Management of cataract caused by inadvertentcapsule penetration during intravitreal injection

of ranibizumabMuhammad Usman Saeed, MBBS, MRCS (Ed), MRCOphth,

Som Prasad, MS, FRCSEd, FRCOphth, FACS

We describe an approach to phacoemulsification of complicated cataract with preexisting poste-rior capsule tear caused by an intravitreal injection. Careful preoperative planning and attention tofluidics, low bottle height, appropriate incisions, careful hydrodelineation without hydrodissection,avoidance of nuclear rotation, and use of a dispersive ophthalmic viscosurgical device to tampo-nade vitreous allows safe phacoemulsification with secure posterior chamber intraocular lens im-plantation. Biaxial microincision cataract surgery can achieve efficient removal of the lens matterwithout rotating the nucleus, reducing the chance of capsule tear extension and loss of nuclearfragments into the posterior pole.

J Cataract Refract Surg 2009; 35:1857–1859 Q 2009 ASCRS and ESCRS

Online Video

TECHNIQUE

Intravitreal injections of agents blocking the actions ofvascular endothelial growth factors (VEGF) have be-come common in the treatment of various vasculardisorders of the eye. Although reportedly low, compli-cations of these procedures include raised intraocularpressure, hyphema, vitreous hemorrhage, and retinaldetachment. We describe the formation and manage-ment of traumatic cataract caused by needle penetra-tion of the posterior capsule during an intravitrealanti-VEGF injection.

SURGICAL TECHNIQUE

The patient is prepared and draped as for routine cat-aract surgery. Two 1.6 mm clear corneal incisions are

Submitted: March 23, 2009.Final revision submitted: May 11, 2009.Accepted: May 13, 2009.

From the Department of Ophthalmology, Arrowe Park Hospital,Wirral, United Kingdom.

Neither author has a financial or proprietary interest in any materialor method mentioned.

Presented in part at the ASCRS Symposium on Cataract, IOL andRefractive Surgery, San Francisco, California, USA, April 2009.

Corresponding author: Muhammad Usman Saeed, MBBS, MRCS(Ed), MRCOphth, Arrowe Park Hospital, Arrowe Park Road, Wirral,CH49 5PE, United Kingdom. E-mail: musmansaeed@aol.com.

Q 2009 ASCRS and ESCRS

Published by Elsevier Inc.

made at the 10 o’clock and 2 o’clock positions witha 1.6 mm angled keratome. Sodium hyaluronate (Hea-lon) is injected in the anterior chamber to maintain thechamber. A continuous curvilinear capsulorhexis ismade with a preformed cystotome needle mountedon a syringe.

Careful hydrodelineation is then performed usinggentle injection of small waves of fluid to reduce therisk for lens matter to dislocate into the posterior seg-ment. Hydrodissection is not done, to prevent hydro-static pressure extending the capsular tear orpushing the lens material back. An irrigating chopperis inserted through one port and a sleeveless phaco-emulsifier handpiece (Bausch & Lomb Millennium,Rochester, NY) is inserted through the 10 o’clockport. The bottle height is kept at 40 cm throughoutthe procedure to exert minimal hydrostatic pressure.Phaco parameters are vacuum 60 mm and ultrasound0-30, pulse per second 100, duty cycle 40 in sculptmode. During nucleus removal, the parameters arechanged to vacuum 180 to 400 mm Hg, ultrasound0 to 50, pulse per second 50, and duty cycle 20. A lon-gitudinal groove is made with the phaco probethrough the 10 o’clock incision, allowing the nucleusto be divided in two within the bag. The nuclear mate-rial is emulsified and removed from the lower part ofthe lens without rotating the nucleus. The phaco probeis then withdrawn, with the irrigation still runningin through the irrigating chopper. An ophthalmic

0886-3350/09/$dsee front matter 1857doi:10.1016/j.jcrs.2009.05.050

1858 TECHNIQUE: MANAGEMENT OF CATARACT CAUSED BY INADVERTENT CAPSULE PENETRATION BY RANIBIZUMAB

viscosurgical device (OVD) is injected to maintain theanterior chamber as the irrigation is gradually turnedoff and the irrigating chopper can then be withdrawnwithout the anterior chamber collapsing (balanced saltsolution [BSS]-OVD exchange).

The irrigating chopper is reinserted, this timethrough the 10 o’clock incision and the phaco probegoes in through the 2 o’clock incision. The secondgroove is made perpendicular to the initial groove,and accessible nuclear material is emulsified and re-moved without rotating the nucleus. The high vac-uum in the nucleus removal mode is used onlywhen the phaco tip is completely occluded with thenucleus material, thereby allowing efficient phacoe-mulsification but minimizing the risk for vitreousdisturbance.

The instruments are withdrawn using the BSS–OVDexchange technique to maintain chamber stability.Sodium hyaluronate 3.0%-chondroitin sulfate 4.0%(Viscoat) is used to mobilize superior nuclear materialinto the lower part of the capsular bag, taking care toplace Viscoat under the nuclear material, preventingdisplacement of nucleus into the vitreous while tam-ponading the vitreous (Video 1). The remaining lensmatter can then be safely emulsified and removed,leaving the epinucleus in place. The remaining corticallens matter is irrigated and aspirated using a bimanualtechnique. If any vitreous presents, a bimanual ante-rior vitrectomy is performed with the aid of triamcin-olone to stain the vitreous.

A 3-piece intraocular lens (IOL) is placed in the cil-iary sulcus after one incision is extended to 2.85 mmand the optic captured through the capsulorhexis,resulting in a secure lens position. Triamcinolone isreinjected into the anterior chamber after the pupilis brought down with acetylcholine chloride (Mio-chol) to identify strands of vitreous in the anteriorchamber that can be removed by bimanual anteriorvitrectomy.

CASE REPORTS

Case 1

A 70-year-old man was referred to us after an injection ofintravitreal ranibizumab for wet age-related macular degen-eration (AMD). A clear lens was documented before the in-jection. Immediately after the injection, clouding of thecrystalline lens was noted. The clouding failed to clear andproduced a cataract with clearly visible longitudinal lines(Figure 1). Visual acuity was reduced to 6/60. Biaxial micro-incision cataract surgery with careful hydrodelineation andminimal rotation was performed using the technique de-scribed above. An IOL was placed in the ciliary sulcuswith the optic capture technique (Video 1). At 1 month, theuncorrected distance visual acuity was 6/36 uncorrectedand 6/24 with pinhole.

J CATARACT REFRACT SUR

Case 2

An 84-year-old woman was referred to us after an injec-tion of intravitreal ranibizumab for wet AMD. Cataract for-mation was noted immediately after the injection. Visualacuity was counting fingers. Biaxial microincision cataractsurgery was successfully accomplished using the techniquedescribed. Visual recovery was limited to 6/60 because ofa retinal pigment epithelium rip.

Both patients had inferotemporal injections, and the pos-terior capsule defect extended from the inferotemporal–mid-peripheral posterior capsule toward the visual axis, causinga 3.0 to 4.0mm tear in the posterior capsule. In both cases, thepreoperative ultrasound B-scan confirmed the absenceof lens matter in the posterior segment before the plannedcataract surgery.

DISCUSSION

Phakic status is an important factor in determining theintravitreal injection site. Most surgeons recommend4.0 mm from the limbus in phakic eyes and 3.5 mmin pseudophakic and aphakic eyes.1 A 26-gauge or30-gauge short needle is used to inject the intravitrealdrug. The advancing needle should be directed to-ward the middle of the vitreous cavity or toward theposterior pole. The injection can be done under a mi-croscope, under direct vision, or through an indirectophthalmoscope based on surgeon preference.

Careful attention to technique can avoid the potentialfor lens damage during intravitreal injections. Jonaset al.2 report a low incidence of rapidly progressive cat-aract (presumed traumatic cataract) of about 0.06%among 5403 intravitreal injections. However, with thewidespreaduse of the intravitreal route to deliver drugsto the posterior segment and the need for repeated injec-tions in conditions such as macular degeneration, lensdamage will occur in a small number of patients. Itmay be more likely with inexperienced surgeons, in

Figure 1. Track (white arrow) of the needle during an intravitreal anti-VEGF injection.

G - VOL 35, NOVEMBER 2009

1859TECHNIQUE: MANAGEMENT OF CATARACT CAUSED BY INADVERTENT CAPSULE PENETRATION BY RANIBIZUMAB

uncooperative patients, or inpatients inwhomthe injec-tion site was too close to the limbus or angled inappro-priately during needle insertion.

In circumstances in which capsular integrity iscompromised, cataract surgery is challenging. Thelens may be expected to behave in a similar fashionto a traumatic cataract or to a situation where a capsu-lar blowout is encountered during hydrodissection.The lens may behave similarly to a traumatic cataractor to a situation in which a capsule blowout is en-countered during hydrodissection.3 Preoperativeclues to the presence of a ruptured posterior capsulemay be the presence of a needle track penetratingthe lens (as in our case), loss of convexity of anteriorlens capsule, presence of a cataract, and demonstra-tion of posterior capsule rupture on B-scan ultraso-nography.4 Such situations demand appropriatemodification of the surgical technique.5 An anteriorapproach with high-speed vitrectomy cutters hasbeen described by Li et al.3 Pavlovic6 describes sulcusimplantation of a polymethyl methacrylate IOL fol-lowed by pars plana lensectomy.

We recommend careful hydrodelineation withouthydrodissection, low bottle height, biaxial bimanualtechnique to avoid lens rotation, use of BSS–Visco-elastic exchange to prevent anterior chamber collapse,along with the use of a dispersive videoelastic agentto tamponade the vitreous and mobilize superiornuclear material.7 Secure IOL placement is achievedusing the optic capture technique, and triamcinolone(Kenalog) is used in an off-label application to ensurethat presenting vitreous is excised.

Effective management of the iatrogenic cataract dueto complicated intravitreal injection is possible with

J CATARACT REFRACT SURG

a good result using biaxial microincision surgerywith the appropriate technique and avoids the needfor formal posterior segment surgery.

REFERENCES1. Aiello LP, Brucker AJ, Chang S, Cunningham ET Jr, D’amico DJ,

Flynn HW Jr, Grillone LR, Hutcherson S, Liebmann JM,

O’Brien TP, Scott IU, Spaide RF, Ta C, Trese MT. Evolving guide-

lines for intravitreous injections. Retina 2004; 24:S3–S19

2. Jonas JB, Spandau UH, Schlichtenbrede F. Short-term complica-

tions of intravitreal injections of triamcinolone and bevacizumab.

Eye 2008; 22:590–591

3. Li KK, Groenewald C, Wong D. Management of traumatic poste-

rior capsular rupture: corneal approach with high speed vitrector.

J Cataract Refract Surg 2005; 31:1666–1668

4. Shi B, Chen W. [Clinical significance of preoperative B-scan ultra-

sonography for traumatic cataracts]. [Chinese] Zhonghua Yan Ke

Za Zhi 1999; 35:371–372

5. Vajpayee RB, Sinha R, Singhvi A, Sharma N, Titiyal JS,

Tandon R. ‘Layer by layer’ phacoemulsification in posterior polar

cataract with pre-existing posterior capsular rent. Eye 2008;

22:1008–1010

6. Pavlovic S. Epilenticular intraocular lens implantation in traumatic

cataract with a ruptured posterior capsule. Am J Ophthalmol

2000; 130:352–353

7. Alio J, Rodrıguez-Prats JL, Galal A, Ramzy M. Outcomes of mi-

croincision cataract surgery versus coaxial phacoemulsification.

Ophthalmology 2005; 112:1997–2003

First Author:Muhammad Usman Saeed, MBBS,MRCS (Ed), MRCOphth

Department of Ophthalmology, ArrowePark Hospital, Wirral, United Kingdom

- VOL 35, NOVEMBER 2009