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Cataract surgical problem
consultation section edited by Samuel Masket, MD
cataract surgical problem
A 73-year-old woman was referred for management of complications, anisometropia, and glare disability after cataract surgery performed 2 years earlier in the right eye. According to the history, cataract surgery resulted in iris and sphincter damage and retinal detachment; the latter required several procedures for reattachment. Silicone oil was ultimately necessary but was removed within the past 6 months; the retina has remained attached. The patient reports loss of depth perception and marked difficulty in binocular coordination. She states that she often closes the right eye for visual comfort. In addition, she notes marked problems with nighttime driving as a result of glare disability. At present, she uses no eye medications. Current examination reveals a visual acuity of 20/50⫺ with ⫺3.50 ⫺1.25 ⫻ 30 in the right eye and 20/30⫹ with ⫹4.50 ⫺1.00 ⫻ 10 in the left eye. The intraocular pressure (IOP) is 15 mm Hg and 13 mm Hg, respectively. A small angle intermittent exotropia is noted, although extraocular motility is full range. The right pupil is nonreactive to light; pupil reaction in the left eye is physiologic. Anterior segment examination of the right eye shows evidence of previous surgery, a clear cornea with reasonably normal-appearing endothelium, and a quiet anterior chamber. Broad peripheral anterior synechias (PAS) are visible nasally, and gonioscopy reveals multiple areas of old PAS. A singlepiece AcrySof姞 intraocular lens (IOL) (Alcon) is decentered nasally, affixed only to a small capsule remnant nasally and tilted so that the temporal aspect of the optic is positioned farther posteriorly than the nasal portion. As seen in the clinical photograph (Figure 1), there is loss of temporal iris tissue, including the sphincter, and the temporal and superior edges of the optic are exposed. Posterior segment examination reveals an optically empty vitreous cavity, a fully attached retina supported by a 360-degree buckle, and a normal-appearing posterior pole. Examination of the left eye shows a moderate inferior cortical cataract that does not impinge on the visual axis. Posterior segment examination is unremarkable. The patient has been fitted with contact lenses for the induced anisometropia but finds that she cannot insert and remove the lenses because of poor dexterity. Given the complex history and findings, how would you approach this problem?
Figure 1. (Masket) Slitlamp photograph without pharmacologic pupil dilation demonstrates modest nasal decentration of the IOL, loss of iris tissue, and baring of the temporal and superior edges of the IOL. Lens tilt cannot be appreciated in the photograph.
f This patient has multiple problems that lead to her visual disability. The complications during the previous cataract surgery resulted in a useful but anisometropic eye with a decentered and tilted IOL. The combination of these factors probably occurred in what was the patient’s previously dominant eye. The breakdown of binocularity caused by anisometropia explains the intermittent exotropia, which is probably associated with subclinical diplopia. Decentration and tilting of the AcrySof lens exposes its square edge to incident light that is not regulated by the damaged and inactive iris, causing the glare and dysphotopsia. Anisometropia is not correctable with a contact lens because of the patient’s age and inherent lack of dexterity. The eye is otherwise quiet with no further complications. I would recommend IOL exchange to solve both the anisometropia and IOL malposition. Of the available lenses, I would not recommend implanting an anglesupported anterior chamber IOL (AC IOL) because of the presence of extensive PAS. An iris-supported lens (Artisan威, Ophtec) would be a good option, but not in an eye with a nonreactive ectopic pupil.
J CATARACT REFRACT SURG—VOL 29, AUGUST 2003
1471
cataract surgical problem
A 73-year-old woman was referred for management of complications, anisometropia, and glare disability after cataract surgery performed 2 years earlier in the right eye. According to the history, cataract surgery resulted in iris and sphincter damage and retinal detachment; the latter required several procedures for reattachment. Silicone oil was ultimately necessary but was removed within the past 6 months; the retina has remained attached. The patient reports loss of depth perception and marked difficulty in binocular coordination. She states that she often closes the right eye for visual comfort. In addition, she notes marked problems with nighttime driving as a result of glare disability. At present, she uses no eye medications. Current examination reveals a visual acuity of 20/50⫺ with ⫺3.50 ⫺1.25 ⫻ 30 in the right eye and 20/30⫹ with ⫹4.50 ⫺1.00 ⫻ 10 in the left eye. The intraocular pressure (IOP) is 15 mm Hg and 13 mm Hg, respectively. A small angle intermittent exotropia is noted, although extraocular motility is full range. The right pupil is nonreactive to light; pupil reaction in the left eye is physiologic. Anterior segment examination of the right eye shows evidence of previous surgery, a clear cornea with reasonably normal-appearing endothelium, and a quiet anterior chamber. Broad peripheral anterior synechias (PAS) are visible nasally, and gonioscopy reveals multiple areas of old PAS. A singlepiece AcrySof姞 intraocular lens (IOL) (Alcon) is decentered nasally, affixed only to a small capsule remnant nasally and tilted so that the temporal aspect of the optic is positioned farther posteriorly than the nasal portion. As seen in the clinical photograph (Figure 1), there is loss of temporal iris tissue, including the sphincter, and the temporal and superior edges of the optic are exposed. Posterior segment examination reveals an optically empty vitreous cavity, a fully attached retina supported by a 360-degree buckle, and a normal-appearing posterior pole. Examination of the left eye shows a moderate inferior cortical cataract that does not impinge on the visual axis. Posterior segment examination is unremarkable. The patient has been fitted with contact lenses for the induced anisometropia but finds that she cannot insert and remove the lenses because of poor dexterity. Given the complex history and findings, how would you approach this problem?
Figure 1. (Masket) Slitlamp photograph without pharmacologic pupil dilation demonstrates modest nasal decentration of the IOL, loss of iris tissue, and baring of the temporal and superior edges of the IOL. Lens tilt cannot be appreciated in the photograph.
f This patient has multiple problems that lead to her visual disability. The complications during the previous cataract surgery resulted in a useful but anisometropic eye with a decentered and tilted IOL. The combination of these factors probably occurred in what was the patient’s previously dominant eye. The breakdown of binocularity caused by anisometropia explains the intermittent exotropia, which is probably associated with subclinical diplopia. Decentration and tilting of the AcrySof lens exposes its square edge to incident light that is not regulated by the damaged and inactive iris, causing the glare and dysphotopsia. Anisometropia is not correctable with a contact lens because of the patient’s age and inherent lack of dexterity. The eye is otherwise quiet with no further complications. I would recommend IOL exchange to solve both the anisometropia and IOL malposition. Of the available lenses, I would not recommend implanting an anglesupported anterior chamber IOL (AC IOL) because of the presence of extensive PAS. An iris-supported lens (Artisan威, Ophtec) would be a good option, but not in an eye with a nonreactive ectopic pupil.
J CATARACT REFRACT SURG—VOL 29, AUGUST 2003
1471