A Surgical Challenge In A Patient With Nanophthalmos

To report a case of cataract surgery in a nanophthalmic patient, that had previously suffered acute angle closure with very difficult control of the intraocular pressure, even after Laser iridotomy. We highlight the surgical and postoperative challenges of cataract surgery in nanophthalmic eyes, especially after the development of inflammation following angle closure glaucoma.

Ophthalmology department, Hospital Professor Fernando da Fonseca, Lisbon, Portugal.

56 year-old male with nanophtalmus presented with acute angle closure glaucoma. Despite being submitted to LASER iridotomy, intraocular pressure only normalized for a short period of time having developed new episodes of angle closure that were controlled with medical hipotensive therapy and a new LASER iridotomy. After stabilization of the intraocular pressure, we performed phacoemulsification of the nucleus with a microincision technique to ensure good anterior chamber stability and although the patient had medium pupillary dilation, no pupil expansion devices were used. Bimanual irrigation aspiration of the cortical material was performed. A 10 mm capsular tension ring was implanted to ensure proper IOL stability due to the presence of a redundant and floppy capsular bag, as can be frequently seen in these cases, and a +49 Diopters intraocular lens was implanted. In the postoperative period marked inflammatory reaction was observed with synechiae and closure of the previous iridotomies that led to a pseudophakic pupillary block and an IOP of 44 mmHg that only resolved after surgical synechiolysis, reopening of the previous iridotomies and triamcinolone injection in the operating room. A good result was obtained 1 month after surgery. Elective cataract surgery of the fellow eye was proposed and surgery, despite challenging due to the inherent characteristics of nanophtalmos, was non complicated with the implantion of a +49 D IOL and no postoperative complications.

Patients with nanophtalmos can be a surgical challenge due to the characteristics of these eyes. The presence of previous angle closure seems to increase markedly the inflammation and potential complications in the postoperative period. Despite being challenging to operate these eyes, in our experience, performing surgery in earlier stages of cataract prior to the development of angle closure seems to yield better surgical outcomes. Proper surgical technique with good preoperative planning is paramount in these cases.