- Email: [email protected]
February Consultation # 6
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
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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