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Phacomorphic Glaucoma With Peripheral Iridotomies

Shakeel Shareef, MD

Shakeel Shareef, MD, presents a case of uncontrolled phacomorphic glaucoma in the setting of patent peripheral iridotomies. The patient underwent clear lens extraction with goniosynechialysis. The surgical video highlights the deliberate planning and steps taken to avoid perioperative complications. The challenges include (1) managing the elevated IOP pre-op with iv. Mannitol to shrink the vitreous gel with maximal lower of IOP 90 minutes after administration; (2) pre-op initiation of Atropine to (a) deepen the anterior chamber to create work space; (b) posterior displacement of the iris-lens diaphragm and placing the lens on stretch by tightening the zonules to facilitate capsulorhexis; (c) countering aqueous misdirection; (d) stabilizing the blood aqueous barrier to minimize post-op inflammation; (3) use of bimanual clear lens extraction with 1 mm tunnel side-port incisions with low flow irrigation to avoid iris herniation; (4) use of capsular staining to decrease the elasticity of the anterior capsule during capsulorrhexis for better handling; (5) use of Healon 5 to maintain the anterior chamber;(6) goniosynechialysis 360 degrees with placement of a viscocohesive to keep the angle open.

Posted: 7/25/2016