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October consultation #5
CONSULTATION SECTION
incarceration through the superior basal iridectomy, and 2 previous IOL recentration attempts, I believe the best option would be to avoid surgery because there is a definite risk for more endothelial cell loss and for cystoid macular edema (CME). I would advise the patient to use pilocarpine 2% eyedrops twice daily, with the last dose before sunset, to constrict the pupil and overcome the edge glare. If the pilocarpine eyedrops are not effective, the AC IOL should be removed after the superior haptic is amputated. Utmost care should be taken to protect the corneal endothelium and prevent loss of anterior chamber or hypotony. This can be done using a combination of dispersive and cohesive OVDs. The incision would be created superiorly at the limbus. After the superior haptic is amputated from the optic junction with microscissors, the IOL would be removed and then the amputated haptic removed, releasing it from the iridectomy. Two oblique paracenteses would be created at 10 o’clock and 2 o’clock. After confirming the absence of vitreous strands in the anterior chamber, I would implant an aphakic iris-claw IOL in the posterior chamber with posterior enclavation of the claws through the 2 paracenteses. Posterior enclavation is much easier than regular anterior enclavation in vitrectomized eyes. With the 5.5 mm optic well centered behind the pupil, the night-vision problem should resolve. Postoperatively, in addition to regular treatment, I would prescribe nonsteroidal antiinflammatory eyedrops for 2 weeks to decrease the risk for CME. In the left eye, I would expect IFIS, with poor pupil dilation and floppy iris, to occur during cataract extraction as well. To avoid iris prolapse, I would perform microcoaxial phacoemulsification with a 2.2 mm temporal corneal incision and a long (2.5 mm) tunnel, entering the anterior chamber away from the root of the iris. I would create a narrow paracentesis just big enough to admit the 22-gauge chopper to decrease leakage from the anterior chamber and thus decrease anterior chamber fluctuations and iris bellowing. The use of a cohesive–viscous OVD could be of value during creation of the capsulorhexis. I would decrease the height of infusion to 70 cm and flow rate to 26 cc/min. Working with a nucleus splitting chopper in the center of the pupil would allow the nucleus to be split, even if the pupil does not dilate or constricts during surgery. Performing single-handed phacoemulsification, when possible, would reduce iris prolapse from the paracentesis and decrease anterior chamber fluctuation. An additional tool to avoid iris complications is the Malyguin iris dilator, which can stabilize the iris and dilate the pupil at the start of surgery before the capsulorhexis. Yehia Mostafa, MD Cairo, Egypt
1799
- It is not clear what the 2 previous surgical repositionings comprised in this case. The AC IOL may be too short and thus has rotated, with 1 footplate entering the peripheral iridectomy, causing the IOL to decenter. The good news is that CDVA in this eye is 20/20. Because of this excellent vision, the lack of presenting vitreous, and the patient’s hesitancy to have further surgery, I would first advise that the easiest way to improve vision in the operated eye is to reposition the IOL again, rotating to a horizontal position. This would require 1 or 2 tiny paracenteses and a Lester-type hook to engage the loop between the footplates of the IOL to retract and rotate it. The same motion would be repeated on the opposite side, walking the IOL to the horizontal position and taking care to avoid iris tuck. I think this would eliminate the glare because the iris margin is not too irregular and should not change the patient’s current refractive error. The incision(s) should be virtually watertight; thus, no OVD should be needed. The patient should be told that this procedure is recommended not only for his visual symptoms but also because his cornea is slowly decompensating. This goal is that IOL repositioning will at least temporarily solve the problem in the right eye and that the patient will now consent to surgery in the left eye. Surgery should be performed with the current techniques for eyes with IFIS, using highly cohesive OVDs to stabilize the iris if dilation is good. If there is inadequate iris dilation, rings or iris hooks could be used. These techniques should lead to successful surgery, giving the patient further confidence in the hope that he will consent to further surgery in the right eye, if required (ie, the AC IOL rotates and a footplate again enters the peripheral iridectomy). If the right eye does require further surgery, a decision would have to be made on whether to implant the next larger AC IOL or exchange the current AC IOL for a scleralsutured PC IOL. Stephen F. Brint, MD Metairie, Louisiana, USA
- I would advise cataract removal with IOL implantation in the left eye as an initial procedure. I have great confidence that the visual outcomes would be excellent, and I would approach the patient accordingly. When tamsulosin or other factors lead to poor dilation and there is a risk for IFIS, I add 1 drop of atropine 1% to the dilating regimen and 0.2 cc intracameral lidocaine 1% PF. I seldom find it necessary to add epinephrine, and with 3.0 to 4.0 mm pupils, I rarely use iris-
J CATARACT REFRACT SURG - VOL 36, OCTOBER 2010
incarceration through the superior basal iridectomy, and 2 previous IOL recentration attempts, I believe the best option would be to avoid surgery because there is a definite risk for more endothelial cell loss and for cystoid macular edema (CME). I would advise the patient to use pilocarpine 2% eyedrops twice daily, with the last dose before sunset, to constrict the pupil and overcome the edge glare. If the pilocarpine eyedrops are not effective, the AC IOL should be removed after the superior haptic is amputated. Utmost care should be taken to protect the corneal endothelium and prevent loss of anterior chamber or hypotony. This can be done using a combination of dispersive and cohesive OVDs. The incision would be created superiorly at the limbus. After the superior haptic is amputated from the optic junction with microscissors, the IOL would be removed and then the amputated haptic removed, releasing it from the iridectomy. Two oblique paracenteses would be created at 10 o’clock and 2 o’clock. After confirming the absence of vitreous strands in the anterior chamber, I would implant an aphakic iris-claw IOL in the posterior chamber with posterior enclavation of the claws through the 2 paracenteses. Posterior enclavation is much easier than regular anterior enclavation in vitrectomized eyes. With the 5.5 mm optic well centered behind the pupil, the night-vision problem should resolve. Postoperatively, in addition to regular treatment, I would prescribe nonsteroidal antiinflammatory eyedrops for 2 weeks to decrease the risk for CME. In the left eye, I would expect IFIS, with poor pupil dilation and floppy iris, to occur during cataract extraction as well. To avoid iris prolapse, I would perform microcoaxial phacoemulsification with a 2.2 mm temporal corneal incision and a long (2.5 mm) tunnel, entering the anterior chamber away from the root of the iris. I would create a narrow paracentesis just big enough to admit the 22-gauge chopper to decrease leakage from the anterior chamber and thus decrease anterior chamber fluctuations and iris bellowing. The use of a cohesive–viscous OVD could be of value during creation of the capsulorhexis. I would decrease the height of infusion to 70 cm and flow rate to 26 cc/min. Working with a nucleus splitting chopper in the center of the pupil would allow the nucleus to be split, even if the pupil does not dilate or constricts during surgery. Performing single-handed phacoemulsification, when possible, would reduce iris prolapse from the paracentesis and decrease anterior chamber fluctuation. An additional tool to avoid iris complications is the Malyguin iris dilator, which can stabilize the iris and dilate the pupil at the start of surgery before the capsulorhexis. Yehia Mostafa, MD Cairo, Egypt
1799
- It is not clear what the 2 previous surgical repositionings comprised in this case. The AC IOL may be too short and thus has rotated, with 1 footplate entering the peripheral iridectomy, causing the IOL to decenter. The good news is that CDVA in this eye is 20/20. Because of this excellent vision, the lack of presenting vitreous, and the patient’s hesitancy to have further surgery, I would first advise that the easiest way to improve vision in the operated eye is to reposition the IOL again, rotating to a horizontal position. This would require 1 or 2 tiny paracenteses and a Lester-type hook to engage the loop between the footplates of the IOL to retract and rotate it. The same motion would be repeated on the opposite side, walking the IOL to the horizontal position and taking care to avoid iris tuck. I think this would eliminate the glare because the iris margin is not too irregular and should not change the patient’s current refractive error. The incision(s) should be virtually watertight; thus, no OVD should be needed. The patient should be told that this procedure is recommended not only for his visual symptoms but also because his cornea is slowly decompensating. This goal is that IOL repositioning will at least temporarily solve the problem in the right eye and that the patient will now consent to surgery in the left eye. Surgery should be performed with the current techniques for eyes with IFIS, using highly cohesive OVDs to stabilize the iris if dilation is good. If there is inadequate iris dilation, rings or iris hooks could be used. These techniques should lead to successful surgery, giving the patient further confidence in the hope that he will consent to further surgery in the right eye, if required (ie, the AC IOL rotates and a footplate again enters the peripheral iridectomy). If the right eye does require further surgery, a decision would have to be made on whether to implant the next larger AC IOL or exchange the current AC IOL for a scleralsutured PC IOL. Stephen F. Brint, MD Metairie, Louisiana, USA
- I would advise cataract removal with IOL implantation in the left eye as an initial procedure. I have great confidence that the visual outcomes would be excellent, and I would approach the patient accordingly. When tamsulosin or other factors lead to poor dilation and there is a risk for IFIS, I add 1 drop of atropine 1% to the dilating regimen and 0.2 cc intracameral lidocaine 1% PF. I seldom find it necessary to add epinephrine, and with 3.0 to 4.0 mm pupils, I rarely use iris-
J CATARACT REFRACT SURG - VOL 36, OCTOBER 2010