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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 654-656

Delayed phacoemulsification in femtosecond laser-assisted cataract surgery: A rare case report


1 Department of Cataract Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
2 Department of Vitreo-Retinal Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai, Tamil Nadu, India

Date of Submission07-Dec-2020
Date of Acceptance07-Mar-2021
Date of Web Publication09-Oct-2021

Correspondence Address:
Dr. Piyush Kohli
Department of Vitreoretinal Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_3624_20

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  Abstract 


A diabetic and asthmatic patient was planned to undergo femtosecond laser-assisted cataract surgery in his left eye. At the end of femtosecond procedure, he developed breathlessness due to noncardiogenic pulmonary edema. The second procedure was postponed for 3 weeks till he received fitness for undergoing further ocular surgery. The second surgery was uncomplicated. There was no corneal decompensation, exaggerated inflammation, intraocular pressure spike, diabetic retinopathy progression, or postoperative cystoid macular edema till 6 months of follow-up. Although not recommended, such a delay may be unavoidable. The delayed surgery is unlikely to compromise the surgical outcome or increase the chances of intra- or postoperative complications.

Keywords: Delayed surgery, femtosecond laser-assisted cataract surgery (FLACS), pulmonary edema


How to cite this article:
Shekhar M, Muthukrishnan GR, Choudhary P, Kohli P, Sankaranathan R, Nagu K. Delayed phacoemulsification in femtosecond laser-assisted cataract surgery: A rare case report. Indian J Ophthalmol Case Rep 2021;1:654-6

How to cite this URL:
Shekhar M, Muthukrishnan GR, Choudhary P, Kohli P, Sankaranathan R, Nagu K. Delayed phacoemulsification in femtosecond laser-assisted cataract surgery: A rare case report. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Oct 18];1:654-6. Available from: https://www.ijoreports.in/text.asp?2021/1/4/654/327685



Cataract surgery is perhaps the most commonly performed surgical procedure in the world, with majority of surgeries performed under local anesthesia. Although local anesthesia is deemed safe even for the elderly and comorbid patients, life-threatening complications can rarely occur.[1],[2],[3]

Femtosecond laser-assisted cataract surgery (FLACS) is gaining popularity due to its potential to improve safety, accuracy, and clinical outcomes of cataract surgery. It is a two-step procedure: the first one done with the help of a femtosecond laser machine and the second one for phacoemulsification and intraocular lens (IOL) placement.[4]

We report the surgical management of a patient who developed pulmonary edema during the first step of FLACS.


  Case Report Top


A 59-year-old diabetic and asthmatic patient was planned to undergo FLACS in his left eye. He had earlier successfully undergone similar surgery in his right eye. His best-corrected visual acuity (BCVA) was 20/20 in the right eye and 20/80 in the left eye. Posterior segment showed stable proliferative diabetic retinopathy (PDR) post pan retinal photocoagulation (PRP) in the right eye and severe non-PDR in the left eye with no evidence of clinically significant macular edema (CSME) in either eye.

Preoperative blood tests including hemogram, sugar levels, kidney function tests, and echocardiography (ECG) were normal. After physical examination and physician fitness, the patient was planned for the surgery. In the preoperative room, At this moment, his vitals were pulse rate 87/min, blood pressure 130/80 mm Hg, and oxygen saturation 97%. As per the protocol of our institute, the first procedure was performed in a separate laser room. The pupil was dilated using topical tropicamide (0.8%) eye drops, the periocular region was cleaned with 10.0% povidone-iodine, anesthesia was achieved using topical proparacaine hydrochloride drops (0.5%), and povidone-iodine drops (5.0%) were installed in the cul-de-sac. The eye was docked and femtosecond laser was used to create capsulotomy, fragment the nucleus and create corneal incisions. Although the ocular procedure went uneventful, the patient developed breathlessness at the end of the procedure. His vitals were pulse rate 152/min, blood pressure 240/120 mm Hg, and oxygen saturation 45%. Immediately, he was evaluated by the attending anesthetist and shifted to the intensive care unit (ICU) of the hospital. The eye was patched and the second procedure was postponed. In the ICU, the patient was administered an intravenous furosemide bolus (120 mg) along with 100% oxygen (6L/min) by nasal cannula. An immediate 12-lead ECG showed sinus tachycardia but no evidence of any new ischemia. Over the next 2 h, a good diuresis was followed by vital stabilization. Thereafter, he was then shifted to a nearby multispeciality hospital. He was diagnosed as noncardiogenic pulmonary edema secondary to acute respiratory distress syndrome most probably due to chronic obstructive pulmonary disease and underwent further treatment. He was advised to use topical antibiotics, steroids, and cycloplegic eye drops. He received fitness for undergoing ocular surgery again after 3 weeks.

The slit-lamp examination done before the second surgery showed a clear cornea, quiet anterior chamber (AC), anterior capsule flap lying at the bottom of the AC, capsule-corneal endothelium touch at its superior margin (away from the visual axis), absence of posterior synechiae, and a fragmented cataractous lens inside the bag with no lens matter in the anterior chamber [Figure 1] and [Figure 2].
Figure 1: Slit lamp images with direct focal illumination (a and b) showing a normal thickness cornea with absence of any Descemet's folds, anterior lens capsule lying in the anterior chamber with corneal endothelium touch only at its superior margin (away from the visual axis) and a cataractous lens

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Figure 2: Slit lamp images with transillumination showing clear cornea with no lens cortex in the anterior chamber with a) anterior lens capsule (black arrows) lying in the anterior chamber; and b) fragmented cataractous lens (black arrow)

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During the second surgery, the corneal incisions created during the first surgery were easily opened using Donnenfeld Femto spatula (Katena Products, USA). The anterior capsular flap was separated from the endothelium with the help of viscoelastics and removed with McPherson forceps. The fragmented lens was then emulsified using the Centurion vision system (Alcon, USA) followed by in-the-bag IOL implantation. The second surgery was uneventful following which the patient regained BCVA 20/20. There was no corneal decompensation (localized or general), exaggerated inflammation, posterior synechiae formation, intraocular pressure (IOP) spike, posterior capsular opacity (PCO) formation, DR progression or appearance of postoperative cystoid macular edema (CME) till 6 months of follow-up.


  Discussion Top


The importance of a premedical checkup of a patient undergoing cataract surgery has been well established.[5] This is especially important in the case of old and comorbid patients. Although rare, patients can develop pulmonary edema after peribulbar anesthetic block.[1],[2],[3]

Our patient developed pulmonary edema during the first step of FLACS. Management of such a situation is challenging. Proceeding with phacoemulsification can be life-threatening as pulmonary edema is a systemic emergency that needs to be managed immediately without losing the critical time interval during which the patient can be resuscitated. On the other hand, postponing phacoemulsification after creating capsulotomy, corneal incisions and nucleus fragmentation can increase the chances of inflammation and secondary glaucoma. We preferred to postpone the second step of the surgery till the patient was systemically stable. Since lens matter completely stayed in the bag after the first step of FLACS, the patient could be successfully managed with topical drops during this interval. The second procedure could be performed without any difficulty as the corneal incisions could be opened easily and no synechiae were noted. There was no difference in surgical steps performed during the delayed second procedure compared to the routine FLACS procedure except for the need to loosen the anterior lens capsule from the corneal endothelium which could be done easily using viscoelastics.

Fortunately, the patient did not develop any postoperative complications. As there was minimal endothelial-anterior capsule touch, no endothelial decompensation occured. Although corneal incisions were made during the first procedure, they were not opened, hence preventing entry of infective organisms. Although anterior capsulotomy was made, lens material did not escape out of the lens bag, preventing exaggerated inflammation and IOP spikes.

Although there are been reports where the patient developed perioperative pulmonary edema, to the best of our knowledge, this is the first case report where the second procedure of FLACS had to be delayed for as long as 3 weeks after the first procedure.[1],[2],[3] Although not recommended, such a delay may be unavoidable.


  Conclusion Top


We suggest that continuous intra-operative monitoring of the vitals should always be done, even in short procedures performed under topical anesthesia like FLACS. Severe patient complaints or any instability in the systemic vitals must be immediately addressed by the attending physician/anesthetist. In case urgent systemic care is needed, the second part of the surgery should be postponed. The delayed surgery is unlikely to compromise the surgical outcome or increase the chances of any intra- or postoperative complications. With the absence of lens matter in the anterior chamber, topical steroids and cycloplegic eye drops should be sufficient to control the resulting inflammation during the interval, however, oral steroids may be required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kumar CM, Lawler PG. Pulmonary oedema after peribulbar block. Br J Anaesth 1999;82:777-9.  Back to cited text no. 1
    
2.
Taylor I, Watters M. Pulmonary oedema after ophthalmic regional anaesthesia in an unfasted patient undergoing elective surgery. Anaesthesia 2001;56:441-6.  Back to cited text no. 2
    
3.
Chhabra A, Singh PM, Kumar M. Pulmonary oedema in a patient undergoing vitreo-retinal surgery under peribulbar block. Indian J Anaesth 2012;56:387-90.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Donaldson KE, Braga-Mele R, Cabot F, Davidson R, Dhaliwal DK, Hamilton R, et al. Femtosecond laser-assisted cataract surgery. J Cataract Refract Surg 2013;39:1753-63.  Back to cited text no. 4
    
5.
Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev 2019;1:CD007293.  Back to cited text no. 5
    


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