- Email: [email protected]
August consultation #3
CONSULTATION SECTION
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Figure 3. Dr. Schmidt custom iris prosthesis before implantation (top left), view of aniridic globe preoperatively (top right), and early postoperative photograph of both eyes (bottom). Note the apparent difference in the color of the device outside the eye compared with the color of the same device in vivo.
- This case is challenging because both functional and cosmetic treatment must be considered. Of the 3 possible options, none would improve visual acuity as the current low acuity might be a result of the ruthenium radiation or the long-standing macular edema caused by the retinal detachment. If this is not the case, visual acuity could be improved by modifying the refraction. Thus, I will focus on the monocular diplopia and cosmetic issue. The first treatment option is the old method of corneal tattooing with Chinese ink in the inferonasal periphery. In a rudimentary way, it could solve the diplopia and the cosmetic problem. The second possibility is to perform 3 McCannel-like double sutures.1 The sphincter edge can be brought near the iris periphery with the central suture, and the 2 lateral sutures would approach part of the iris stroma. In this way, the large iridectomy can be partly closed, although the pupil may be somewhat distorted/diverted, and the monocular diplopia would be solved. The third possibility is the use of a custom piggyback implant. It could have the shape of a 6.0 to 8.0 mm iris-claw lens, leaving a 4.0 mm free pupil. The remaining poly(methyl methacrylate) (PMMA)
could be dyed to match the iris in the fellow eye. Another kind of piggyback could be a partial iris prosthesis, again dyed to match the fellow-eye iris, covering only the iridectomy area and extending with 2 haptics (approximately 12.0 mm) of PMMA or polypropylene (Prolene) implanted in the sulcus over the capsular bag where the distension ring is located. Nevertheless, I have found that in quite a few cases, partial or total artificial iris implantation is not completely satisfactory because of a postoperative pressure increase that requires valve surgery. In this case, the adage ‘‘a bird in the hand is worth two in the bush’’ could be applied. Nevertheless, the decision depends on the patient and whether he accepts the explanation of the therapeutic possibilities and that some complications could appear later (ie, with the third option). I would choose a tinted irisclip device. Jose´ Luis Menezo, MD, PhD, FEBO Valencia, Spain REFERENCE 1. McCannel MA. A retrievable suture idea for anterior uveal problems. Ophthalmic Surg 1976; 7:98–103
J CATARACT REFRACT SURG - VOL 34, AUGUST 2008
1233
Figure 3. Dr. Schmidt custom iris prosthesis before implantation (top left), view of aniridic globe preoperatively (top right), and early postoperative photograph of both eyes (bottom). Note the apparent difference in the color of the device outside the eye compared with the color of the same device in vivo.
- This case is challenging because both functional and cosmetic treatment must be considered. Of the 3 possible options, none would improve visual acuity as the current low acuity might be a result of the ruthenium radiation or the long-standing macular edema caused by the retinal detachment. If this is not the case, visual acuity could be improved by modifying the refraction. Thus, I will focus on the monocular diplopia and cosmetic issue. The first treatment option is the old method of corneal tattooing with Chinese ink in the inferonasal periphery. In a rudimentary way, it could solve the diplopia and the cosmetic problem. The second possibility is to perform 3 McCannel-like double sutures.1 The sphincter edge can be brought near the iris periphery with the central suture, and the 2 lateral sutures would approach part of the iris stroma. In this way, the large iridectomy can be partly closed, although the pupil may be somewhat distorted/diverted, and the monocular diplopia would be solved. The third possibility is the use of a custom piggyback implant. It could have the shape of a 6.0 to 8.0 mm iris-claw lens, leaving a 4.0 mm free pupil. The remaining poly(methyl methacrylate) (PMMA)
could be dyed to match the iris in the fellow eye. Another kind of piggyback could be a partial iris prosthesis, again dyed to match the fellow-eye iris, covering only the iridectomy area and extending with 2 haptics (approximately 12.0 mm) of PMMA or polypropylene (Prolene) implanted in the sulcus over the capsular bag where the distension ring is located. Nevertheless, I have found that in quite a few cases, partial or total artificial iris implantation is not completely satisfactory because of a postoperative pressure increase that requires valve surgery. In this case, the adage ‘‘a bird in the hand is worth two in the bush’’ could be applied. Nevertheless, the decision depends on the patient and whether he accepts the explanation of the therapeutic possibilities and that some complications could appear later (ie, with the third option). I would choose a tinted irisclip device. Jose´ Luis Menezo, MD, PhD, FEBO Valencia, Spain REFERENCE 1. McCannel MA. A retrievable suture idea for anterior uveal problems. Ophthalmic Surg 1976; 7:98–103
J CATARACT REFRACT SURG - VOL 34, AUGUST 2008