Comment on: Outcomes of manual small incision cataract surgery in hypermature morgagnian cataract.

Abstract

We read the article by Christy et al. and must congratulate the authors for this interesting retrospective analysis.1 Here, we want to add our experience of performing more than 20 000 manual small-incision cataract surgeries and more than 1000 hypermature Morgagnian cataract surgeries combined over 8 years. We believe these points will benefit all the authors, especially in the developed world where phacoemulsification takes the upper hand. During manual small-incision cataract surgeries in Morgagnian cataract, cystitome has no limited role. Since there is milky fluid in the bag, there is no firm base to perform a continuous curvilinear capsulorhexis (CCC) with cystitome. The cystitome can only be used to initiate the capsulorhexis by puncturing the anterior lens capsule, but CCC has to be performed only with the help of utrata forceps. We suggest a smaller CCC in these cases because the nucleus size is small and can be easily prolapsed through a 5 mm CCC. A small CCC has 2 advantages. In patients with weak zonular support, a capsular tension ring can be easily implanted, and when there is a posterior capsular rent, the intraocular lens (IOL) can be placed in the sulcus with confidence.2 Can opener capsulotomy should be avoided in these cases because radial nick over the capsule can stretch the zonular fibers and may result in zonular dialysis. Moreover, the option of placing a capsular tension ring is eliminated with can opener capsulotomy. For performing a successful CCC, we usually follow this technique. After a small puncture over the capsule with a cystitome, the milky fluid is washed with saline through a hydrodissection cannula to give a clear view of the anterior lens capsule, and the bag is inflated with an ophthalmic viscosurgical device to provide a firm hold for performing the CCC with forceps. The alternative way is instead of saline, an ophthalmic viscosurgical device can be directly used. In cases of pseudoexfoliation with small pupils and Morgagnian cataract, we recommend not to perform multiple sphincterotomies, as we are all aware of the hypotheses that the smaller the pupillary size, the weaker the zonular fibers.3 The surgeon should expect 360 weak zonular fibers in such cases and be prepared for whole bag removal and secondary IOL implantation. Multiple sphincterotomies will refrain us from implanting an iris-claw in the same sitting and will invite more postoperative anterior chamber reaction and photophobia for the patient. In cases of phacolytic glaucoma with Morgagnian cataract, the first step should be paracentesis placement and anterior chamber wash with saline through a hydrodissection cannula. This will provide a clear view of the anterior chamber and help in planning the case meticulously. If there is whole bag removal in such cases, if the anterior vitreous phase is intact, and when there is minimal to no anterior chamber inflammation, we recommend a secondary IOL such as an iris-claw or scleral-fixed IOL in the same sitting. In cases with severe anterior chamber inflammation and requiring anterior vitrectomy, we suggest to wait at least 2 to 3 months before a secondary IOL placement. We believe these salient points will help plan these cases with good postoperative outcomes.