The Use of the Anterior Chamber Maintainer in Special Cataract Cases

doi:10.4236/ojoph.2012.24028

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Open Journal of Ophthalmology, 2012, 2, 127-130

http://dx.doi.org/10.4236/ojoph.2012.24028 Published Online November 2012 (http://www.SciRP.org/journal/ojoph)

127

The Use of the Anterior Chamber Maintainer in Special

Cataract Cases

Vasileios Lakidis1, Antonios Lakidis2,3, Despoina Kolokotroni2, Diamantis Almaliotis2,

Vasileios Karampatakis2

1Bioclinic, Department of Ophthalmology, Thessaloniki, Greece; 2Laboratory of Experimental Ophthalmology Aristotle University

of Thessaloniki, Greece; 3The 1st Eye Clinic of AHEPA Hospital, Aristotle University of Thessaloniki, Greece.

Email: almaliotis[email protected]

Received July 11th, 2012; revised September 27th, 2012; accepted October 8th, 2012

ABSTRACT

Purpose: To point out the indications for the use of the Anterior Chamber Maintainer (ACM) in order to facilitate cata-

ract surgery in selective cases. Materials and Methods: In a time interval of 4 years the ACM was used in 28 special

cataract cases 17 patients had high myopia (12 - 25 dpt, axial length 28 - 34 mm), 3 patients had vitreo-retinal pathology

known pre-operatively and 8 cases were previously vitrectomized with silicon oil. In these cases the ACM was intro-

duced either from the beginning or during the surgical procedure when excessive fluctuations of the Anterior Chamber

(AC) were observed. Results: Though the new generation phaco machines tend to maintain the stability of the AC, the

use of the ACM contributed to even greater stability during the insertion and the removal of probes and during the

whole procedure, eliminating the risk of complications. All these risky cases were accomplished without intraoperative

complications. The surgeons experienced a sense of increased safety during the procedure. Conclusions: The use of the

ACM in cataract cases with high risk for complications offers a much greater stability of the AC, by eliminating the

fluctuations of the posterior capsule and consequently prevents intraoperative and potentially postoperative complica-

tions.

Keywords: ACM; Cataract Surgery; Intraoperative Complications

1. Introduction

The anterior segment surgeons very often have to man-

age special and difficult cataract cases. The use of the

ACM stabilizes the intraocular presence during surgery

[1] thus increasing safety in high risk cases Cataract sur-

geons have to be extra cautious when they manage eyes

with high axial length. In high myopic eyes pathological

degenerations of the sclera, choroid, retina and the vitre-

ous often exist [2-6]. The most common type of cataract

in high myopic eyes is the sub capsular cataract, which

usually appears in younger ages and tends to progress

rather fast [7]. Retinal degenerations of high myopic eyes

are a risk factor of retinal detachment after cataract sur-

gery and this fact is influenced by the age of the patient,

the axial length of the eye, the pre-existence of retinal

degenerations, history of retinal detachment surgery of

the other eye, the surgical procedure and the integrity of

the capsular bag [8-11]. In these cataract cases the rupture

of the posterior capsule may have serious intra-operative

and post-operative complications.

Another challenge for the surgeons of the anterior seg-

ment is the cataract surgery in previously vitrectomized

eyes (pars plana vitrectomy). It is known that there is a

higher rate of intra-operative and post-operative compli-

cations in those eyes. These complications occur due to the

anatomical changes in the previously vitrectomized eyes,

such as swallow anterior chamber, intra-operative miosis

[12,13], unstable posterior capsule [14], posterior capsule

opacities [15], loose zonule and lack of support to the lens

from the vitreous [16].

Despite all these difficulties, phaco surgery are consi-

dered safe and it is safer than the ECCE [17], however it is

known that the use of an ACM increases the safety during

anterior segment surgery [18].

The purpose of this report is to point out the indica-

tions of the use of the ACM in risky cataract cases so as

to facilitate surgery and prevent complication.

2. Material and Methods

2.1. Selection of Patients

28 special cataract cases were operated by the use of an

ACM.

Our material consisted of 28 eyes. 17 eyes had myopia

The Use of the Anterior Chamber Maintainer in Special Cataract Cases

128

higher than 12 dpt (12 - 25 dpt and axial length 28 - 34

mm), deep anterior chamber and some of them phacodo-

nesis. 3 eyes had vitreo-retinal pathology (vitreo-retinal

tractions such as diabetic retinopathy or retinal degenera-

tions) known preoperatively and treated with prophylac-

tic laser in the past and 8 eyes were previously vitrecto-

mized and the vitreous cavity was filled with silicon oil.

The ACM was introduced, on the purpose to control

the depth and the pressure in the anterior chamber when

the phaco tip and the irrigation aspiration cannulas are

inserted or removed from the eye during the procedure

and also to keep the posterior capsule constantly far from

the phaco tip minimizing the fluctuations.

2.2. Surgical Procedure

The Millennium from Bause and Lomb and the Infinity

from Alcon Laboratories were used.

After the sterilization of the surgical field and topical

anesthesia, 2 side ports were created at 3 and 9 o’clock for

bimanual irrigation-aspiration and another corneal inci-

sion at a lower temporal position for the introduction of

the ACM.

After the injection of the viscoelastic and the capsu-

lorhexis, the ACM remained open at a height of about 60

cm from the eye.

The ACM remained open during the hydro-dissection,

the phacoemulsification and the aspiration of cortex. After

the aspiration of the cortical material the ACM flow was

interrupted and viscoelastic was injected in the anterior

chamber and the capsular bag for the insertion of the

lens.

The aspiration of the viscoelastic was done with open

flow of the ACM, even behind the IOL.

Every incision was carefully “sealed” by injecting BSS

in the corneal stroma and the withdrawal of the ACM

was done by simultaneous injection of BSS through a side-

port.

The goal was to keep the AC as stable as possible dur-

ing the procedure.

3. Results

In all these special cases, no intraoperative complications

were observed, though according to the international lit-

erature and according to our experience high rates of com-

plications are expected in such cases.

The intraoperative fluctuations of the anterior chamber

and the surge phenomena were greatly eliminated.

No rupture of the posterior capsule occurred. In vitrecto-

mized eyes with silicon oil the presence of the ACM pre-

vented the invasion of silicon into the anterior chamber.

The surgeons experienced an increased sense of safety

during the procedure.

No postoperative cornea edema was observed. The IOP

ranged within the expected normal values with no in-

crease related to the surgery. There were no negative

consequences on the expected final visual acuity. In a

follow up period of 2 - 5 years, no clinical CME was

detected and also retinal detachment did not occur in the

eyes with high myopia and also in the eyes with known

pre-existing retinal pathology (Table 1). All eyes were

examined postoperatively for retinal pathology, and risk

for retinal detachment and 3 more eyes were treated ap-

propriately (with prophylactic laser) since a significant

percentage of these eyes (5 eyes in the follow up period)

required Nd:YAG capsulotomy postoperatively which may

increase the risk of retinal detachment.

No silicon oil was detected in the anterior chamber in

the vitrectomized eyes.

4. Discussion

The use of the ACM in our material contributed greatly

to the success of phaco in special cataract cases such as

in high myopic patients.

Alio et al. [19] reported that the possibility of retinal

detachment in high myopic patients who underwent phaco

was 2.7%. Other researchers reported that the possibility

of retinal detachment after phaco in myopic patients was

quite higher 8% [20], and only 0.4% - 1.2% of the general

population that undergo phaco surgery [20].

In another study, Wilbrandt et al. [21] were the first

who described the effects that take place during the phaco

of high myopic cases thoroughly. They named these ef-

fects as LIRDS (lens-iris diaphragm retropulsion syn-

drome). It takes place during the insertion of the phaco tip

in the eye and causes instant increase of the anterior cham-

ber depth and dilation of the iris (“tomato-iris”). This

phenomenon occurs due to the weight of the water co-

lumn of the infusion. LIRDS usually rises in eyes with

weak zonules pathology. They used an anterior chamber

maintainer (Lewicky type) and lowered the height of the

bottle in order to overcome this syndrome. The use of the

ACM in our material stabilized the depth of the anterior

chamber and undoubtedly was proved to be valuable for

the safety of the procedure.

On the other hand, high ratio of complications is ob-

served in previously vitrectomized eyes that undergo

Table 1. Pre-existing ocular pathology in 28 special cataract

cases.

Number of

eyes Ocular

pathology Intraoperative

complications postoperative

complications

17 Myopia (12 - 25 dpt) No No

3 Vitreo-retinal

pathology No No

8 Vitrectomized with

silicone No No

The Use of the Anterior Chamber Maintainer in Special Cataract Cases 129

phaco. Cole et al. [22] studied these complications. More

specifically, in 12.5% rupture of the posterior capsule

occurred, in 5.6% retinal detachment and in a few cases

loss of vitreous and zonule rupture were recorded. Anato-

mical changes that take place after pars plana vitrectomy

prejudice the onset of complications. Yung et al. [23] in-

vestigated the pathophysiological changes that occurred

in eyes that underwent vitrectomy and admission of silicon

oil. A hypertrophic response of the anterior capsule of

about 20 - 25 μm was observed. Also, the epithelium of

the lens was hypertrophic and fibrosis of the posterior

surface of the anterior capsule occurred. These changes

make the work of the cataract surgeon really difficult in

relation to the posterior capsule fluctuations as a result of

the lack of support due to the previous vitrectomy. The

role of the ACM in previously vitrectomized eyes, with

silicon oil is really of significant importance. It is well-

known that during phaco, when the phaco tip is removed,

silicon oil pervade through zonule to the anterior cham-

ber. More specifically, the intraocular pressure drops sig-

nificantly when the phaco tip is removed from the eye.

Due to the collapses of the anterior chamber, the iris dia-

phragm is protruded and the zonular spaces become wider.

Through these spaces silicon oil drops, pass into the ante-

rior chamber. The ACM in our cases, stabilized the intra-

ocular pressure and thus prevented the passage of the si-

licon oil to the anterior chamber.

Furthermore, the ACM, due to the stability of the depth

of the anterior chamber, diminishes the vitreo-retinal trac-

tions in pathological cases such as proliferative diabetic

retinopathy. Some researchers [24] tried to eliminate these

vitreo-retinal tractions, in patients with diabetic retino-

pathy, with the use of intravitreal injections of bevani-

zumab. They aimed at reducing the proliferative neovas-

cularisation, the edema and the tractions between the vi-

treous and the retina. ACM is obviously useful in these

cataract cases.

Another application of the ACM is in cases of rupture

of the anterior capsule (capsulorhexis tear). In our opinion

(experience in a great number of phaco cases), the appli-

cation of the ACM stabilizes the pressure in the anterior

chamber and it may prevent the extension of the rupture

to the posterior capsule.

Other researchers [25] investigated the vitreous loss

that is observed in cases of rupture of the posterior cap-

sule during phaco. They compared cataract cases that were

performed by experienced surgeons with or without the

ACM. They concluded that both groups had the same per-

centage of post-operative complications and also a greater

vitreous loss was observed when the rupture of the poste-

rior capsule occurred with the presence of an ACM. In

our material no capsule rupture occurred.

It also has to be mentioned that complicated cataract

surgery is related with higher incidence of CME. It has to

be outpointed that none of our patients developed clinical

CME.

Conclusively, according to our experience, the use of

an ACM facilitates the operation and makes surgeon feel

safer. It increases the safety of the phaco procedure by

increasing the stability of the depth of the anterior cham-

ber and by reducing the posterior capsule fluctuations

during the insertion and withdrawal of the phaco tip and

the irrigation aspiration cannulas. Thus many intra-opera-

tive and postoperative complications may be prevented.

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