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Year : 2007  |  Volume : 55  |  Issue : 2  |  Page : 146-148

Phacoemulsification in total white cataract with Stevens-Johnson syndrome

Iladevi Cataract and IOL Research Centre, Raghudeep Eye Clinic, Gurukul Road, Memnagar, Ahmedabad, India

Date of Submission02-May-2005
Date of Acceptance30-Jun-2006

Correspondence Address:
Abhay R Vasavada
Iladevi Cataract and IOL Research Centre, Raghudeep Eye Clinic, Gurukul Road, Memnagar, Ahmedabad
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0301-4738.30713

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Cataract surgery with Stevens-Johnson syndrome (S-J) is associated with a high incidence of complications and can worsen the primary disease. We report a case of phacoemulsification of a total, white cataract barely visible through the vascularized, keratinized cornea in the only seeing eye of a patient with S-J syndrome. We describe the intra-operative difficulties encountered during phacoemulsification and the surgical tools and techniques employed to overcome the surgical difficulties. The postoperative course was uneventful and the patient regained useful, navigational vision.

Keywords: Phacoemulsification, Stevens-Johnson syndrome, total cataract

How to cite this article:
Vasavada AR, Dholakia SA. Phacoemulsification in total white cataract with Stevens-Johnson syndrome. Indian J Ophthalmol 2007;55:146-8

How to cite this URL:
Vasavada AR, Dholakia SA. Phacoemulsification in total white cataract with Stevens-Johnson syndrome. Indian J Ophthalmol [serial online] 2007 [cited 2019 Dec 12];55:146-8. Available from:

Vision can be severely impaired due to the ocular manifestations of Stevens-Johnson (S-J) syndrome.[1] Total white cataract causes further hindrance to vision. Cataract surgery has a high incidence of complications,[2] increased susceptibility to infections[3] and can worsen the disease. Therefore, it is necessary to obtain a satisfactory technical utilization to minimize complications.

We report a case of phacoemulsification of a white cataract barely visible through the vascularized, keratinized cornea in the only seeing eye of a patient with S-J syndrome. The objective of reporting this case is to describe difficulties encountered and techniques employed.

  Case Report Top

A 33-year-old male with a two-year history of S-J syndrome was referred to us. The left eye had become blind with no perception of light whereas vision in the right eye was counting fingers at 4 meters. During the acute stage, the patient had developed suppurative ulcerative keratitis in both eyes. The keratitis caused corneal perforation in both eyes. In the left eye, the resultant pseudo-cornea made the cornea totally opaque. Examination of anterior chamber structures was not possible. Adherent leucoma had formed in the right eye at the 2 o'clock position, 3 mm from the nasal limbus and 1.5 mm from the inferior limbus with development of anterior synechiae at the site of perforation. Examination of the right eye revealed keratin plaques on the cornea with neo-vascularization. Both eyes revealed severe tear deficiency. The subject was treated with antibiotics, preservative-free tear supplements and lubricating gel. For the last 6 months, he had noticed progressive dimness of vision in the right eye and was referred for cataract surgery [Figure - 1][Figure - 2].

Visual acuity in the right eye was perception of light with accurate projection of rays. Examination of right eye revealed total white cataract barely visible through keratinized and vascularized cornea. Further examination revealed severe dry eye with no wetting on Schirmer test. Ultrasound B scan revealed normal posterior segment. Reliable biometry was not obtainable. The patient never wore glasses and based on history, intra ocular lens with power of +21.0 D was chosen.

Ciprofloxacin 0.3% eye drops were administered four times 48 hours before surgery. The pupil was dilated with cyclopentolate hydrochloride 1% and phenylepherine hydrochloride 10% eye drops. The surgical procedure was performed under topical anesthesia with Lignocaine jelly 2%. Dry eye necessitated frequent lubrication. Lignocaine jelly served as a lubricant in addition to possessing anesthetic properties.[4] Another means of moistening the cornea was applying viscoelastic frequently. The layer of hydroxy propyl methyl cellulose acted as a refractive surface, thereby enhancing visibility.

After conjunctival peritomy, minimal cauterization was performed. A paracentesis was performed with a 15° ophthalmic slit knife (Alcon surgical, Fort Worth, USA). The anterior chamber was re-formed with sodium hyaluronate 1.4% (Healon GV®, Advanced Medical Optics, Santa Ana, CA, USA). A valvular scleral incision was constructed temporally with satin slit (3.0 mm) (Alcon surgical, Fort Worth, USA) after a pocket was made with crescent blade. Ultimate soft-shell technique[5] was implemented to stain anterior capsule using trypan blue by injecting 0.1 ml trypan blue dye in the concentration of 0.06 mg/mL. As the capsule was fragile, frequent re-grasping of flap performed capsulorhexis.

Phacoemulsification was performed with Alcon Infiniti Vision SystemTM (Alcon Surgical, Fort Worth, USA) using the slow motion technique.[6] The parameters were: Ultrasound energy 40%, vacuum 80 mmHg and aspiration flow rate 25cc/minutes. Care was taken to perform phacoemulsification at the posterior plane within the confines of capsulorhexis [Figure - 3] using the soft-shell technique. Bimanual irrigation-aspiration was performed for cortex removal. Alcon AcrySof® Natural (+21.0D) was implanted in the bag, confirmed by nudging the capsulorhexis edge with a dialer and by reflection of the yellow color of IOL. The incision and paracentesis were sutured with 10.0 Nylon for additional safety.

On first postoperative day, mild corneal edema was observed which subsided within a week. Steroids were not prescribed. Ciprofloxacin eye drops were prescribed four times a day and tear supplements were administered hourly. Visual acuity was finger counting 4 m at one week and six months follow-up with well-centered IOL [Figure - 4].

  Discussion Top

Poor visibility made the case challenging at every step. Trypan blue is an indispensable tool to enhance visibility during surgery when white cataract is combined with corneal opacity.[7] Dye-staining combined with frequent re-grasping allowed capsulorhexis to be performed. It is necessary to achieve a complete capsulorhexis for safe emulsification. The blue-stained rim aided in confining phacoemulsification maneuvers to the posterior plane. Preoperative dilation was achieved with a cycloplegic and mydriatic since pigmented eyes have propensity for more inflammation. Although proparacaine eye drops may be less epithelial toxic, they have a short duration of action. Owing to anticipated prolonged surgery, long-acting jelly was preferred to avoid supplementation.

Due to diseased cornea, scleral tunnel was preferred.[8] The ultimate soft shell technique enabled coating of the endothelial cells with viscoelastic thereby protecting it during emulsification. By presetting low aspiration parameters, gradual occlusion break was facilitated. Another technique for superior surgical control was bimanual irrigation-aspiration. By preventing incisional distortion, chamber stability was maintained and thorough cortical clean-up was possible, confirmed postoperatively by no residual cortex. Extreme caution was required at every step. It was a judicious combination of the above as well as the skill and experience of the surgeon, which enabled successful phacoemulsification.

Steroids were not prescribed due to fear of super-added infection. Cyclopentolate helped to reduce the inflammation due to cycloplegic effect. Although not used in this case, alternate routes (such as intracameral injection triamcinolone at the end of surgery) to deliver steroids may be helpful to decrease inflammation without increasing risk of infection. Preservative-free tear supplements were liberally used. It is essential to counsel patients on the importance of tear substitutes because of the risk of developing infection.

In conclusion, phacoemulsification of white cataract in a patient with S-J syndrome was safely performed with modern tools and appropriate techniques. However, phacoemulsification in such cases should only be undertaken by well-experienced surgeons due to increased risk of complications. Alternative approaches include an extracapsular cataract surgery[8] or manual small incision cataract surgery.

  References Top

Kompella VB, Sangwan VS, Bansal AK, Garg P, Aasuri MK, Rao GN. Ophthalmic complications and management of Stevens-Johnson syndrome at a tertiary eye care centre in South India. Indian J Ophthalmol 2002;50:283-6.  Back to cited text no. 1
Radtke N, Meyers S, Kaufman HE. Sterile corneal ulcers after cataract surgery in keratoconjunctivitis sicca. Arch Ophthalmol 1978;96:51-2.  Back to cited text no. 2
Ram J, Sharma A, Pandav SS Gupta A, Bambery P. Cataract Surgery in patients with dry eyes. J Cataract Refract Surg 1998;24:1119-24.  Back to cited text no. 3
Arshinoff SA, Khoury E. HsS versus a balanced salt solution as a corneal wetting agent during routine cataract extraction and lens implantation. J Cataract Refract Surg 1997;23:1221-5.  Back to cited text no. 4
Arshinoff SA. Using BSS with viscoadaptives in the ultimate soft-shell technique. J Cataract Refract Surg 2002;28:1509-14.  Back to cited text no. 5
Osher RH. Slow motion phacoemulsification approach. J Cataract Refract Surg 1993;19:667.  Back to cited text no. 6
Bhartiya P, Sharma N, Ray M, Sinha R, Vajpayee RB. Trypan blue assisted phacoemulsification in corneal opacities. Br J Ophthalmol 2002;86:857-9.  Back to cited text no. 7
Sangwan VS, Burman S. Cataract surgery in Stevens Johnson syndrome. J Cataract Refract Surg 2005;31:860-2.  Back to cited text no. 8


  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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