White Intumescent Cataract
Evaluation and surgical management.
CASE PRESENTATION
A 56-year-old woman is referred for evaluation of a rapid and profound decrease in vision in her right eye. The patient states that everything she sees with her right eye “is in a constant fog” and “seems to be worsening fast.” She has difficulty with depth perception and currently wears a bandage over her right eye when driving to decrease glare. The patient reports no history of trauma, ocular surgery, or intraocular injections. She describes an episode of vertical and horizontal diplopia that occurred approximately 1 year ago, resolved without treatment, and was attributed to high blood pressure. Her ocular history includes borderline glaucoma and hypertensive retinopathy in both eyes. Her medications include amlodipine and simvastatin.
On examination, BCVA is counting fingers in the right eye and 20/25 in the left eye with a manifest refraction of +1.25 -0.75 x 105º. Manual keratometry reveals 2.00 D of anterior corneal astigmatism in the right eye. The IOP is 18 mm Hg OD and 19 mm Hg OS. A slit-lamp examination is remarkable for 2+ to 3+ milky nuclear sclerosis and 4+ cortical changes in the right eye and 1+ to 2+ milky nuclear sclerosis and 1+ to 2+ cortical changes in the left eye. There is no view of the posterior segment in the right eye, and B-scan ultrasound is unremarkable. The left eye has a 0.55 cup-to-disc ratio but is otherwise unremarkable.
After discussing the risks and benefits of surgery, the patient elects to proceed with cataract surgery on her right eye. What additional testing, if any, would be helpful when planning surgery? What concerns do you have regarding the risks of surgery? What special procedures or steps during surgery would you consider in order to minimize these risks?
The patient decides to have conventional cataract surgery without addressing her astigmatism. A femtosecond laser is used. After viewing a video of the laser treatment (see below), do you have any additional concerns? If so, how might these concerns affect your surgical plan?
—Case prepared by Cathleen M. McCabe, MD
MARIA S. ROMERO, MD
White cataracts are a surgical challenge, and patients should receive thorough counseling before they undergo surgery. Anterior bulging of the crystalline lens and the presence of fluid pockets on OCT images of the anterior segment are suggestive of an intumescent cataract. If these findings are present, intravenous mannitol or a vitreous tap can help to decrease pressure in the posterior chamber.
The benefit of a laser versus a manual capsulotomy is that the former is performed in a closed space, which reduces the pressure differential between the anterior chamber and inside the capsule, thereby decreasing the risk of a runaway radial tear that could lead to the Argentinian flag sign and the risk of a posterior capsular tear. The drawback of a laser capsulotomy is that milky proteins may interfere with the laser, thus leaving the capsulotomy incomplete.1 If this occurs, however, the capsulotomy can easily be completed manually. When I have lacked access to a femtosecond laser in a case such as this one, I have performed a two-staged capsulorhexis, as described by Kara et al.2
However the capsulotomy is executed, I would stain the anterior capsule with trypan blue dye and instill an OVD that has a high molecular weight. After performing gentle hydrodissection, I would tap down the nucleus to prevent it from blocking the anterior capsulotomy and blowing out the posterior capsule.
Whatever technique is used to fragment the lens, it should be one that minimizes cumulative dissipated energy. Protecting the posterior capsule will be important because the cortex is nonexistent, and only a thin layer of epinucleus remains as the scaffold of the posterior capsule. Postoperative steroid therapy can decrease corneal edema.
1. Taravella MJ, Meghpara B, Frank G, Gensheimer W, Davidson R. Femtosecond laser-assisted cataract surgery in complex cases. J Cataract Refract Surg. 2016;42(6):813-816.
2. Kara-Junior N, Santhiago MR, Kawakami A, Carricondo P, Hilda WT. Mini-rhexis for white intumescent cataracts. Clinics (Sao Paulo). 2009;64(4):309-312.
