Sir,

Learning phacoemulsification cataract surgery can prove a difficult step for trainees, despite the advances in technology, which have led to its increased efficacy and safety. Aspiring ophthalmic surgeons should familiarise themselves with phacoemulsification in a wet laboratory before operating on patients, and it is now mandatory that UK ophthalmic trainees attend a basic surgery course before ‘hands on’ experience in the operating theatre.1, 2 However, the prosthetic and animal eyes used for training purposes are not the same as human eyes, and at some stage the trainee will have to operate for the first time on a ‘live’ patient. One of the skills to master when learning phacoemulsification is how to gauge the groove depth while sculpting. It needs to be sufficiently deep to allow easy cracking of the nucleus, yet not so deep as to damage the posterior capsule. Sculpting is particularly difficult in patients with a poor red reflex.3

Enhanced lens visualisation can assist junior surgeons when learning phacoemulsification. To the best of our knowledge, there are no published reports of lens enhancing dyes being used in living human eye operations, although Werner et al4 described ways of enhancing visualisation when learning phacoemulsification on post-mortem human eyes in the laboratory. However, not all trainees have access to post-mortem human eyes, and differences still exist as compared to operating on real patients. We describe the first use of triamcinolone acetonide (Kenalog®) to enhance lens visualisation during phacoemulsification. Triamcinolone acetonide is safe for intracameral use, and has been used both to treat vitreoretinal diseases and to assist surgeons performing vitrectomy.5, 6, 7

Case report

Three eyes of three patients with visually debilitating cataract underwent triamcinolone acetonide-assisted phacoemulsification with foldable intraocular lens implant. Two patients were women, aged 78 and 71 years (visual acuity 6/24 and 6/12, respectively) and one was a man, aged 75 years (visual acuity 6/12). All had moderate to marked nuclear lens opacity. One had additional cortical lens opacities. Informed consent was obtained. Following cortical cleaving hydrodissection with 2 ml of balanced salt solution (BSS®), 0.2 ml of triamcinolone acetonide (20 mg/ml) was injected under the anterior capsule via a blunt-tipped hydrodissection cannula. This was in the same capsule–cortex plane as the BSS hydrodissection. The injection of triamcinolone acetonide as an opaque white solution produced a brilliant golden layer, appearing just in front of the posterior capsule when viewed through the operating microscope. Figure 1 demonstrates the appearance of the crystalline lens before and after triamcinolone acetonide injection. The golden layer formed by the triamcinolone acetonide allowed immediate appreciation of both the thickness of the lens and the position of the phaco tip in relation to the posterior capsule while sculpting. The Kenalog rapidly dissipated once the lens was rotated and no triamcinolone acetonide particles were evident within the eye after the phacoemulsification was completed. All three operations were completed successfully with no complications, and each operated eye achieved a visual acuity of 6/9 unaided or better when examined 2 weeks postoperatively.

Figure 1
figure 1

Appearance of the crystalline lens after hydrodissection (a) and the improved lens delineation after triamcinolone acetonide injection (b).

Full size image

Comment

Some surgical techniques are best mastered by operating on live patients. Capsulorrhexis is one such technique, and the anterior capsule enhancement used by experienced surgeons in difficult cases can also be used by trainees during more straightforward cases.8, 9 We have shown that lens visualisation can also be safely enhanced during phacoemulsification, allowing easier assessment of the depth of the phaco ‘grooves’ and thickness of the peripheral lens while sculpting. It is reported that up to 36% of posterior capsule tears occur during this stage of cataract surgery,10 and we suggest that the improved lens visualisation achieved with triamcinolone acetonide could help to reduce complications when learning phacoemulsification.