Steps for Marfan Syndrome Cataract Surgery

Steps for safely and efficiently doing Marfan Cataract

Dave Woods MD 

6/20/2020

Plan for 60 minutes with LMA general sedation.

• 1 or 2 peritomies, 6:00 & 12:00 sclerotomy 2 mm back from limbus, 1 mm from scleral spur, 3 mm long w diamond

• 5 corneal small posterior sideports for MST hooks (3 are placed inferior every 2.5 clock hours), 1 sideport with endocoat at vitreous face, 2 more sideports for bimanual IA etc.

• The sharpest cystitome is to make your own bent 30g sharp cystitome. Start rhexis away from you, make it small, and come back to you in my CCW normal direction, put in an MST hook for traction at inferior areas to stabilize countertraction to tear against.

• Very gentle hydrodissection/hydrodelineation 

• Bimanual IA, slow and gentle with lower aspiration

• Provisc & CTR into the bag.

• Now place 1st Ahmed Capsular Tension Segment inferiorly, CTS #1:

  • Do the Safran approach without needles, just Gore-tex thread using loaded gore-tex 27g needle to pass into sclera for 1st pass.  Thread gore-tex suture into 27 gauge needle and pass into sclera, then reach in main wound to retrieve gore-tex.   Loop into CTS,   Place CTS into bag (long end first).  (its possible to place CTS through 2.2 mm wound).  Take still externalized end of gore-tex in main wound and use micro-grasper through a sclerotomy to pull back out sclerotomy, and tie and fixate, 3 mm apart from first site in 25% scleral groove.

  • Could also dock straightened CV-8 Gore-tex needle to ab externo placed 25 gauge needle to tie CTS to sclera

• Place IOL in the bag

• CTS #2 Superiorly.  Secure with Safran approach.  

• Tighten with slip knot (2 throws same direction, 1st inside the V, 2nd outside the V on far side and under, throw same direction), pull up short end and down on long end to slip tighter, pull horizontally to lock.  Can pull knot apart if need to loosen, and will tighten knot nicely this way.

• Bimanual IA to remove the remaining viscoelastic.

• Seal wounds

• Close Conjunctiva.

After Case:  

• add external Ofloxacin QID, EMN TID for conj/sclerotomies if has AC Moxifloxacin (needs external coverage).

• See Retina for Retinal Check

• Add Vitamin C if you would like faster wound healing

Updated list of Extra Supplies for Marfan’s Case:

MST Hooks

1 Viscoat

2 Provisc

30 g needle on Tb syringe, bent by MD with sharp tip (sharpest cystitome possible).

Bimanual I/A (True Bimanual, sideport size)

Bent short 25 g needle on empty Tb Syringe … if docking to needle. Peribulbar needle will work.

Bent short 27 g needle on empty Tb Syringe25 gauge or smaller ... Retina MICRO-GRASPER small enough to go through sclerotomy of 25 gauge 

13 mm CTR

Ahmed CTS …   x i or ii

CV-8 Gore-Tex double armed suture, don’t cut … x i or ii per CTS

MD will need to straighten these with 2 needle drivers (unless Safran approach, then cut off needles 

10-0 Vicryl Suture to close conj and any sideports at End

Dave Woods MD