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Session Title: Complex Cases and Surgery
Session Date/Time: Monday 07/10/2013 | 14:30-16:00
Paper Time: 15:30
Venue: Forum (Ground Floor)
First Author: : S.Jha INDIA
Co Author(s): : N. Panwar
To prove that once stuck in a difficult situation like fluid misdirection into vitreous cavity during hydroprocedures in phacoemulsification and while operating cases of lens induced glaucoma, with a careful usage of 25 G trocar and cannula , one can comfortably decompress the eye ball and the phacoemulsification can proceed comfortably thereafter.
Two cases are being reported, one case was a regular phacoemulsification which on doing regular hydro procedures was found to have very intraocular pressure ( IOP) while on table, similar to that of expulsive haemorrhage. Second case was that of a lens induced glaucoma, which was planned for phacoemulsification, but due to poor systemic conditions neither i.v. mannitol nor oral glycerol could be given for control of IOP.
In the first case, while being caught in the middle of surgery with very high IOP during hydration, we used a 25 G trocar and cannula in inferonasal quadrant at 3.5 mm from limbus to create a sclerotomy and left it open till the eye was suitably decompressed. After a comfortable IOP was attained, the sclerotomy was plugged and the surgery was completed . The cannula was removed at the end of the surgery. In the second case ( lens induced glaucoma) , in which the baseline pressures were very high ( around 35 mm Hg) , we made a sclerotomy with 25 G trocar cannula , so as to decrease the pressures. The cannula was removed at the end of the surgery after plugging
In both the above cases , the intractable IOP could well be controlled using 25 trocar cannula and the surgery could be completed easily without any risk of posterior capsular tear/ vitreous loss. The post operative visual gain of both the cases were also comparable to regular cataract extractions
With new generation phacoemulsification machines the surgery has become more predictable, however despite these advancements, sometimes nature is difficult to conquer. The zonules of the crystalline lens are not absolutely water and air tight and the may sometimes allow balanced salt solution to get into vitreous cavity during phacoemulsification, creating a situation akin to malignant glaucoma, mimicking expulsive hemorrhage. It can be distinguished from later with the presence of red glow in certain situations. Choice to the surgeon is to close and wait even upto 24 hours for fluid to get absorbed. Another difficult situation can be uncontrolled lens induced glaucoma where surgery can no longer be postponed and frequent infusion of mannitol is not desirable due to poor systemic condition. But using the above mentioned technique the IOP is well controlled and surgery can be carried out smoothly. We strongly recommend the usage of 25 G trocar and cannula in both the above situations.
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