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Cataract surgical problem
consultation section edited by Samuel Masket, MD
cataract surgical problem
A 40-year-old man is referred for cataract management. He has a history of intravenous (heroin) drug abuse but has been well controlled with methadone maintenance over the past 5 years. During a period of drug use in 1992, he sustained an injury to the right eye that resulted in a very gradual reduction in vision. He now notes very poor visual function and requests cataract management. Current ocular findings include a best corrected visual acuity (BCVA) of counting fingers at 3 feet in the right eye and 20/30⫹ in the left eye and an intraocular pressure (IOP) by applanation tonometry of 19 mm Hg and 14 mm Hg, respectively. Gonioscopy shows 360 degree angle recession in the right eye and an open normal angle in the left eye. A slitlamp examination of the right eye reveals a deep and quiet anterior chamber; there are multiple small tears in the pupil sphincter, particularly inferiorly. There is no afferent pupillary defect. A white, dense cataract is noted to be dislocated superotemporally, with approximately 6 clock hours of zonule loss inferonasally (Figure 1). The hyaloid face is intact over the area of zonular dehiscence. Examination of the posterior segment is limited because of the cataract, but the optic nerve, macula, and retinal periphery appear normal. Anterior and posterior segment examinations of the left eye are unremarkable. How would you manage the right eye?
f The lack of a relative afferent pupillary defect and the gradual decrease in vision suggest that the cataract is the likely cause of visual loss and that cataract removal with intraocular lens (IOL) implantation should result in good visual rehabilitation. Regardless, in all cases of significant trauma, I caution patients that the prognosis is guarded because of the traumatic nature of the cataract, increased difficulty of surgery, and ongoing increased risk of developing posttraumatic complications such as glaucoma, retinal detachment, or both. Surgical options include (1) intracapsular extraction with a sulcus-fixated posterior chamber IOL (PC IOL); (2) pars plana vitrectomy/lensectomy with a sutured PC IOL; (3) phacoemulsification with placement of a capsular tension ring (CTR) or a Cionni-modified CTR and in-the-bag placement of a PC IOL. I would not 1152
Figure 1. (Masket) Standard (top) and reflex red (bottom) views of a dense dislocated cataract with approximately 6 hours of zonule loss.
consider placing an anterior chamber IOL (AC IOL) in this patient because of his young age, the history of trauma, and the presence of angle recession. I strongly favor the third surgical option, especially since the anterior hyaloid face is intact and with this approach, a vitrectomy will likely be unnecessary. Before deciding, however, it is a good idea to examine the patient while he is supine to see whether the lens “hinges” posteriorly into the vitreous cavity. If it does, there is more zonular weakness than originally suspected
J CATARACT REFRACT SURG—VOL 27, AUGUST 2001
cataract surgical problem
A 40-year-old man is referred for cataract management. He has a history of intravenous (heroin) drug abuse but has been well controlled with methadone maintenance over the past 5 years. During a period of drug use in 1992, he sustained an injury to the right eye that resulted in a very gradual reduction in vision. He now notes very poor visual function and requests cataract management. Current ocular findings include a best corrected visual acuity (BCVA) of counting fingers at 3 feet in the right eye and 20/30⫹ in the left eye and an intraocular pressure (IOP) by applanation tonometry of 19 mm Hg and 14 mm Hg, respectively. Gonioscopy shows 360 degree angle recession in the right eye and an open normal angle in the left eye. A slitlamp examination of the right eye reveals a deep and quiet anterior chamber; there are multiple small tears in the pupil sphincter, particularly inferiorly. There is no afferent pupillary defect. A white, dense cataract is noted to be dislocated superotemporally, with approximately 6 clock hours of zonule loss inferonasally (Figure 1). The hyaloid face is intact over the area of zonular dehiscence. Examination of the posterior segment is limited because of the cataract, but the optic nerve, macula, and retinal periphery appear normal. Anterior and posterior segment examinations of the left eye are unremarkable. How would you manage the right eye?
f The lack of a relative afferent pupillary defect and the gradual decrease in vision suggest that the cataract is the likely cause of visual loss and that cataract removal with intraocular lens (IOL) implantation should result in good visual rehabilitation. Regardless, in all cases of significant trauma, I caution patients that the prognosis is guarded because of the traumatic nature of the cataract, increased difficulty of surgery, and ongoing increased risk of developing posttraumatic complications such as glaucoma, retinal detachment, or both. Surgical options include (1) intracapsular extraction with a sulcus-fixated posterior chamber IOL (PC IOL); (2) pars plana vitrectomy/lensectomy with a sutured PC IOL; (3) phacoemulsification with placement of a capsular tension ring (CTR) or a Cionni-modified CTR and in-the-bag placement of a PC IOL. I would not 1152
Figure 1. (Masket) Standard (top) and reflex red (bottom) views of a dense dislocated cataract with approximately 6 hours of zonule loss.
consider placing an anterior chamber IOL (AC IOL) in this patient because of his young age, the history of trauma, and the presence of angle recession. I strongly favor the third surgical option, especially since the anterior hyaloid face is intact and with this approach, a vitrectomy will likely be unnecessary. Before deciding, however, it is a good idea to examine the patient while he is supine to see whether the lens “hinges” posteriorly into the vitreous cavity. If it does, there is more zonular weakness than originally suspected
J CATARACT REFRACT SURG—VOL 27, AUGUST 2001