristics. Amidst the steroids, TA possibly is as good as ozurdex, but then complications with ozurdex are low.

We are currently evolving as far as the ideal treatment for DME is concerned. I do miss the days when all we had was laser and base our decision on clinical exam no OCT, no injections, less confusion!

regards