Challenges Of Cataract Surgery In Young Adults With Buphthalmic Eyes

To report the challenges of cataract surgery in young adults with primary congenital glaucoma (PCG) and buphthalmos. Buphthalmic eyes have unique anatomy and tissue properties, and behave differently than pediatric PCG patients or adult patients without buphthalmos. We present 4 cases of buphthalmic eyes with preoperative and postoperative visual and glaucoma outcomes and we show the surgical techniques and pearls to prevent and manage surgical complications.

Young adults with PCG and Buphthalmos who require cataract surgery pose several challenges due to their unique ocular anatomy. Haab’s striae might obstruct the visualization during surgery and become worse as surgery progresses, corneal stretching might cause leak wounds and anterior chamber depth fluctuations.  Deep anterior chamber and zonular instability adds to the difficulty when handling surgical instruments intraocularly and the iris might be stretched and floppy.

Patients with PCG and buphthalmic eyes requiring cataract surgery with or without concurrent glaucoma surgery were included. Their clinical presentations were recorded including preoperative visual acuity and intraocular pressure (IOP), number of glaucoma medications. Biometry testing was obtained, and surgery planned for each case individually. The surgical procedures were recorded. In this video series we highlight surgical challenges and provide surgical pearls to safely perform cataract surgery in buphthalmic eyes and how to manage complications.

The first case is a 22 year old male, VA 20/100, IOP 30mmHg, axial length (AL) 30.53mm, anterior chamber depth (ACD) 5.19mm. Post operatively VA 20/60, IOP 15mmHg.

The second case is a 37 year old female, VA 20/200, IOP 46mmHg, AL 25.92, ACD 4.37mm. Post operatively, VA 20/50, IOP 17mmHg.

The third case is a 39-year-old male with HM, IOP 33mmHg, AL 32.46, ACD 2.22mm. He underwent repeat penetrating keratoplasty and three months later cataract extraction with vitreous loss, IOL in sulcus with anterior vitrectomy and GDI. Post operatively, VA HM, IOP 8 mmHg on Brimonidine.

Case 4 is a 30 year old female with HM vision, IOP of 16 mmHg on 4 drops and with a previous glaucoma drainage device. Axial length was 31.93mm. 

Cataract surgery in young adults with buphthalmic eyes needs special consideration due to many associated problems secondary to increased axial length, high myopia, zonular laxity, decreased scleral rigidity and corneal haze.

In those cases and video series we highlight surgical challenges and provide surgical pearls to perform cataract surgery in buphtalmic eyes.Take home points are: placement and suturing plate to the sclera prior to cataract surgery, use of iris expansion devices when poor pupillary dilation, appropriate sized capsulorrhexis of approximately 5-5.5 mm to prevent IOL dislocation, use of capsular tension rings in zonular instability, judicious use of viscoelastic and wound suturing prevents post operative wound leak.