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Unique cataract cases call for special measures

Dorado Beach, Puerto Rico—Special situations sometimes arise in cataract surgery that call for the use of special measures.

William W. Culbertson, MD, described three such techniques: cryoanalgesia, pupil dilation with an injectable device for the presence or expectation of small pupils, and sealed capsule irrigation.

Dr. Culbertson also presented some examples of when these techniques might be utilized in a presentation at the Current Concepts in Ophthalmology meeting here. The conference was sponsored by The Johns Hopkins University School of Medicine, Wilmer Eye Institute, Baltimore, and supported by Ophthalmology Times.

Cryoanalgesia can be used in cataract surgery for patients with sensitivity to local anesthetic, situations in which postoperative inflammation must be prevented, and in patients with endothelial problems, according to Dr. Culbertson. He is professor of ophthalmology at the Bascom Palmer Eye Institute, University of Miami.

The cryoanalgesia technique, which was originally proposed by Francisco Gutierrez-Carmona, MD, of Madrid, calls for precooling of all irrigation and infusion solutions and viscoelastic agents to 4° C.

Figure 1.  In preparation for cryoanalgesia, an ice bath in a plastic bag is applied to the lids and globe for 15                  minutes, after which topical povidone iodine is applied.

An ice bath in a plastic bag is applied to the lids and globe for 15 minutes, after which topical povidone iodine is applied. The globe is irrigated with chilled balanced salt solution (BSS) while the incisions are being made. The chilled viscoelastic is injected, and phaco is performed with the chilled BSS. Finally, the IOL is inserted while the incision is irrigated with chilled BSS. Dr. Culbertson recounted using this procedure to remove a cataract from a 62-year-old woman who was allergic to topical and local anesthetic and was not a good candidate for general anesthesia.

Figure 2.  The incision site is irrigated with chilled balanced salt solution during incisions and maneuvers.

The patient felt nothing during the procedure," Dr. Culbertson said. "She behaved as if we had injected a retrobulbar anesthetic. The phaco proceeded normally.

"When we put the acrylic IOL in place it was slow to expand, and we waited a minute or two before it expanded sufficiently to dial it into the capsular bag," he said. "The only other problem is that the surgeon's and assistant's hands get cold. Otherwise, the procedure went normally but required more in the way of preparation. Importantly, the eye looked very good the day after the surgery."