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Cataract surgical problem: Reply
CONSULTATION SECTION
position, thereby reducing the patient’s myopia and anisometropia. Glare and halos would also be eliminated by proper IOL centration. If the light streaks continue, one could perform an Nd:YAG posterior capsulotomy after a suitable period. DAVID W. LANGERMAN, MD Orangeburg, New York, USA
f In this patient’s right eye, reopening the capsular bag and implanting the inferior haptic in the bag could recenter the IOL. Alternatively, a posterior CCC and optic capture behind the posterior CCC would provide proper IOL centration and also correct the dioptric power. If astigmatism is a major concern, a limbal relaxing incision could be performed. After satisfactory management of the right eye, I would perform topical temporal clear corneal cataract extraction with implantation of a 3-piece IOL, seeking emmetropia in the left eye. VLADIMIR PFEIFER, MD Ljubljana, Slovenia
f This 70-year-old patient has pigment dispersion that appears definitively to be the result of a haptic being placed in the sulcus unintentionally after cataract surgery. Single-piece acrylic AcrySof IOLs are good for use in the capsular bag. They are easy to insert and stay well centered in the long term. However, the square, bulky haptics of single-piece AcrySof lenses are not intended for sulcus fixation. The main reason is a spacing issue as well as the sharp haptic edges, which can promote pigment dispersion leading to secondary glaucoma. This patient has an intraocular pressure (IOP) of 18 mm Hg in the right eye and 14 mm Hg in the left eye. It is unclear whether the angles show a collection of pigment dispersion. However, one would assume this given the presence of endothelial pigment and iris transillumination defects corresponding to the shape of the IOL haptic. The posterior capsule is intact and clean, which is important. Management of this patient would be surgical. The capsular bag should be able to be reopened with a viscoelastic agent. I would direct sodium hyaluronate 1.4% (Healon GV威) or Healon5 under the anterior capsule leaflet where the capsule overlies the optic edge. I would next use a push–pull instrument and place the inferior haptic in the capsular bag. The lens appears to be decen1726
tered inferiorly, and if the capsular bag is readily opened, the lens should center as it was intended to originally. It would be important to completely evacuate all the Healon5 to avoid a postoperative induced IOP spike. Should difficulties arise, I would explant the lens by reinflating the bag with a viscoelastic agent and removing the superior haptic from the capsular bag. I would use a spatula 180 degrees from the incision and a folding forceps through the clear corneal incision to refold the lens and explant it from the eye. I would implant a 3-piece IOL (Sensar or Alcon MA60) in the ciliary sulcus with optic capture, if possible, or with capsular bag fixation, if possible. From the description of the patient’s chart, I think IOL explantation and exchange are less likely to be necessary, but I would still have a backup 3-piece lens in case the inferior haptic cannot be put in the capsular bag. I believe the positive dysphotopsia is the result of the decentered lens, with perhaps the edge of the haptic being present in the pupil during nocturnal or dim-light conditions. This should improve after the lens is recentered and then placed symmetrically in the capsular bag. I do not think it is necessary to switch to a nonacrylic lens or promote IOL explantation and exchange because of the dysphotopsia and the presence of a decentered lens with asymmetrical capsule sulcus fixation. I would reevaluate the left eye after the right eye is fixed, presumably when the glare and halos (positive dysphotopsias) in the right eye have been reduced or eliminated. If the patient has glare symptoms in the left eye that are worse than the vision in the right eye, I would consider cataract surgery in the left eye. KERRY D. SOLOMON, MD Charleston, South Carolina, USA
f The AcrySof single-piece acrylic posterior chamber IOL is my preferred lens; however, it is not designed for ciliary sulcus placement, where the thick, squared-edge haptic design may cause iris irritation and chafing. This is especially true if the haptics are asymmetrically fixated, causing IOL tilt. The symptoms in this patient’s right eye are the result of a combination of factors including iris transillumination defects, IOL tilt, asymmetric capsular bag fibrosis, and posterior capsule striae. All of these developed from placing 1 haptic in the capsular bag and the other in the ciliary sulcus. It is likely that by reopening the capsular bag with a cohesive viscoelastic agent and depositing the sulcus-
J CATARACT REFRACT SURG—VOL 28, OCTOBER 2002
position, thereby reducing the patient’s myopia and anisometropia. Glare and halos would also be eliminated by proper IOL centration. If the light streaks continue, one could perform an Nd:YAG posterior capsulotomy after a suitable period. DAVID W. LANGERMAN, MD Orangeburg, New York, USA
f In this patient’s right eye, reopening the capsular bag and implanting the inferior haptic in the bag could recenter the IOL. Alternatively, a posterior CCC and optic capture behind the posterior CCC would provide proper IOL centration and also correct the dioptric power. If astigmatism is a major concern, a limbal relaxing incision could be performed. After satisfactory management of the right eye, I would perform topical temporal clear corneal cataract extraction with implantation of a 3-piece IOL, seeking emmetropia in the left eye. VLADIMIR PFEIFER, MD Ljubljana, Slovenia
f This 70-year-old patient has pigment dispersion that appears definitively to be the result of a haptic being placed in the sulcus unintentionally after cataract surgery. Single-piece acrylic AcrySof IOLs are good for use in the capsular bag. They are easy to insert and stay well centered in the long term. However, the square, bulky haptics of single-piece AcrySof lenses are not intended for sulcus fixation. The main reason is a spacing issue as well as the sharp haptic edges, which can promote pigment dispersion leading to secondary glaucoma. This patient has an intraocular pressure (IOP) of 18 mm Hg in the right eye and 14 mm Hg in the left eye. It is unclear whether the angles show a collection of pigment dispersion. However, one would assume this given the presence of endothelial pigment and iris transillumination defects corresponding to the shape of the IOL haptic. The posterior capsule is intact and clean, which is important. Management of this patient would be surgical. The capsular bag should be able to be reopened with a viscoelastic agent. I would direct sodium hyaluronate 1.4% (Healon GV威) or Healon5 under the anterior capsule leaflet where the capsule overlies the optic edge. I would next use a push–pull instrument and place the inferior haptic in the capsular bag. The lens appears to be decen1726
tered inferiorly, and if the capsular bag is readily opened, the lens should center as it was intended to originally. It would be important to completely evacuate all the Healon5 to avoid a postoperative induced IOP spike. Should difficulties arise, I would explant the lens by reinflating the bag with a viscoelastic agent and removing the superior haptic from the capsular bag. I would use a spatula 180 degrees from the incision and a folding forceps through the clear corneal incision to refold the lens and explant it from the eye. I would implant a 3-piece IOL (Sensar or Alcon MA60) in the ciliary sulcus with optic capture, if possible, or with capsular bag fixation, if possible. From the description of the patient’s chart, I think IOL explantation and exchange are less likely to be necessary, but I would still have a backup 3-piece lens in case the inferior haptic cannot be put in the capsular bag. I believe the positive dysphotopsia is the result of the decentered lens, with perhaps the edge of the haptic being present in the pupil during nocturnal or dim-light conditions. This should improve after the lens is recentered and then placed symmetrically in the capsular bag. I do not think it is necessary to switch to a nonacrylic lens or promote IOL explantation and exchange because of the dysphotopsia and the presence of a decentered lens with asymmetrical capsule sulcus fixation. I would reevaluate the left eye after the right eye is fixed, presumably when the glare and halos (positive dysphotopsias) in the right eye have been reduced or eliminated. If the patient has glare symptoms in the left eye that are worse than the vision in the right eye, I would consider cataract surgery in the left eye. KERRY D. SOLOMON, MD Charleston, South Carolina, USA
f The AcrySof single-piece acrylic posterior chamber IOL is my preferred lens; however, it is not designed for ciliary sulcus placement, where the thick, squared-edge haptic design may cause iris irritation and chafing. This is especially true if the haptics are asymmetrically fixated, causing IOL tilt. The symptoms in this patient’s right eye are the result of a combination of factors including iris transillumination defects, IOL tilt, asymmetric capsular bag fibrosis, and posterior capsule striae. All of these developed from placing 1 haptic in the capsular bag and the other in the ciliary sulcus. It is likely that by reopening the capsular bag with a cohesive viscoelastic agent and depositing the sulcus-
J CATARACT REFRACT SURG—VOL 28, OCTOBER 2002