The routine case that was not routine : Dr. Deepak Megur

Added: 2026-06-06

[00:00:00]This film is intended for eye surgeons for training and education purposes.

[00:00:05]Viewer discretion is strongly recommended.

[00:00:08]Hi friends, welcome to yet another interesting case. This case is a reminder of one of the most important truths in cataract surgery. Nothing is routine. The moment we start assuming that a case is simple, predictable, and routine, that's often the exact moment when surgery decides to surprise us. And today, I want to take you through one such recent experience. At first glance, this looked like a fairly ordinary cataract case. A 65-year-old lady presents with a cataract. The eye looked quite innocuous. There was pseudoexfoliation. The pupil was moderately dilating, but there was nothing dramatically alarming in the slit lamp examination. The nucleus was not very hard. The case was planned as for routine phacoemulsification with a toric intraocular lens. So, on paper, this looked like a standard cataract surgery. But as we all know, in surgery, the real case begins only after the patient is draped. And that is where the first warning sign actually appeared.

[00:01:04]Once the patient was draped, I realized that she was extremely anxious. She was just unable to fixate on the microscope light. She kept moving her eyes continuously. Her comprehension was fine. She was able to understand what we're trying to tell, but despite repeated reassurance and repeated request to look at the light, the eye movements continued. Initially, I thought perhaps the discomfort or anxiety was contributing to the movements, so I decided to give a small sub-Tenon's lidocaine injection of 1.5 ml, hoping that the better analgesia would make her calmer and reduce the ocular movements. Unfortunately, it did not help. The patient continued to move her eye. At this point, I had to make a judgment call. The cataract was not very hard. The case did not appear very complex, so I decided to proceed carefully, make the two standard side port and incisions. Capsulorhexis stained. At this stage, because of pseudoexfoliation, moderately dilating pupil, I felt that pupil could come down further during surgery. So, I didn't want to take a chance. So, I decided to use the BX pupil expansion ring. The main incision is created.

[00:02:09]Now, I've used hundreds of BX rings before. It's a very familiar device in my hands. But this case taught me something very important. Even a familiar device can become difficult in an unfamiliar situation. Now, as soon as the BX ring was introduced into the eye, I realized that something was not right.

[00:02:28]The patient was moving her eyes continuously, of course. The anterior chamber was shallow, and the BX ring was sitting dangerously close to the corneal endothelium. I was unable to negotiate the device down smoothly onto the surface of the iris.

[00:02:44]Usually, with adequate chamber depth and good control, the device can be positioned without much difficulty. But here, the combination of a shallow chamber, patient moving the eyes, and limited working space made the situation unexpectedly difficult for me. I tried to inject viscoelastic hoping to create space and push the device posteriorly, but the viscoelastic cannula was under the BX device, and the OD actually pushed the device even more anteriorly, closer to the endothelium. Now, the problem had become a little more serious. The ring was close to the cornea, the patient's eye was moving, chamber was shallow, and I was trying to find a safe plane to bring the device down onto the surface of the iris. Now, this is the kind of situation where a small technical difficulty can quickly escalate into a major intraoperative challenge.

[00:03:38]So, I had to use multiple instruments, very delicate maneuvers, to get the BX in position properly on the iris surface.

[00:03:45]But during the entire process, the patient continued to move her eyes relentlessly. And with every moment, the risk of endothelial touch and Descemets membrane trauma increased.

[00:04:03]Eventually, I managed to place the B string correctly, but by then I had a strong suspicion that endothelial trauma localized Descemets detachment had already occurred. Look at this line and near the main incision. This was my suspicion. At this point, I asked my assistant to show me the IOL master report again and there it was. The chamber was only 2.19 mm. So, usually I'm very meticulous in planning most of my cases. Every case, I look at each of the biometry readings and then plan my surgery. This was one case where I thought it was a routine one at the slit lamp examination. I just didn't closely look into the anterior chamber depths.

[00:04:42]So, the message is the devil is in the detail. Now, because the case looked apparently straightforward, I'd not given enough weight to this particular entity. So, this is an important lesson.

[00:04:55]A shallow anterior chamber may not look dramatic at the slit lamp with an innocuous looking cataract, but in certain situations in the OR, when combined with a moving pupil and a pupil expansion device, it can create some unforgiving surgical environment.

[00:05:13]So, the first learning point, before using any pupil expansion device, especially in pseudoexfoliation eyes, look carefully at the anterior chamber depth. In a shallow chamber, one has to be very mindful of ensuring that the manipulation is as gentle and away from the cornea as possible. And if you find that the patient is slightly uncooperative, then just ensuring complete akinesia with good analgesia would be a better choice.

[00:05:43]Now, the second warning sign appears. As I started tearing the anterior capsule, I could see wrinkles appearing in the advancing edge of the tear. Now, this is a very important sign. When you see this anterior capsule wrinkling while making the rexis, it tells you the zonules are not healthy. This is just not pseudoexfoliation with small pupil. It also has diffuse zonulopathy, and this eye would deserve a CTR. So, we've got three different uh situations. The patient is unable to fix it and look at the eye, keeps on moving the eye.

[00:06:13]Chamber is shallow, zonules are weak.

[00:06:16]Nevertheless, we need to proceed as carefully as possible. Hydrodissection is completed. The nucleus management is quite easy because the nucleus was not dense, but the nagging problem of eye movement continues throughout every step of the surgery. Every step has to be done with extra caution. So, in such situations, you know, maintaining control is probably the most important thing, and it is also the most difficult one. So, you should always ensure that you are in control of the situation. So, once the nucleus is removed, cortex aspiration is performed carefully.

[00:06:49]Because the zonular weakness was diffuse, I decided to implant a capsule tension ring.

[00:06:56]The ring is negotiated into the capsular bag.

[00:07:00]Once the bag is stabilized, the toric intraocular lens was implanted into the eye.

[00:07:07]After lens implantation, time to remove the BHT device. The ring was disengaged carefully from the iris and slowly negotiated out of the eye.

[00:07:19]The viscoelastic in front and behind the lens is irrigated out. At this stage, the corneal findings become very clear.

[00:07:28]Near the main incision, there is an obvious region where Descemet's folds are seen. Localized corneal edema is visible, and I can see a localized Descemet's membrane detachment in that area.

[00:07:39]The question now was whether to inject air or gas immediately. In this case, I felt that the Descemet's was limited and lamellar and hoped that it would reattach on its own. So, I decided not to inject any gas or air at the end of the surgery. The surgery was completed.

[00:07:56]But the next day, the cornea told the story. Dense localized corneal edema starting from the area of the wound and extending towards the center of the pupil. On anterior segment OCT, the corneal thickness map showed significant edema in that region. The OCT also demonstrated a localized Descemet's membrane detachment which was much more in its dimensions than what I had expected. Fortunately, it appeared to be lamellar rather than a large scrolled-in or complete detachment. These shallow localized detachments can often reattach spontaneously with conservative management. So, the patient was started on hypertonic saline and topical steroid therapy.

[00:08:37]The plan was clear. Observe closely and if the Descemet's did not reattach, then I would definitely go in and put in intracameral air or gas. The patient was followed up very carefully and uh thankfully, over the next several days, the Descemet membrane reattached and the corneal edema gradually reduced. The cornea became clearer, the OCT showed improvement in corneal thickness, and the area of detachment settled well. So, the final outcome was good, but the case left behind some very important lessons.

[00:09:08]These are the lessons I want every young ophthalmologist to take home. Number one, do not assume that every patient is suitable for topical anesthesia. Topical anesthesia is wonderful. It's quick, elegant, and works beautifully in most patients. But uh topical anesthesia does not control eye movements. If the patient is extremely anxious, unable to fix, or keeps moving the eye despite repeated instructions, topical anesthesia can convert a simple case into a difficult to This is not routine, but this is unusual case, but we should be prepared for the worst. In this particular case, the patient probably would have benefited from a block. A peribulbar or a sub-Tenon's block might have reduced the ocular movements and provided surgical control. In some setups, mild IV sedation is a routine and may help such anxious patients. But in many Indian practices like mine, in routine IV sedation with a standby anesthesiologist is not always part of the workflow. So, the anesthesiologist is usually in for selected cases. But this case reminds us that patient selection for topical anesthesia can be critical.

[00:10:13]The second lesson is obviously a look at pseudoexfoliation and the anterior chamber depth. You should not ignore these findings. You always will be surprised intraoperatively when you ignore this. An anterior chamber depth of 2.9 mm is shallow. In such eye, every intraocular maneuver happens close to the endothelium. A pupil expansion device obviously has less room to be maneuvered. The phaco tip works closer to the cornea. So, before surgery, especially in pseudoexfoliation eyes, do not just look at the IOL power or the axial length. Look carefully at the anterior chamber depth. The next lesson.

[00:10:49]A familiar device does not guarantee a familiar surgery. The Beehler ring is an excellent device and I've used in hundreds of cases with no issues at all. But in this case, the problem was not the device itself.

[00:11:02]The problem was the surgical environment. A shallow chamber, moving eye, pseudoexfoliation. So, in this case, even a familiar device can throw us surprises because the working space was compromised. So, the bottom line, never take anything for granted. This case had a soft moderate nucleus, manageable pupil, planned a toric lens.

[00:11:25]It looked like a straightforward cataract surgery. But there were multiple surprises. A difficult pupil expansion device insertion, which I had least expected, resulted in an endothelial damage and disinsertion detachment.

[00:11:38]Thankfully, the cornea recovered and the final outcome was good, but the lesson remains powerful. As surgeons, we must respect every eye because every eye has its own personality. Some eyes cooperate beautifully, some eyes warn us before surgeries, and some eyes reveal their secrets only after we enter the anterior chamber. So, to all young eye surgeons watching this, before every case, pause for a few seconds. Look for these things. Is the patient cooperative? Is the chamber deep enough? Is there anything I need to be worried about? Do I need to block this case instead of a topical anesthesia? So on and so forth.

[00:12:13]These small pauses and preparation helps us to gain confidence in cataract surgery and prevent big surprises. And in cataract surgery, confidence is important, but however, overconfidence is dangerous. Best surgeons are not the ones who assume that everything will go well. The best surgeons are the ones who are prepared when things do not go as expected. So, remember, respect the routine cases, respect all the small warning signs, and never underestimate a quiet-looking eye. Thank you for watching, and I hope this case was useful, especially for the budding eye surgeons. See you in the next surgical story.