Effect of Anterior Chamber Instability during Phacoemulsification Combined with Intraocular Lens Implantation

Abstract

Purpose. To determine the incidence of anterior chamber (AC) instability during phacoemulsification (phaco) combined with intraocular lens implantation and investigate its effect on intraocular tissues. Methods. Among the 248 enrolled eyes, 121 and 127 eyes were categorized into the irrigation and nonirrigation groups, respectively, depending on the use of a self-made anterior chamber maintainer (ACM) during phaco. AC stability was evaluated using operating microscopy and intraoperative optical coherence tomography (iOCT). Slit-lamp examination of AC flare and cells was performed 1 day postoperatively. Corrected distance visual acuity (CDVA), intraocular pressure (IOP), endothelial cell density (ECD), central corneal thickness (CCT), posterior vitreous detachment (PVD), and central foveal thickness (CFT) were evaluated preoperatively and at 1 week, 1 month, and 3 months postoperatively. Results. There was good consistency in AC stability evaluation between operating microscopy and iOCT. The incidence of AC instability was significantly different between groups after the phaco and irrigation/aspiration tips were withdrawn from the AC P < 0.001 . At 1 day postoperatively, after excluding eyes in which the AC could not be visualized, AC cell grades were significantly lower in the irrigation group (P = 0.014). There was no significant difference in CDVA, IOP, ECD, and CCT between groups during the 3-month follow-up P > 0.05 . At 1 month and 3 months postoperatively, PVD occurred in 8 (16.3%) and 14 (28.6%) eyes and in 22 (40.7%) and 37 (68.5%) eyes in the irrigation and nonirrigation groups, respectively (P = 0.006 and P < 0.001 ). CFT was significantly higher in the nonirrigation group at 1 and 3 months postoperatively (P = 0.018 and P = 0.010). Conclusions. Both operating microscopy and iOCT are efficient for AC stability evaluation. When the phaco and I/A tips were withdrawn from the AC, there was frequent instability. Intraoperative AC instability can increase surgery-induced inflammation and lead to postoperative complications such as PVD, retinal detachment, and macular edema. The self-made ACM can effectively reduce the incidence of intraoperative AC instability and these complications.

Swab Pressing vs Stromal Hydration to Prevent Incision Leakage and Transient Collapse of Anterior Chamber in Phacoemulsification

“…However, most intraoperative leakage may not receive sufficient attention from surgeons probably because these subtle changes are difficult to observe under surgical microscope with coaxial illumination. By using the external slit illuminator on the surgical microscope, we found that anterior chamber collapse immediately after the withdrawal of the handpiece is more common than expected, in accordance with a previous study . This collapse might cause rapid forward movement of the iris lens diaphragm and contact between the corneal endothelium and IOL or posterior capsule immediately (Video).…”

“…Reformation of the anterior chamber had to be performed prior to stromal hydration. Indeed, there are several alternative methods to prevent anterior chamber collapse after the final removal of OVD, such as using an anterior chamber maintainer, performing stromal hydration beforehand, and removing OVD through paracenteses in bimanual fashion. Swab pressing still shows potential to be applied at each time when the handpiece is withdrawn to prevent intraoperative incision leakage responsible for transients collapse of anterior chamber.…”

“…This collapse might cause rapid forward movement of the iris lens diaphragm and contact between the corneal endothelium and IOL or posterior capsule immediately (Video). On the top of these problems, the dramatic drop in intraocular pressure (IOP) from more than 50 mm Hg due to incision leakage may result in potential damage to the intraocular structure, especially the posterior segment …”

“…In fact, incision leakage could occur not just after but also during the surgery, even in well-constructed incisions, especially immediately after the withdrawal of the handpiece . However, most intraoperative leakage may not receive sufficient attention from surgeons probably because these subtle changes are difficult to observe under surgical microscope with coaxial illumination.…”

Twist Technique to Stop Fluid Leakage and Fixate the Eye During Bimanual Cortex Removal in Phacoemulsification

“…1 To achieve a safe cortex aspiration, a stable anterior chamber (AC) is mandatory. 2 One common reason for fluctuation of the depth of the AC and the fluttering of the posterior capsule is the outflow of fluid through the side port. This unavoidable leakage may occur even when the size of the side port is equal to that of the irrigation probe.…”