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Cataract Surgical Problem
CONSULTATION SECTION
Cataract Surgical Problem Edited by Rupert M. Menapace, MD
A 65-year old man presents with an ectopic pupil and a very dense, partly calcified nuclear cataract in both eyes. The inferior iris and sphincter are lacking, as are the zonules along the coloboma (Figure 1). The intraocular pressure (IOP) is 18 mm Hg in the right eye and 20 mm Hg in the left eye. The keratometry readings are 40.9 @ 80 and 43.2 @ 170 in the left eye and 40.7 @ 105 and 43.0 @ 15 in the right eye. In both eyes, the axial length (AL) measured with ultrasound is approximately 28.8 mm and the endothelial cell count (ECC) is 2800 cells/mm2. B-scan ultrasonography shows the retina is attached and the optic nerve head centrally excavated. Given the inferior eccentricity of the pupil and hypermaturity of the cataract with lacking zonular support, at least inferiorly, in both eyes of the patient, what approach would you use to remedy the patient from his almost blinding disease?
- Surgery is, of course, mandatory in this blind man with bilateral congenital iris coloboma that includes the zonules. Obtaining information before the intervention is important, and this surgery is full of risks. The risk for postoperative corneal edema must also be discussed. The history would probably give information about whether the coloboma includes the posterior segment, which would
Figure 1. Bilateral irido–zonular coloboma with ectopic pupil and hypermature cataract.
2200
Q 2012 ASCRS and ESCRS Published by Elsevier Inc.
be important information in terms of the postoperative outcome. The anesthesia approach should be carefully considered. General anesthesia is probably a good choice because the surgery will be time consuming. I would recommend a temporal incision, which would give good accessibility to the surgical field. It is a small eye with shallow anterior chamber and a low ECC, and a highly cohesive ophthalmic viscosurgical device (OVD) would help maintain the anterior chamber depth and protect the cornea during surgery. The pupil is small and decentered, and this could be solved using 2 iris retractors in the pupil upward at 10 o'clock and 2 o'clock. Dying the anterior capsule would make creating the anterior capsulorhexis much easier. A capsulorhexis without tears is mandatory to allow the procedure to continue. Next, the 2 remaining iris retractors would be placed in the capsulorhexis downward where the zonules are missing to keep the lens in place. With a balanced salt solution, the nucleus would be loosened from the capsule and rotated in the bag; there is probably not much cortex left in this very dense cataract. I would try to perform phacoemulsification in the bag to protect the cornea. With an empty capsular bag, you are a successful surgeon and the most difficult part of the surgery is now done. A capsular tension ring (CTR) would help keep the IOL in place. I would choose a 1-piece hydrophobic acrylic intraocular lens (IOL) and implant it in the bag. Placing the IOL in the sulcus in such an eye would present a high probability that the IOL would rest on the retina the day after surgery. After removing the iris retractors, I would leave the iris untouched. Because this is a congenital malformation, the patient would probably not benefit from iris surgery. After surgery, I would prescribe topical dexamethasone 3 to 5 times a day. After the cornea clears, the dexamethasone would be tapered over some weeks. With a happy patient and a clear cornea, surgery could be performed in the other eye within some weeks. Charlotta Zetterstr€ om, MD, PhD Stockolm, Sweden
- I would enter the eye in the usual manner and fill the anterior chamber with a dispersive OVD from distal to proximal, covering the area of missing zonules. Colobomatous eyes sometimes dilate adequately, 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2012.10.006
Cataract Surgical Problem Edited by Rupert M. Menapace, MD
A 65-year old man presents with an ectopic pupil and a very dense, partly calcified nuclear cataract in both eyes. The inferior iris and sphincter are lacking, as are the zonules along the coloboma (Figure 1). The intraocular pressure (IOP) is 18 mm Hg in the right eye and 20 mm Hg in the left eye. The keratometry readings are 40.9 @ 80 and 43.2 @ 170 in the left eye and 40.7 @ 105 and 43.0 @ 15 in the right eye. In both eyes, the axial length (AL) measured with ultrasound is approximately 28.8 mm and the endothelial cell count (ECC) is 2800 cells/mm2. B-scan ultrasonography shows the retina is attached and the optic nerve head centrally excavated. Given the inferior eccentricity of the pupil and hypermaturity of the cataract with lacking zonular support, at least inferiorly, in both eyes of the patient, what approach would you use to remedy the patient from his almost blinding disease?
- Surgery is, of course, mandatory in this blind man with bilateral congenital iris coloboma that includes the zonules. Obtaining information before the intervention is important, and this surgery is full of risks. The risk for postoperative corneal edema must also be discussed. The history would probably give information about whether the coloboma includes the posterior segment, which would
Figure 1. Bilateral irido–zonular coloboma with ectopic pupil and hypermature cataract.
2200
Q 2012 ASCRS and ESCRS Published by Elsevier Inc.
be important information in terms of the postoperative outcome. The anesthesia approach should be carefully considered. General anesthesia is probably a good choice because the surgery will be time consuming. I would recommend a temporal incision, which would give good accessibility to the surgical field. It is a small eye with shallow anterior chamber and a low ECC, and a highly cohesive ophthalmic viscosurgical device (OVD) would help maintain the anterior chamber depth and protect the cornea during surgery. The pupil is small and decentered, and this could be solved using 2 iris retractors in the pupil upward at 10 o'clock and 2 o'clock. Dying the anterior capsule would make creating the anterior capsulorhexis much easier. A capsulorhexis without tears is mandatory to allow the procedure to continue. Next, the 2 remaining iris retractors would be placed in the capsulorhexis downward where the zonules are missing to keep the lens in place. With a balanced salt solution, the nucleus would be loosened from the capsule and rotated in the bag; there is probably not much cortex left in this very dense cataract. I would try to perform phacoemulsification in the bag to protect the cornea. With an empty capsular bag, you are a successful surgeon and the most difficult part of the surgery is now done. A capsular tension ring (CTR) would help keep the IOL in place. I would choose a 1-piece hydrophobic acrylic intraocular lens (IOL) and implant it in the bag. Placing the IOL in the sulcus in such an eye would present a high probability that the IOL would rest on the retina the day after surgery. After removing the iris retractors, I would leave the iris untouched. Because this is a congenital malformation, the patient would probably not benefit from iris surgery. After surgery, I would prescribe topical dexamethasone 3 to 5 times a day. After the cornea clears, the dexamethasone would be tapered over some weeks. With a happy patient and a clear cornea, surgery could be performed in the other eye within some weeks. Charlotta Zetterstr€ om, MD, PhD Stockolm, Sweden
- I would enter the eye in the usual manner and fill the anterior chamber with a dispersive OVD from distal to proximal, covering the area of missing zonules. Colobomatous eyes sometimes dilate adequately, 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2012.10.006