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Cataract surgical problem
consultation section edited by Samuel Masket, MD
cataract surgical problem
A very active 81-year-old man was referred for “horrific glare” 6 weeks after cataract surgery in the left eye. His history reveals that 4 months earlier, he had uneventful, temporally oriented phacoemulsification with placement of a plate-haptic silicone intraocular lens (IOL) in the right eye. However, the left eye, operated on in a similar fashion more recently, sustained unintended but significant damage to the inferotemporal iris (Figures 1 and 2). The patient reports great difficulty with night driving, a task necessary for his work. He refused a custom contact lens. The examination reveals a best corrected visual acuity of 20/25⫹ in both eyes with a modest myopic error. In both eyes, there is a healed temporal clear corneal incision and a wellcentered plate-haptic silicone IOL with an intact posterior capsule. The involved left eye demonstrates a small anterior capsulorhexis, and there is modest peripheral capsule fibrosis. Posterior segment examination is unremarkable in both eyes. How would you approach this problem?
Figure 1. (Masket) External view of left eye shows loss of iris tissue in the inferotemporal quadrant.
f I would address this patient’s problem by tincture of time. It looks to me as though the capsulorhexis is slightly ovaled, but the anterior capsule is still completely clear. Over time, the portion of the anterior capsule that overlays the plate-haptic IOL lens will not only opacify, it will also be associated with some phimosis of the capsulorhexis. I would encourage the patient to use sunglasses or other means to give him relief from glare for the present, which should allow enough time for anterior capsule opacification (ACO) phimosis to take place. This simple course of action may eliminate his symptoms. I would consider crimping the iris with sutures at the areas of greatest tissue loss if the patient is still symptomatic after ACO and phimosis occur. However, if the iris appears too atrophic and the suture starts to cut through as it is being tied, I would implant a pseudo-iris IOL in the ciliary sulcus. I. HOWARD FINE, MD Eugene, Oregon, USA 238
Figure 2. (Masket) Slitlamp view of the left eye reveals the iris defect and a plate-haptic silicone IOL in the capsular bag.
f Iris defects, especially when located horizontally, often lead to glare and photophobia due to the lack of a complete iris diaphragm. In this case, we would initially favor a noninvasive option. We would wait a minimum of 4 to 6 weeks to allow postoperative opacification and fibrosis of the anterior capsule, which might reconstruct a physiological pupil, creating a pseudo pupil. Silicone lenses are more likely to produce anterior capsule fibrosis and shrinkage than most hydrophobic acrylic lenses, although the etiology is unknown.1 The mean ACO scores in 1 study were highest with largeand small-hole, single-piece, plate-haptic silcone lenses.2
J CATARACT REFRACT SURG—VOL 29, FEBRUARY 2003
cataract surgical problem
A very active 81-year-old man was referred for “horrific glare” 6 weeks after cataract surgery in the left eye. His history reveals that 4 months earlier, he had uneventful, temporally oriented phacoemulsification with placement of a plate-haptic silicone intraocular lens (IOL) in the right eye. However, the left eye, operated on in a similar fashion more recently, sustained unintended but significant damage to the inferotemporal iris (Figures 1 and 2). The patient reports great difficulty with night driving, a task necessary for his work. He refused a custom contact lens. The examination reveals a best corrected visual acuity of 20/25⫹ in both eyes with a modest myopic error. In both eyes, there is a healed temporal clear corneal incision and a wellcentered plate-haptic silicone IOL with an intact posterior capsule. The involved left eye demonstrates a small anterior capsulorhexis, and there is modest peripheral capsule fibrosis. Posterior segment examination is unremarkable in both eyes. How would you approach this problem?
Figure 1. (Masket) External view of left eye shows loss of iris tissue in the inferotemporal quadrant.
f I would address this patient’s problem by tincture of time. It looks to me as though the capsulorhexis is slightly ovaled, but the anterior capsule is still completely clear. Over time, the portion of the anterior capsule that overlays the plate-haptic IOL lens will not only opacify, it will also be associated with some phimosis of the capsulorhexis. I would encourage the patient to use sunglasses or other means to give him relief from glare for the present, which should allow enough time for anterior capsule opacification (ACO) phimosis to take place. This simple course of action may eliminate his symptoms. I would consider crimping the iris with sutures at the areas of greatest tissue loss if the patient is still symptomatic after ACO and phimosis occur. However, if the iris appears too atrophic and the suture starts to cut through as it is being tied, I would implant a pseudo-iris IOL in the ciliary sulcus. I. HOWARD FINE, MD Eugene, Oregon, USA 238
Figure 2. (Masket) Slitlamp view of the left eye reveals the iris defect and a plate-haptic silicone IOL in the capsular bag.
f Iris defects, especially when located horizontally, often lead to glare and photophobia due to the lack of a complete iris diaphragm. In this case, we would initially favor a noninvasive option. We would wait a minimum of 4 to 6 weeks to allow postoperative opacification and fibrosis of the anterior capsule, which might reconstruct a physiological pupil, creating a pseudo pupil. Silicone lenses are more likely to produce anterior capsule fibrosis and shrinkage than most hydrophobic acrylic lenses, although the etiology is unknown.1 The mean ACO scores in 1 study were highest with largeand small-hole, single-piece, plate-haptic silcone lenses.2
J CATARACT REFRACT SURG—VOL 29, FEBRUARY 2003