Expulsive Hge In Posterior Microphthalmos

Show the diffi culti es when doing phaco in posterior microphthalmos cases and what to do andwhat not to do in these cases especially in this case in which posterior microphthalmos associated withmature hard cataract, PEX with poor dilati on of pupil , zonular dialysis , elevated IOP and very shallowanterior chamber

The Memorial institute for ophthalmic research (MIOR)

Female patient 60 y old complaining of drop of vision in left eye . Examination of lt eye show mature hard cat with shallow AC , PEX with poor dilation of pupil , limited zonular dialysis and IOP 30 mmhg. U/s show very small axial length 16 mm with localized area of choroidal effusion . Give her anti glaucoma treatment and follow up IOP and start preparing for phaco. One hour before phaco start mannitol and her IOP became 16 just before surgery. Start phaco using Iris hooks to dilate pupil then stain and do capsulirehexis in veryshallow AC while doing phacoemulsification of nucleus i use CTR to avoid increase dialysis . I complete phaco and implant IOL  but notice IOL tilted vertically in bag I tried many times to reposit even with Healon but tilted again . I decided to do anterior vitrectomy through sclerotomy3 mm from limbus after few seconds notice blood in vitreous and expulsive hge rapidly I get out and sutured sclerotomy
Results: Aft er surgery VA was HM with elevated Iop and ultrasound show localized Supra choroidal hge with vitreous hge . Follow up for 2 weeks under full anti glaucoma treatment . In follow up hge start to improveand IOP controlled and I decided to continue conservative without interventi on but in 3rd week VA dropedto PLGP and ultrasound show retinal detachment. PPV was done for here and we found during surgery that site of sclerotomy although at 3 mm it is not in paraplana but in retina and it cause retinal tear which cause retinal detachment 

There is risk of expulsive hge during doing phaco for posterior microphthalmos so if this occuronly urgently close the globe and prepare all your tools for this moment as not to lose any second

Try to avoid anterior vitrectomy in these cases and if it is a must do your sclerotomy 1.5-2.00 mm and do veryminimal anterior vitrectomy

Mannitol is mandatory before surgery

In such diffi cult cases u should prepareall your weapons healon , stain, CTR , 3piece IOL , Iris hooks