Open Journal of Ophthalmology, 2012, 2, 127-130 Published Online November 2012 (
The Use of the Anterior Chamber Maintainer in Special
Cataract Cases
Vasileios Lakidis1, Antonios Lakidis2,3, Despoina Kolokotroni2, Diamantis Almaliotis2,
Vasileios Karampatakis2
1Bioclinic, Department of Ophthalmology, Thessaloniki, Greece; 2Laboratory of Experimental Ophthalmology Aristotle University
of Thessaloniki, Greece; 3The 1st Eye Clinic of AHEPA Hospital, Aristotle University of Thessaloniki, Greece.
Received July 11th, 2012; revised September 27th, 2012; accepted October 8th, 2012
Purpose: To point out the indications for the use of the Anterior Chamber Maintainer (ACM) in order to facilitate cata-
ract surgery in selective cases. Materials and Methods: In a time interval of 4 years the ACM was used in 28 special
cataract cases 17 patients had high myopia (12 - 25 dpt, axial length 28 - 34 mm), 3 patients had vitreo-retinal pathology
known pre-operatively and 8 cases were previously vitrectomized with silicon oil. In these cases the ACM was intro-
duced either from the beginning or during the surgical procedure when excessive fluctuations of the Anterior Chamber
(AC) were observed. Results: Though the new generation phaco machines tend to maintain the stability of the AC, the
use of the ACM contributed to even greater stability during the insertion and the removal of probes and during the
whole procedure, eliminating the risk of complications. All these risky cases were accomplished without intraoperative
complications. The surgeons experienced a sense of increased safety during the procedure. Conclusions: The use of the
ACM in cataract cases with high risk for complications offers a much greater stability of the AC, by eliminating the
fluctuations of the posterior capsule and consequently prevents intraoperative and potentially postoperative complica-
Keywords: ACM; Cataract Surgery; Intraoperative Complications
1. Introduction
The anterior segment surgeons very often have to man-
age special and difficult cataract cases. The use of the
ACM stabilizes the intraocular presence during surgery
[1] thus increasing safety in high risk cases Cataract sur-
geons have to be extra cautious when they manage eyes
with high axial length. In high myopic eyes pathological
degenerations of the sclera, choroid, retina and the vitre-
ous often exist [2-6]. The most common type of cataract
in high myopic eyes is the sub capsular cataract, which
usually appears in younger ages and tends to progress
rather fast [7]. Retinal degenerations of high myopic eyes
are a risk factor of retinal detachment after cataract sur-
gery and this fact is influenced by the age of the patient,
the axial length of the eye, the pre-existence of retinal
degenerations, history of retinal detachment surgery of
the other eye, the surgical procedure and the integrity of
the capsular bag [8-11]. In these cataract cases the rupture
of the posterior capsule may have serious intra-operative
and post-operative complications.
Another challenge for the surgeons of the anterior seg-
ment is the cataract surgery in previously vitrectomized
eyes (pars plana vitrectomy). It is known that there is a
higher rate of intra-operative and post-operative compli-
cations in those eyes. These complications occur due to the
anatomical changes in the previously vitrectomized eyes,
such as swallow anterior chamber, intra-operative miosis
[12,13], unstable posterior capsule [14], posterior capsule
opacities [15], loose zonule and lack of support to the lens
from the vitreous [16].
Despite all these difficulties, phaco surgery are consi-
dered safe and it is safer than the ECCE [17], however it is
known that the use of an ACM increases the safety during
anterior segment surgery [18].
The purpose of this report is to point out the indica-
tions of the use of the ACM in risky cataract cases so as
to facilitate surgery and prevent complication.
2. Material and Methods
2.1. Selection of Patients
28 special cataract cases were operated by the use of an
Our material consisted of 28 eyes. 17 eyes had myopia
Copyright © 2012 SciRes. OJOph
The Use of the Anterior Chamber Maintainer in Special Cataract Cases
higher than 12 dpt (12 - 25 dpt and axial length 28 - 34
mm), deep anterior chamber and some of them phacodo-
nesis. 3 eyes had vitreo-retinal pathology (vitreo-retinal
tractions such as diabetic retinopathy or retinal degenera-
tions) known preoperatively and treated with prophylac-
tic laser in the past and 8 eyes were previously vitrecto-
mized and the vitreous cavity was filled with silicon oil.
The ACM was introduced, on the purpose to control
the depth and the pressure in the anterior chamber when
the phaco tip and the irrigation aspiration cannulas are
inserted or removed from the eye during the procedure
and also to keep the posterior capsule constantly far from
the phaco tip minimizing the fluctuations.
2.2. Surgical Procedure
The Millennium from Bause and Lomb and the Infinity
from Alcon Laboratories were used.
After the sterilization of the surgical field and topical
anesthesia, 2 side ports were created at 3 and 9 o’clock for
bimanual irrigation-aspiration and another corneal inci-
sion at a lower temporal position for the introduction of
the ACM.
After the injection of the viscoelastic and the capsu-
lorhexis, the ACM remained open at a height of about 60
cm from the eye.
The ACM remained open during the hydro-dissection,
the phacoemulsification and the aspiration of cortex. After
the aspiration of the cortical material the ACM flow was
interrupted and viscoelastic was injected in the anterior
chamber and the capsular bag for the insertion of the
The aspiration of the viscoelastic was done with open
flow of the ACM, even behind the IOL.
Every incision was carefully “sealed” by injecting BSS
in the corneal stroma and the withdrawal of the ACM
was done by simultaneous injection of BSS through a side-
The goal was to keep the AC as stable as possible dur-
ing the procedure.
3. Results
In all these special cases, no intraoperative complications
were observed, though according to the international lit-
erature and according to our experience high rates of com-
plications are expected in such cases.
The intraoperative fluctuations of the anterior chamber
and the surge phenomena were greatly eliminated.
No rupture of the posterior capsule occurred. In vitrecto-
mized eyes with silicon oil the presence of the ACM pre-
vented the invasion of silicon into the anterior chamber.
The surgeons experienced an increased sense of safety
during the procedure.
No postoperative cornea edema was observed. The IOP
ranged within the expected normal values with no in-
crease related to the surgery. There were no negative
consequences on the expected final visual acuity. In a
follow up period of 2 - 5 years, no clinical CME was
detected and also retinal detachment did not occur in the
eyes with high myopia and also in the eyes with known
pre-existing retinal pathology (Table 1). All eyes were
examined postoperatively for retinal pathology, and risk
for retinal detachment and 3 more eyes were treated ap-
propriately (with prophylactic laser) since a significant
percentage of these eyes (5 eyes in the follow up period)
required Nd:YAG capsulotomy postoperatively which may
increase the risk of retinal detachment.
No silicon oil was detected in the anterior chamber in
the vitrectomized eyes.
4. Discussion
The use of the ACM in our material contributed greatly
to the success of phaco in special cataract cases such as
in high myopic patients.
Alio et al. [19] reported that the possibility of retinal
detachment in high myopic patients who underwent phaco
was 2.7%. Other researchers reported that the possibility
of retinal detachment after phaco in myopic patients was
quite higher 8% [20], and only 0.4% - 1.2% of the general
population that undergo phaco surgery [20].
In another study, Wilbrandt et al. [21] were the first
who described the effects that take place during the phaco
of high myopic cases thoroughly. They named these ef-
fects as LIRDS (lens-iris diaphragm retropulsion syn-
drome). It takes place during the insertion of the phaco tip
in the eye and causes instant increase of the anterior cham-
ber depth and dilation of the iris (“tomato-iris”). This
phenomenon occurs due to the weight of the water co-
lumn of the infusion. LIRDS usually rises in eyes with
weak zonules pathology. They used an anterior chamber
maintainer (Lewicky type) and lowered the height of the
bottle in order to overcome this syndrome. The use of the
ACM in our material stabilized the depth of the anterior
chamber and undoubtedly was proved to be valuable for
the safety of the procedure.
On the other hand, high ratio of complications is ob-
served in previously vitrectomized eyes that undergo
Table 1. Pre-existing ocular pathology in 28 special cataract
Number of
eyes Ocular
pathology Intraoperative
complications postoperative
17 Myopia (12 - 25 dpt) No No
3 Vitreo-retinal
pathology No No
8 Vitrectomized with
silicone No No
Copyright © 2012 SciRes. OJOph
The Use of the Anterior Chamber Maintainer in Special Cataract Cases 129
phaco. Cole et al. [22] studied these complications. More
specifically, in 12.5% rupture of the posterior capsule
occurred, in 5.6% retinal detachment and in a few cases
loss of vitreous and zonule rupture were recorded. Anato-
mical changes that take place after pars plana vitrectomy
prejudice the onset of complications. Yung et al. [23] in-
vestigated the pathophysiological changes that occurred
in eyes that underwent vitrectomy and admission of silicon
oil. A hypertrophic response of the anterior capsule of
about 20 - 25 μm was observed. Also, the epithelium of
the lens was hypertrophic and fibrosis of the posterior
surface of the anterior capsule occurred. These changes
make the work of the cataract surgeon really difficult in
relation to the posterior capsule fluctuations as a result of
the lack of support due to the previous vitrectomy. The
role of the ACM in previously vitrectomized eyes, with
silicon oil is really of significant importance. It is well-
known that during phaco, when the phaco tip is removed,
silicon oil pervade through zonule to the anterior cham-
ber. More specifically, the intraocular pressure drops sig-
nificantly when the phaco tip is removed from the eye.
Due to the collapses of the anterior chamber, the iris dia-
phragm is protruded and the zonular spaces become wider.
Through these spaces silicon oil drops, pass into the ante-
rior chamber. The ACM in our cases, stabilized the intra-
ocular pressure and thus prevented the passage of the si-
licon oil to the anterior chamber.
Furthermore, the ACM, due to the stability of the depth
of the anterior chamber, diminishes the vitreo-retinal trac-
tions in pathological cases such as proliferative diabetic
retinopathy. Some researchers [24] tried to eliminate these
vitreo-retinal tractions, in patients with diabetic retino-
pathy, with the use of intravitreal injections of bevani-
zumab. They aimed at reducing the proliferative neovas-
cularisation, the edema and the tractions between the vi-
treous and the retina. ACM is obviously useful in these
cataract cases.
Another application of the ACM is in cases of rupture
of the anterior capsule (capsulorhexis tear). In our opinion
(experience in a great number of phaco cases), the appli-
cation of the ACM stabilizes the pressure in the anterior
chamber and it may prevent the extension of the rupture
to the posterior capsule.
Other researchers [25] investigated the vitreous loss
that is observed in cases of rupture of the posterior cap-
sule during phaco. They compared cataract cases that were
performed by experienced surgeons with or without the
ACM. They concluded that both groups had the same per-
centage of post-operative complications and also a greater
vitreous loss was observed when the rupture of the poste-
rior capsule occurred with the presence of an ACM. In
our material no capsule rupture occurred.
It also has to be mentioned that complicated cataract
surgery is related with higher incidence of CME. It has to
be outpointed that none of our patients developed clinical
Conclusively, according to our experience, the use of
an ACM facilitates the operation and makes surgeon feel
safer. It increases the safety of the phaco procedure by
increasing the stability of the depth of the anterior cham-
ber and by reducing the posterior capsule fluctuations
during the insertion and withdrawal of the phaco tip and
the irrigation aspiration cannulas. Thus many intra-opera-
tive and postoperative complications may be prevented.
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