A Surgical Nightmare With An Ecce-Lent Result!

To present a case of a 65yo man with sclerotic, post traumatic cataract, with multiple complications during (corneal wound burn) and after surgery (suprachoroidal hemorrhage) and their proactive management.

Ophthalmology Clinic, University Hospital of Larissa, Greece

A 65-year-old man presents with monocular, post traumatic (50 years ago), brunescent cataract, with prominent zonular instability. Initially, phacoemulsification was decided, but a corneal burn was noticed at the main incision site during the creation of the groove (Cumulative Dissipated Energy was 80). In order to avert additional setbacks, it was decided to leave the eye aphakic, suture and cover the wound with conjunctiva, and defer to a staged ECCE. Unfortunately, during the patient’s follow up, a small suprachoroidal hemorrhage -that was attributed to wound leakage- was noticed, so a dilemma was posed; Whether a pars plana vitreoretinal approach -with 20G fragmatome removal of the nucleus- was more appropriate, instead of the “more open” ECCE procedure that might further complicate the suprachoroidal hemorrhage. Finally, an ECCE was performed 10 days later, with satisfying results.

The choice of Phaco, ECCE or a pars plana VR procedure in brunescent cataracts with zonular dehiscence such as our case, depends heavily on the surgeon’s skill and experience. While phaco is preferred for its small incisions and fast recovery, the higher energy used might cause corneal and endothelial damage, while manipulations might lead to capsule rupture or dislocation. In high risk cases such as this, the small-incision fragmatome option might offer an advantage in handling VR complications and also avoiding further suprachoroidal hemorrhage spread. “Old school” ECCE with a larger incision and its slower recovery time, might be a riskier approach, but offers corneal and endothelial protection and is safer in cases of zonular weakness.