Surgical options in the face of positive pressure

Deep Anterior Lamellar Keratoplasty Over Penetrating Keratoplasty to Mitigate Positive Vitreous Pressure Complications

This report describes deep anterior lamellar keratoplasty over penetrating keratoplasty (DALK-over-PKP) as an alternative technique to mitigate complications related to positive vitreous pressure (PVP) during PKP. We accomplished this by repairing the punctured cornea and performing a modified DALK where a full-thickness donor graft is placed over the host Descemet membrane, which is then removed after partial suturing of the graft. This mitigates the driving force behind the PVP by maintaining a closed-anterior chamber.

Avoiding Complications From Patient Positioning for Intraocular Surgery

Collaboration of the surgical and anesthesia teams for patient positioning is essential to assure patient comfort and safety, preventing systemic and ophthalmic complications. The goals and rationales of positioning for intraocular surgery are discussed including placing the head above the heart, elevating the chin, using a head rest that is sufficiently firm, maximizing anesthesia care team access and minimizing fire risk, and taping the patient's head to the operating table to reduce unexpected movement with intraocular injury.

Retrospective Study of Vitreous Tap Technique Using Needle Aspiration for Management of Shallow Anterior Chamber during Phacoemulsification

Purpose

To evaluate the technique of vitreous tap using needle aspiration for management of anterior chamber shallowness during phacoemulsification.

Methods

A retrospective study included 26 eyes of 17 patients who underwent phacoemulsification in which vitreous tap was performed using a 27-gauge needle attached to a 5 ml syringe, inserted 3.5 mm from the limbus to aspirate 0.2 ml of liquefied vitreous if a cohesive (OVD) failed to sufficiently deepen the anterior chamber.

Results

Preoperative anterior chamber depth was 2.31 ± 0.26 mm, axial length was 21.7 ± 0.67 mm, lens thickness was 4.5 ± .19 mm, and cataract grade was 3.77 ± 1.4. Preoperative CDVA in LogMAR units was 0.98 ± 0.75. Coexisting angle closure glaucoma was present in 7 patients (26.92%) preoperatively. Vitreous needle tap was successful in vitreous removal on the first attempt in 26 eyes (100%). Postoperative follow-up period was 22.88 ± 10.24 (4–39) months. The final postoperative CDVA in LogMAR units was 0.07 ± 0.1, while the final postoperative IOP was 16.54 ± 1.45 mmHg. No complications related to vitreous tap were noted.

Conclusion

Vitreous needle tap is a simple, cost-effective, and safe technique for management of shallow anterior chamber in phacoemulsification.

Healon5 in the management of intraoperative expulsive hemorrhage

We present a patient with systemic hypertension, glaucoma, and previous vitrectomy who experienced a large expulsive choroidal hemorrhage during a procedure to reposition and iris fixate a subluxated intraocular lens. Liberal use of sodium hyaluronate 2.3% (Healon5) resulted in cessation of the hemorrhage, allowing completion of the case. Healon5 may cause cessation of bleeding through a tamponade effect and thus be useful in treating patients experiencing an intraoperative expulsive hemorrhage.