- Email: [email protected]
February Consultation # 5
CONSULTATION SECTION
with CIF-4 needles, I would engage the peripheral iris suture in a mattress-suture fashion to tack the iris back to the scleral wall. The sutures should enter the peripheral iris in such a manner as to divide the iridodialysis into thirds and should exit the scleral wall under the scleral flap, 0.5 to 1.0 mm posterior to the limbus. I would cut the needles free from the suture and then tighten, tie, and rotate the suture, after which I would bury the knot. Next, I would create a 5.5 to 6.0 mm capsulorhexis followed by generous viscodissection to prolapse the nucleus into the anterior chamber for emulsification. Low aspiration, low vacuum, and low bottle levels would be used to minimize the risk for pressurizing the posterior segment and decreasing the chance of further vitreous prolapse. I would viscodissect the cortex free from the capsular bag periphery and complete gentle, automated aspiration of cortex. Then, I would reinflate the capsular bag with Provisc. I would preload 9-0 Prolene suture double armed with CTC or CIF-4 needles through the fixation hook eyelet of a modified CTR (model 1-L, Morcher GmbH). The modified CTR would be fed manually into the capsular bag using a dull instrument to provide countertraction to the capsulorhexis edge, thereby preventing further damage to the zonules. I would manipulate the fixation hook to be certain it rests anterior to the anterior capsule rim and then dial it to the center of the zonular dialysis. Each needle would be then passed anterior to the anterior capsule rim and out through the ciliary sulcus, exiting the sclera under the partial-thickness scleral flap. Before removing 1 of the needles from the posterior scleral bed, I would use a 15-degree blade to enlarge the scleral needle tract, which would make the task of burying the knot easier. The needles would be cut free from the suture and the knot tied, rotated, and buried. I would inject a single-piece acrylic posterior chamber IOL in the capsular bag. The OVD would be aspirated from behind the IOL but left in the anterior chamber for now. I would inject acetylcholine chloride (Miochol) to evaluate pupil size. It is likely that several ‘‘sphincter repair’’ suture passes will be required to constrict and ‘‘round’’ the pupil. This would be accomplished via corneal stab incisions using a modified Siepserstyle technique.3 Once this is accomplished, I would aspirate the remaining OVD and then hydrate the incisions and check them for integrity. I would close the conjunctival peritomy over the repositioned scleral flap with 10-0 nylon suture. I would have this patient begin a postoperative drop regimen immediately after surgery. In addition to prescribing Vigamox 3 times the day before surgery, I typically have these complex problem patients begin prednisolone acetate drops (Econopred) 6 times a day and nepafenac (Nevanac) 3 times a day beginning 3 days before surgery to decrease the risk for CME.
(Dr. Cionni has a financial interest in the modified CTR device and is a consultant to Alcon Labs Inc.) Robert Cionni, MD Cincinnati, Ohio, USA
REFERENCES 1. Cionni RJ, Osher RH. Management of profound zonular dialysis or weakness with a new endocapsular ring designed for scleral fixation. J Cataract Refract Surg 1998; 10:1299–1306 2. Burk SE, Da Mata AP, Snyder ME, et al. Visualizing vitreous using Kenalog suspension. J Cataract Refract Surg 2003; 29:645–651 3. Osher RH, Snyder ME, Cionni RJ. Modification of the Siepser slip-knot technique. J Cataract Refract Surg 2005; 31:1098–1100
- The main anterior segment problems in this patient are inferonasal iridodialysis with a scrolled and adhered iris, 4 clock hours of inferonasal zonular dialysis, vitreous in the anterior chamber, anterior lens opacification, and central posterior subcapsular cataract with extensive angle recession. The retinal problems are an ERM and CME. Visual acuity is 20/200 with a Retinal Acuity Meter reading of 20/25. Because this patient has an ERM with CME, the former is in all likelihood causing traction. Also, despite the good result on the Retinal Acuity Meter at present, the CME is likely to worsen if the ERM is left untreated. Obviously, this patient needs surgery but only by someone experienced in both anterior and posterior segment surgery or in collaboration with a vitreoretinal surgeon. The important surgical considerations would be anterior segment reconstruction, cataract extraction, ERM peeling, and IOL implantation.1–4 Another important consideration is to aim at maximum preservation of the conjunctiva in anticipation of the requirement for glaucoma surgery at a later date in view of the patient’s extensive angle recession. Other than the routine investigations, ultrasound biometry or anterior segment optical coherence tomography (OCT) can also be done to obtain a more accurate assessment of the status of the zonules, although this is optional. The patient would require a preoperative fundus fluorescein angiography and OCT. The OCT would confirm the presence of a gap between the retina and the ERM and the topographical location where peeling of the membrane should ideally be initiated. The first step in the surgical plan would be cataract extraction. I would use bimanual phacoemulsification with the 700 mm cataract surgical instruments of microphakonit as this would create the smallest incisions needed for cataract surgery. In this patient, the 2 incisions needed be made 90 degrees apart. An anterior vitrectomy would be performed
J CATARACT REFRACT SURG - VOL 33, FEBRUARY 2007
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CONSULTATION SECTION
in the area of vitreous prolapse. Next, a McCannel suture would be used to pull the scrolled iris out of the way so as not to hinder or be aspirated into the phaco ports. As this is a long-standing injury, it may not be possible to unscroll the iris before the McCannel suture, and this is not a must, although it may be attempted using viscodissection and blunt instruments. If it is does not unscroll, one can excise this part of the iris at the end of surgery and place a segmental aniridia ring or prosthetic iris implant (Figure 4). Next, in view of the zonular dialysis, once the capsulorhexis is completed (using a 26-gauge needle bent in the form of a cystotome), an endocapsular ring (ECR) or a segmental Cionni ring would be inserted. Once the ECR is inserted, gentle hydrodissection would be performed. I would then use the 700 mm instruments (phaco tip, irrigating chopper, and bimanual I/A probes) for the rest of the cataract extraction, making sure to avoid all radial traction maneuvers. In such a young patient, the nucleus would be soft and small and could be easily prolapsed out and emulsified. Cortical aspiration would then be performed, with IOL implantation deferred until the end of the vitreoretinal part of the surgery. Next, the inferotemporal vitrectomy port would be made for a Chandelier illumination system (Synergetcis, Photon), in which xenon light is attached to the infusion cannula. This gives excellent illumination, and one can perform a proper bimanual vitrectomy as it is not necessary for the surgeon to hold an endoilluminator in his or her hand.
A reinverter system that makes the image erect again must be used if the surgeon uses a wide-field lens (Volk or Oculus). The supermacula lens (Volk) provides better magnification and stereopsis to aid in easy identification of any lifted edge of the ERM. The 2 superior ports would be made with the transconjunctival vitrectomy system, which helps preserve the superior conjunctiva for future trabeculectomies. The incisions for the 700 mm microphakonit are so small and stable that they avoid the need for closure before vitrectomy, as would be required for coaxial phacoemulsification or conventional bimanual phacoemulsification. These ultrasmall self-sealing incisions are stable; there is no leakage, chamber shallowing, or iris prolapse through the incisions despite the high intravitreal pressures during vitrectomy. In addition, there is no reduced globe resistance or wound instability during infusion cannula insertion with microphakonit clear corneal incisions. After completing the vitrectomy, I would peel the membrane off the surface of the retina, preferably from the center to the periphery, after finding an edge of the membrane. Intravitreal unpreserved triamcinolone at the end of the vitrectomy will also aid in more rapid resolution of the CME. As the superior ports are made with the transconjunctival sutureless surgical system by displacing the conjunctiva aside and then inserting the trocar cannula system, it becomes minimally invasive and atraumatic to the superior conjunctiva, which is therefore preserved for future trabeculectomies that may be required. At the end of surgery, the trocar is simply pulled and the wound becomes self-sealing. One of the clear corneal incisions would then be enlarged and a foldable IOL implanted in the bag, taking care to keep the haptics in the direction of the zonular dialysis. If the iridodialysis could not be scrolled out initially, that part of the iris can be removed with the vitrectomy probe and aniridia rings implanted in the sulcus in this area. Stromal hydration would then be done and the wounds tested for integrity. Postoperatively, the patient would be put on topical antibiotics and steroids and monitored closely. His retinal status could be followed by repeat fundus fluorescein angiography and OCT. Amar Agarwal, MS, FRCS, FRCOphth Chennai, India
REFERENCES
Figure 4. Implantation of aniridia rings.
184
1. Agarwal S, Agarwal A, Agarwal A. Phacoemulsification, 3rd ed (2-volume set). Thorofare, NJ, Slack, 2004 2. Agarwal A, ed. Phaco Nightmares; Conquering Cataract Catastrophes. Thorofare, NJ, Slack, 2006
J CATARACT REFRACT SURG - VOL 33, FEBRUARY 2007
CONSULTATION SECTION
3. Agarwal A, ed. Handbook of Ophthalmology. Thorofare, NJ, Slack, 2005 4. Jacob S, Agarwal A, Agarwal A, et al. Efficacy of a capsular tension ring for phacoemulsification in eyes with zonular dialysis. J Cataract Refract Surg 2003; 29:315–321
- This patient previously had severe nonpenetrating trauma to the left eye, resulting in a large iridodialysis with focal zonular loss and vitreous prolapsing into the anterior chamber. There is also an ERM with CME and surprisingly good visual potential. A traumatic cataract has now formed, and the patient desires visual rehabilitation, which would involve cataract surgery combined with anterior segment reconstruction. With an ERM and preexisting CME, I would treat him with a topical nonsteroidal antiinflammatory agent before and after surgery. Before the cataract is removed and the iridodialysis repaired, vitreous prolapsing into the anterior chamber should be addressed. Through a paracentesis, I would instill a small amount of Kenalog, previously washed free of its preservatives, to visualize the location of all vitreous anterior to the iris.1 I would next create a pars plana incision in the superior temporal quadrant. Using the previously placed paracentesis as a port for low-flow irrigation, pars plana core vitrectomy would be performed under direct visualization using rapid cutting and low levels of aspiration. A temporary scleral plug would then be placed in the pars plana incision so that the posterior segment could be accessed once again at the end of the case. Next, a retentive OVD would be placed over the lens and iris. A gentle sweep with a cyclodialysis spatula between the iris and anterior lens capsule is usually enough to lyse any adhesions. Depending on the condition of the iris, it may be possible to simply push away the now-free pupil edge using an OVD. If this maneuver is not successful, and depending on the condition of the iris, 1 or 2 disposable iris hooks could be placed to adequately enlarge the pupil for the creation of the capsulorhexis. It may also be necessary to fashion the capsulorhexis slightly more nasally than temporally so that after the placement of a CTR, the lens capsule and IOL will be centered. Gentle hydrodissection would next be accomplished, taking care to completely mobilize the lens material. For a patient of this age, my preference would be to use a Simcoe-style manual I/A cannula to aspirate what is probably a soft nucleus. With its low fluid flow and quickly variable surgeoncontrolled aspiration, manual I/A in such a case would be ideal. If the status of the remaining zonules is tenuous, persistent cortical remnants could be aspirated under OVD without irrigation. The capsular bag would next be inflated with an OVD and a standard CTR gently inserted in the capsular fornix. From the photograph, it looks as though the lens is not significantly displaced and adequate centration of the capsular bag would likely result from this approach
alone. If significant iris stromal defects are present, as an alternative, a Morcher type 96F partial aniridia CTR, could be used. However, if the final position of the capsular bag is displaced nasally, a Morcher 2C Cionni CTR could be used to recenter the capsular bag using an 8-0 tetrafluoroethylene polymer (Gore-Tex) suture tied to the fixation eyelet, exiting the eye under a scleral flap. For the IOL, I prefer a single-piece acrylic, such as the SN60AT (Alcon). Combined with a CTR, a single-piece acrylic IOL would be ideal for this type of case as these lenses unfold quite slowly, minimizing the potential for stress on the remaining zonules as the IOL gently expands to fill the capsular bag. The iridodialysis repair would be performed with the anterior chamber once again filled with a retentive OVD. Here, I prefer to use a micrograsper to stabilize the peripheral iris while passing a double-armed suture through the margin of its severed edge. Several horizontal mattress sutures would be necessary to secure the large peripheral iris defect to the area of the iris root (M.E. Snyder, MD, ‘‘Repairing the Iris’’ [online]. Available at: http://www. revophth.com/2000/October/RPf11rirs0010.htm. Accessed December 4, 2006). If the pupil does not end up round and centered, a properly placed 10-0 Prolene suture through 2 points next to the remaining iris sphincter and tied with a Siepser knot will help restore a more normal cosmetic appearance to the eye.2 After the OVD is aspirated from the anterior chamber, a small amount of washed triamcinolone should be instilled to confirm that no vitreous has migrated into the anterior chamber. The vitrector would then be reinserted through the pars plana to remove any OVD that may have passed into the posterior segment with the original paracentesis used as the infusion port. After injecting a small amount of intravitreal triamcinolone to cover the preexisting CME, I would secure the pars plana scleral incision with a 7-0 polyglactin (Vicryl) suture. With severe angle recession, this patient will need to be followed closely for a postoperative pressure spike and will also require lifelong follow-up for the development of posttraumatic glaucoma. Serial OCTor fluorescein angiography will be required during the treatment of the CME. A total vitrectomy, combined with membrane stripping, may be necessary in the future. Warren E. Hill, MD Mesa, Arizona, USA
REFERENCES 1. Burk SE, Da Mata AP, Snyder ME, et al. Visualizing vitreous using Kenalog suspension. J Cataract Refract Surg 2003; 29:645–651 2. Siepser SB. The closed chamber slipping suture technique for iris repair. Ann Ophthalmol 1994; 26:71–72
J CATARACT REFRACT SURG - VOL 33, FEBRUARY 2007
185
with CIF-4 needles, I would engage the peripheral iris suture in a mattress-suture fashion to tack the iris back to the scleral wall. The sutures should enter the peripheral iris in such a manner as to divide the iridodialysis into thirds and should exit the scleral wall under the scleral flap, 0.5 to 1.0 mm posterior to the limbus. I would cut the needles free from the suture and then tighten, tie, and rotate the suture, after which I would bury the knot. Next, I would create a 5.5 to 6.0 mm capsulorhexis followed by generous viscodissection to prolapse the nucleus into the anterior chamber for emulsification. Low aspiration, low vacuum, and low bottle levels would be used to minimize the risk for pressurizing the posterior segment and decreasing the chance of further vitreous prolapse. I would viscodissect the cortex free from the capsular bag periphery and complete gentle, automated aspiration of cortex. Then, I would reinflate the capsular bag with Provisc. I would preload 9-0 Prolene suture double armed with CTC or CIF-4 needles through the fixation hook eyelet of a modified CTR (model 1-L, Morcher GmbH). The modified CTR would be fed manually into the capsular bag using a dull instrument to provide countertraction to the capsulorhexis edge, thereby preventing further damage to the zonules. I would manipulate the fixation hook to be certain it rests anterior to the anterior capsule rim and then dial it to the center of the zonular dialysis. Each needle would be then passed anterior to the anterior capsule rim and out through the ciliary sulcus, exiting the sclera under the partial-thickness scleral flap. Before removing 1 of the needles from the posterior scleral bed, I would use a 15-degree blade to enlarge the scleral needle tract, which would make the task of burying the knot easier. The needles would be cut free from the suture and the knot tied, rotated, and buried. I would inject a single-piece acrylic posterior chamber IOL in the capsular bag. The OVD would be aspirated from behind the IOL but left in the anterior chamber for now. I would inject acetylcholine chloride (Miochol) to evaluate pupil size. It is likely that several ‘‘sphincter repair’’ suture passes will be required to constrict and ‘‘round’’ the pupil. This would be accomplished via corneal stab incisions using a modified Siepserstyle technique.3 Once this is accomplished, I would aspirate the remaining OVD and then hydrate the incisions and check them for integrity. I would close the conjunctival peritomy over the repositioned scleral flap with 10-0 nylon suture. I would have this patient begin a postoperative drop regimen immediately after surgery. In addition to prescribing Vigamox 3 times the day before surgery, I typically have these complex problem patients begin prednisolone acetate drops (Econopred) 6 times a day and nepafenac (Nevanac) 3 times a day beginning 3 days before surgery to decrease the risk for CME.
(Dr. Cionni has a financial interest in the modified CTR device and is a consultant to Alcon Labs Inc.) Robert Cionni, MD Cincinnati, Ohio, USA
REFERENCES 1. Cionni RJ, Osher RH. Management of profound zonular dialysis or weakness with a new endocapsular ring designed for scleral fixation. J Cataract Refract Surg 1998; 10:1299–1306 2. Burk SE, Da Mata AP, Snyder ME, et al. Visualizing vitreous using Kenalog suspension. J Cataract Refract Surg 2003; 29:645–651 3. Osher RH, Snyder ME, Cionni RJ. Modification of the Siepser slip-knot technique. J Cataract Refract Surg 2005; 31:1098–1100
- The main anterior segment problems in this patient are inferonasal iridodialysis with a scrolled and adhered iris, 4 clock hours of inferonasal zonular dialysis, vitreous in the anterior chamber, anterior lens opacification, and central posterior subcapsular cataract with extensive angle recession. The retinal problems are an ERM and CME. Visual acuity is 20/200 with a Retinal Acuity Meter reading of 20/25. Because this patient has an ERM with CME, the former is in all likelihood causing traction. Also, despite the good result on the Retinal Acuity Meter at present, the CME is likely to worsen if the ERM is left untreated. Obviously, this patient needs surgery but only by someone experienced in both anterior and posterior segment surgery or in collaboration with a vitreoretinal surgeon. The important surgical considerations would be anterior segment reconstruction, cataract extraction, ERM peeling, and IOL implantation.1–4 Another important consideration is to aim at maximum preservation of the conjunctiva in anticipation of the requirement for glaucoma surgery at a later date in view of the patient’s extensive angle recession. Other than the routine investigations, ultrasound biometry or anterior segment optical coherence tomography (OCT) can also be done to obtain a more accurate assessment of the status of the zonules, although this is optional. The patient would require a preoperative fundus fluorescein angiography and OCT. The OCT would confirm the presence of a gap between the retina and the ERM and the topographical location where peeling of the membrane should ideally be initiated. The first step in the surgical plan would be cataract extraction. I would use bimanual phacoemulsification with the 700 mm cataract surgical instruments of microphakonit as this would create the smallest incisions needed for cataract surgery. In this patient, the 2 incisions needed be made 90 degrees apart. An anterior vitrectomy would be performed
J CATARACT REFRACT SURG - VOL 33, FEBRUARY 2007
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CONSULTATION SECTION
in the area of vitreous prolapse. Next, a McCannel suture would be used to pull the scrolled iris out of the way so as not to hinder or be aspirated into the phaco ports. As this is a long-standing injury, it may not be possible to unscroll the iris before the McCannel suture, and this is not a must, although it may be attempted using viscodissection and blunt instruments. If it is does not unscroll, one can excise this part of the iris at the end of surgery and place a segmental aniridia ring or prosthetic iris implant (Figure 4). Next, in view of the zonular dialysis, once the capsulorhexis is completed (using a 26-gauge needle bent in the form of a cystotome), an endocapsular ring (ECR) or a segmental Cionni ring would be inserted. Once the ECR is inserted, gentle hydrodissection would be performed. I would then use the 700 mm instruments (phaco tip, irrigating chopper, and bimanual I/A probes) for the rest of the cataract extraction, making sure to avoid all radial traction maneuvers. In such a young patient, the nucleus would be soft and small and could be easily prolapsed out and emulsified. Cortical aspiration would then be performed, with IOL implantation deferred until the end of the vitreoretinal part of the surgery. Next, the inferotemporal vitrectomy port would be made for a Chandelier illumination system (Synergetcis, Photon), in which xenon light is attached to the infusion cannula. This gives excellent illumination, and one can perform a proper bimanual vitrectomy as it is not necessary for the surgeon to hold an endoilluminator in his or her hand.
A reinverter system that makes the image erect again must be used if the surgeon uses a wide-field lens (Volk or Oculus). The supermacula lens (Volk) provides better magnification and stereopsis to aid in easy identification of any lifted edge of the ERM. The 2 superior ports would be made with the transconjunctival vitrectomy system, which helps preserve the superior conjunctiva for future trabeculectomies. The incisions for the 700 mm microphakonit are so small and stable that they avoid the need for closure before vitrectomy, as would be required for coaxial phacoemulsification or conventional bimanual phacoemulsification. These ultrasmall self-sealing incisions are stable; there is no leakage, chamber shallowing, or iris prolapse through the incisions despite the high intravitreal pressures during vitrectomy. In addition, there is no reduced globe resistance or wound instability during infusion cannula insertion with microphakonit clear corneal incisions. After completing the vitrectomy, I would peel the membrane off the surface of the retina, preferably from the center to the periphery, after finding an edge of the membrane. Intravitreal unpreserved triamcinolone at the end of the vitrectomy will also aid in more rapid resolution of the CME. As the superior ports are made with the transconjunctival sutureless surgical system by displacing the conjunctiva aside and then inserting the trocar cannula system, it becomes minimally invasive and atraumatic to the superior conjunctiva, which is therefore preserved for future trabeculectomies that may be required. At the end of surgery, the trocar is simply pulled and the wound becomes self-sealing. One of the clear corneal incisions would then be enlarged and a foldable IOL implanted in the bag, taking care to keep the haptics in the direction of the zonular dialysis. If the iridodialysis could not be scrolled out initially, that part of the iris can be removed with the vitrectomy probe and aniridia rings implanted in the sulcus in this area. Stromal hydration would then be done and the wounds tested for integrity. Postoperatively, the patient would be put on topical antibiotics and steroids and monitored closely. His retinal status could be followed by repeat fundus fluorescein angiography and OCT. Amar Agarwal, MS, FRCS, FRCOphth Chennai, India
REFERENCES
Figure 4. Implantation of aniridia rings.
184
1. Agarwal S, Agarwal A, Agarwal A. Phacoemulsification, 3rd ed (2-volume set). Thorofare, NJ, Slack, 2004 2. Agarwal A, ed. Phaco Nightmares; Conquering Cataract Catastrophes. Thorofare, NJ, Slack, 2006
J CATARACT REFRACT SURG - VOL 33, FEBRUARY 2007
CONSULTATION SECTION
3. Agarwal A, ed. Handbook of Ophthalmology. Thorofare, NJ, Slack, 2005 4. Jacob S, Agarwal A, Agarwal A, et al. Efficacy of a capsular tension ring for phacoemulsification in eyes with zonular dialysis. J Cataract Refract Surg 2003; 29:315–321
- This patient previously had severe nonpenetrating trauma to the left eye, resulting in a large iridodialysis with focal zonular loss and vitreous prolapsing into the anterior chamber. There is also an ERM with CME and surprisingly good visual potential. A traumatic cataract has now formed, and the patient desires visual rehabilitation, which would involve cataract surgery combined with anterior segment reconstruction. With an ERM and preexisting CME, I would treat him with a topical nonsteroidal antiinflammatory agent before and after surgery. Before the cataract is removed and the iridodialysis repaired, vitreous prolapsing into the anterior chamber should be addressed. Through a paracentesis, I would instill a small amount of Kenalog, previously washed free of its preservatives, to visualize the location of all vitreous anterior to the iris.1 I would next create a pars plana incision in the superior temporal quadrant. Using the previously placed paracentesis as a port for low-flow irrigation, pars plana core vitrectomy would be performed under direct visualization using rapid cutting and low levels of aspiration. A temporary scleral plug would then be placed in the pars plana incision so that the posterior segment could be accessed once again at the end of the case. Next, a retentive OVD would be placed over the lens and iris. A gentle sweep with a cyclodialysis spatula between the iris and anterior lens capsule is usually enough to lyse any adhesions. Depending on the condition of the iris, it may be possible to simply push away the now-free pupil edge using an OVD. If this maneuver is not successful, and depending on the condition of the iris, 1 or 2 disposable iris hooks could be placed to adequately enlarge the pupil for the creation of the capsulorhexis. It may also be necessary to fashion the capsulorhexis slightly more nasally than temporally so that after the placement of a CTR, the lens capsule and IOL will be centered. Gentle hydrodissection would next be accomplished, taking care to completely mobilize the lens material. For a patient of this age, my preference would be to use a Simcoe-style manual I/A cannula to aspirate what is probably a soft nucleus. With its low fluid flow and quickly variable surgeoncontrolled aspiration, manual I/A in such a case would be ideal. If the status of the remaining zonules is tenuous, persistent cortical remnants could be aspirated under OVD without irrigation. The capsular bag would next be inflated with an OVD and a standard CTR gently inserted in the capsular fornix. From the photograph, it looks as though the lens is not significantly displaced and adequate centration of the capsular bag would likely result from this approach
alone. If significant iris stromal defects are present, as an alternative, a Morcher type 96F partial aniridia CTR, could be used. However, if the final position of the capsular bag is displaced nasally, a Morcher 2C Cionni CTR could be used to recenter the capsular bag using an 8-0 tetrafluoroethylene polymer (Gore-Tex) suture tied to the fixation eyelet, exiting the eye under a scleral flap. For the IOL, I prefer a single-piece acrylic, such as the SN60AT (Alcon). Combined with a CTR, a single-piece acrylic IOL would be ideal for this type of case as these lenses unfold quite slowly, minimizing the potential for stress on the remaining zonules as the IOL gently expands to fill the capsular bag. The iridodialysis repair would be performed with the anterior chamber once again filled with a retentive OVD. Here, I prefer to use a micrograsper to stabilize the peripheral iris while passing a double-armed suture through the margin of its severed edge. Several horizontal mattress sutures would be necessary to secure the large peripheral iris defect to the area of the iris root (M.E. Snyder, MD, ‘‘Repairing the Iris’’ [online]. Available at: http://www. revophth.com/2000/October/RPf11rirs0010.htm. Accessed December 4, 2006). If the pupil does not end up round and centered, a properly placed 10-0 Prolene suture through 2 points next to the remaining iris sphincter and tied with a Siepser knot will help restore a more normal cosmetic appearance to the eye.2 After the OVD is aspirated from the anterior chamber, a small amount of washed triamcinolone should be instilled to confirm that no vitreous has migrated into the anterior chamber. The vitrector would then be reinserted through the pars plana to remove any OVD that may have passed into the posterior segment with the original paracentesis used as the infusion port. After injecting a small amount of intravitreal triamcinolone to cover the preexisting CME, I would secure the pars plana scleral incision with a 7-0 polyglactin (Vicryl) suture. With severe angle recession, this patient will need to be followed closely for a postoperative pressure spike and will also require lifelong follow-up for the development of posttraumatic glaucoma. Serial OCTor fluorescein angiography will be required during the treatment of the CME. A total vitrectomy, combined with membrane stripping, may be necessary in the future. Warren E. Hill, MD Mesa, Arizona, USA
REFERENCES 1. Burk SE, Da Mata AP, Snyder ME, et al. Visualizing vitreous using Kenalog suspension. J Cataract Refract Surg 2003; 29:645–651 2. Siepser SB. The closed chamber slipping suture technique for iris repair. Ann Ophthalmol 1994; 26:71–72
J CATARACT REFRACT SURG - VOL 33, FEBRUARY 2007
185