- Email: [email protected]
February Consultation # 7
CONSULTATION SECTION
- Like most cases of severe trauma, there are many issues to address and one should always be prepared for the unexpected. First, one must deal with the vitreous in the anterior chamber. Ideally, the vitreous would be removed from below with a pars plana vitrector and anterior chamber maintainer. This would minimize further damage to the zonules. I would then place a cohesive OVD to tamponade the defect. The next step is to release the adhesions of the iris to the lens. The surgeon should be prepared for an occult capsule rupture in the area of the focal opacity where the iris is most adherent to the lens. Then, I would repair the iridodialysis. Although there was no loss of iris tissue, I have found that many times, there is significant iris atrophy after this much time; the notable ectropion uvea is a further clue that the iris in this area will not be normal. Careful dissection of the iris and the pigment may allow for stretching the iris and suturing the peripheral iris to the iris root. I would use a 10-0 Prolene double-armed suture to engage the peripheral iris margin with the first needle and pass the suture through the scleral wall at the level of the iris root. The second needle would be similarly passed through the iris and out the sclera and the suture tightened and tied externally, pulling the peripheral iris to the scleral wall. The knot would be trimmed and buried in the sclera. More realistically, the
186
surgeon must be prepared to excise this iris and deal with the defect later. We could then turn our attention to the cataract. The capsulorhexis will be difficult because of the anterior capsule scarring. Again, the surgeon should be prepared for an occult rupture. If the capsule and capsulorhexis are intact, I would place a CTR. With the zonular dialysis visible, it is not likely the bag will be unstable enough to require suture stabilization with a Cionni modified ring, but that may be a possibility and a ring should be on hand. There is disagreement on the best time to insert the CTR, but if it is possible to safely remove the nucleus and the cortex before placing the CTR, that is my preference. However, significant bag instability may require that it be placed earlier in the procedure. The surgeon could then place the IOL of choice; in this case, I would opt for a single-piece acrylic IOL. If the iridodialysis could not be primarily repaired and that portion of the iris has been excised, the iris defect could be addressed using artificial iris segments, which are not currently available in the United Stated. Morcher and Ophtec currently make segments, and HumanOptics will soon offer a very lifelike segment that is far superior cosmetically to those currently available.
J CATARACT REFRACT SURG - VOL 33, FEBRUARY 2007
Mark H. Blecher, MD Philadelphia, Pennsylvania, USA
- Like most cases of severe trauma, there are many issues to address and one should always be prepared for the unexpected. First, one must deal with the vitreous in the anterior chamber. Ideally, the vitreous would be removed from below with a pars plana vitrector and anterior chamber maintainer. This would minimize further damage to the zonules. I would then place a cohesive OVD to tamponade the defect. The next step is to release the adhesions of the iris to the lens. The surgeon should be prepared for an occult capsule rupture in the area of the focal opacity where the iris is most adherent to the lens. Then, I would repair the iridodialysis. Although there was no loss of iris tissue, I have found that many times, there is significant iris atrophy after this much time; the notable ectropion uvea is a further clue that the iris in this area will not be normal. Careful dissection of the iris and the pigment may allow for stretching the iris and suturing the peripheral iris to the iris root. I would use a 10-0 Prolene double-armed suture to engage the peripheral iris margin with the first needle and pass the suture through the scleral wall at the level of the iris root. The second needle would be similarly passed through the iris and out the sclera and the suture tightened and tied externally, pulling the peripheral iris to the scleral wall. The knot would be trimmed and buried in the sclera. More realistically, the
186
surgeon must be prepared to excise this iris and deal with the defect later. We could then turn our attention to the cataract. The capsulorhexis will be difficult because of the anterior capsule scarring. Again, the surgeon should be prepared for an occult rupture. If the capsule and capsulorhexis are intact, I would place a CTR. With the zonular dialysis visible, it is not likely the bag will be unstable enough to require suture stabilization with a Cionni modified ring, but that may be a possibility and a ring should be on hand. There is disagreement on the best time to insert the CTR, but if it is possible to safely remove the nucleus and the cortex before placing the CTR, that is my preference. However, significant bag instability may require that it be placed earlier in the procedure. The surgeon could then place the IOL of choice; in this case, I would opt for a single-piece acrylic IOL. If the iridodialysis could not be primarily repaired and that portion of the iris has been excised, the iris defect could be addressed using artificial iris segments, which are not currently available in the United Stated. Morcher and Ophtec currently make segments, and HumanOptics will soon offer a very lifelike segment that is far superior cosmetically to those currently available.
J CATARACT REFRACT SURG - VOL 33, FEBRUARY 2007
Mark H. Blecher, MD Philadelphia, Pennsylvania, USA