Traumatic Retinal Break From Viscoelastic Cannula During Cataract Surgery

The overall incidence of retinal detachment after extracapsular cataract extraction is between 1% and 2%.^1-3 Retinal detachment after cataract surgery usually occurs after a posterior vitreous detachment creates one or more retinal tears in the region of the vitreous base. In rare cases, direct surgical trauma to the posterior segment can cause a retinal break and subsequent retinal detachment. To our knowledge, this is the first report of a retinal tear secondary to direct trauma from a cannula used to inject viscoelastic material.

A 59-year-old woman was referred to the Retina Service at the Scheie Eye Institute, Philadelphia, Pa, for evaluation after cataract surgery. The patient had undergone extracapsular cataract extraction by phacoemulsification the previous day. After the cataract was extracted, a syringe containing the viscoelastic hyaluronate sodium with an appropriate-sized cannula tip was inserted into the eye. While the viscoelastic was being injected into the capsular bag, the cannula was forcefully ejected from the syringe. The cannula pierced the posterior capsule of the lens centrally (Figure 1) and drove inferiorly into the posterior segment, where it directly struck the retina. The cannula was removed, an anterior vitrectomy was performed, and a posterior chamber intraocular lens was placed. The clear corneal incision was left unsutured.

On postoperative day 1, the patient noted floaters in the right eye. Her visual acuity was 20/40 and the intraocular pressure was 23 mmHg. Slitlamp examination was notable for a Seidel-negative clear corneal incision, minimal anterior segment inflammation, and a well-centered posterior chamber intraocular lens. A few pigmented cells were present in the vitreous.

The patient was referred to our service because the posterior segment examination showed a blood clot that emanated through a peripheral retinal break inferonasally and an operculated hole at the 9-o'clock meridian. The posterior pole was normal. The retinal breaks were treated with laser retinopexy.

Six weeks later the patient had a visual acuity of 20/20. The preretinal hemorrhage was almost completely resorbed, and no new retinal breaks or tears were seen. The retinopexy surrounded both retinal tears with moderate pigmentary response; no subretinal fluid was present. The patient retained 20/20 visual acuity and was without complication at 12 months of follow-up.

Iatrogenic retinal breaks occur rarely during cataract surgery and are often related to inadvertent ocular penetration during anesthetic administration.⁴ Direct surgical trauma to the posterior segment structures is rarely caused by intraocular manipulation, as instruments are under direct visualization and surgical control. This case illustrates a possible cause of inadvertent trauma: the forceful ejection of an unsecured cannula during injection of viscoelastic. Because of the high resistance provided by the viscoelastic, significant pressure is generated during injection, allowing for a sudden, explosive release of the cannula into the eye. To avoid this surgical complication, the surgeon should secure the connections of all surgical instruments, including cannulas, phacoemulsification tips, and intraocular lens injectors, before inserting them into the eye, especially if prepared by an assistant. Aiming the cannulas toward the angle and lens injectors toward the ciliary body may prevent forceful posterior capsular tears and retinal breaks. If traumatic retinal breaks do occur, retinopexy should be considered to prevent retinal detachment.⁵

Corresponding author: Albert M. Maguire, MD, Retina Service, Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania, 51 N 39th St, Philadelphia, PA 19104.