- Email: [email protected]
October Consultation # 6
CONSULTATION SECTION
tension ring and a symmetrically biconvex IOL with an optic diameter of at least 6.0 mm. Oliver Findl, MD, MBA London, United Kingdom
REFERENCE 1. Cauchi P, Azuara-Blanco A, McKenzie J. Corneal toxicity and inflammation secondary to retained perfluorodecalin. Am J Ophthalmol 2005; 140:322–323
- This patient deserves further evaluation. We must know why the BCVA is limited to 20/50. Is the reason corneal, lenticular, or macular? Perhaps the recurrent iritis and surgery have caused cystoid macular edema (CME). An OCT evaluation can determine whether combined treatment with a topical steroid and NSAID is necessary. Surgery is not indicated until this issue is resolved. Next, because there is the history of a prolonged shallow chamber, gonioscopy should determine the status of the angle. If significant peripheral anterior synechias are present, even though the IOP is within the normal range, the asymmetric pressure may be secondary and more stringent follow-up with visual fields and optic nerve photographs is warranted. The thicker cornea does not account for the asymmetry, although the relatively low IOP in the fellow eye may be due to the thin cornea. I would want to be assured that the pressure of 9 mm Hg is not associated with low-grade chronic iritis in the left eye. Bilateral uveitis mandates a systemic workup. Although the etiology is unknown in most cases, it can be identified and treated in others. Ideally, the status of the corneal endothelium should be assessed. I would want an endothelial cell count before further manipulation. Perfluorocarbon is toxic to the endothelium. As it also mechanically interferes with vision, it should be removed. The remaining material in the posterior segment could still present anteriorly, but I would not take the extreme measures its removal would necessitate. Regarding counseling, I would address the patient’s concerns sequentially, starting with the Purkinje image. The commonly used IOL at the time of placement had the variable power on the back surface and a flat anterior surface, making reflective images off the acrylic material more obvious. Although newer IOLs have eliminated the planar front surface, the patient can expect some degree of glint in the eye, even with modern alternatives. I believe that exchanging the well-centered and functional IOL, particularly in the setting of an open capsule (even after vitrectomy), would be an unacceptable risk. The dilated and irregular pupil produces functional and cosmetic problems
1685
and deserves intervention. The bubbles in the front of the eye should be removed (although the posterior remnant might migrate forward and require attention later). The IOL tilt and optic capture by the pupillary margin and iridoplegia cause irregular astigmatism and glare. I would demonstrate with a slitlamp photograph. Although tilt can be analyzed with the Pentacam (Oculus, Inc.) or Visante (Carl Zeiss Meditec) system or by wavefront analysis, these tests are purely academic as optic capture can also promote iritis and therefore must be resolved. No comment was made about refractive error. If appropriate, the possibility of improving astigmatism can be considered; this would require topography if peripheral astigmatic keratotomy is incorporated into the surgical plan. The patient must understand the risks of surgery, including infection and the possibility of recurrent iritis and its consequences, including CME. A perfect cosmetic result cannot be guaranteed. Because the other eye is still the better eye, I would be inclined to advise resolving the ongoing issues in the right eye before performing cataract surgery in the left eye, in which I would implant a 1-piece acrylic blue-filtering aspherical IOL. The increased risk for retinal detachment in this fellow eye must be emphasized. I would argue against using silicone, although it causes less reflection. The timing of surgery should be at the patient’s election based on her activities of daily living. If the patient consents, my recommendation would be to plan surgery with peribulbar anesthesia once any CME is resolved. I would start topical NSAIDs 1 week before surgery, give 1 dose of oral moxifloxacin 3 hours before surgery, and administer the usual topical prophylaxis preoperatively and postoperatively. I would not use mydriatics. Working through several paracenteses, I would first control the chamber with Viscoat, isolating the PFC bubbles for manual removal with a 26-gauge cannula on a syringe. Next, I would perform viscodissection to break the posterior synechias. The haptics are confirmed to be symmetrically located in the bag. Irrigation of Miochol E would allow me to see the miotic pupil shape and size. I would perform modified McCannel pupilloplasty with a 10-0 polypropylene suture and locking Siepser knot technique. I would suture the inferior iris well across the inferior part of the IOL to prevent recapture; 1 or 2 additional sutures might be necessary to ‘‘round’’ the pupil. Alternatively, depending on the miotic pupil size and shape, I would use a pursestring suture for a cosmetic outcome, making sure the pupil covers the inferior edge as recapture is possible without an adequate barrier. After manual removal of most of the OVD, I would irrigate a small amount of purified (preservative removed) triamcinolone acetate suspension into the anterior chamber to
J CATARACT REFRACT SURG - VOL 33, OCTOBER 2007
1686
CONSULTATION SECTION
reduce postoperative inflammation. Once I ascertain that the paracenteses are secure, I would measure the IOP with an intraoperative Barraquer tonometer, leaving the pressure between 15 mm Hg and 22 mm Hg. One oral acetazolamide (Diamox) sequel would be prescribed immediately postoperatively. Lisa Brothers Arbisser, MD Bettendorf, Iowa, USA Rock Island, Illinois, USA Salt Lake City, Utah, USA
proposition, but use of viscodissection may facilitate this approach. The PFC should not be left in the eye for an extended period, so I would perform the operation in conjunction with a PPV. This would be performed by a vitreoretinal colleague to remove the PFC from the posterior chamber. Endolaser or a buckling procedure may be warranted depending on the status of the retina. Tim Johnson, MD Iowa City, Iowa, USA
Dr. Arbisser has honoraria and research grants from Alcon and AMO.
- As important as the surgical approach is the discussion of expectations and risks with the patient. The patient must understand the risk for recurrent iritis and retinal detachment if the decision is made to proceed with an operation. My sense is that cosmetics are important to her, but this should be balanced against issues of visual function. I would also involve the vitreoretinal surgeon in the decision-making process because removal of the PFC is a consideration. Any surgical intervention carries the risk for reactivating the uveitis. If the patient elects to proceed with surgery, I would initiate topical therapy (eg, prednisolone acetate [Pred Forte] 4 times a day or every 2 hours for 1 to 2 weeks before surgery) and deliver sub-Tenon’s or intraocular triamcinolone acetate (Kenalog) at the time of surgery. Postoperatively, an extended course of steroids and probably an NSAID would be appropriate. Despite the statement in the case report that the IOL is in the capsular bag, it is obvious that the inferior portion of the optic is outside the bag. The photographs do not allow visualization of the anterior capsule, but I presume the initial capsule tear was larger than the optic and the anterior and posterior capsules are now fused beyond the edge of the optic. Options for dealing with the IOL include repositioning it or an IOL exchange. Given the previous Nd:YAG laser capsulotomy, I would favor leaving the existing IOL. I would perform careful synechialysis to relieve the adhesions. Use of viscodissection could help reduce the need for blunt and sharp dissection and thus minimize the risk for postoperative uveitis. If the anterior capsule opening were smaller than the optic, it would be useful to reopen the bag to allow complete optic capture within the bag. However, I think the opening is too large in this case. To prevent future optic capture, the pupil should be constricted with interrupted polypropylene sutures or an iris cerclage. An alternative that avoids suturing the iris would be to exchange the IOL and place an IOL with a larger optic (eg, AcrySof MA50BM with 6.5 mm optic) in the sulcus. An open posterior capsule makes this a riskier
- This patient’s unfortunate situation is multifactorial. Clearly, her downgaze complaints stem from the PFC in the anterior chamber. This can be addressed by removal, most preferably at the slitlamp, before other interventions, as the PFC will likely migrate in the posterior segment with the patient in the reclining position and would require a combined approach with the vitreoretinal team to remove. With a small retained bubble posteriorly, a combined vitreoretinal and anterior segment approach is reasonable, although it often comes with logistical challenges. The recurrent iritis might be exacerbated by the sharp anterior edge of the AcrySof MA30BA IOL rubbing against the iris surface. This could be addressed by synechialysis, performed bluntly or using intraocular 23-gauge microscissors, as needed, combined with repositioning the IOL optic through the posterior capsule opening, IOL exchange for a round anterior edge IOL, or both. Pupil cerclage would prevent subsequent optic capture of the iris. The reflections off the anterior surface of the IOL may be less cosmetically disturbing with a pupil repair procedure, reducing the aperture by pupil cerclage (or imbricating) sutures, IOL exchange, or both. The AcrySof MA30 series IOLs had only 5.0 diopters of power on the anterior surface and thus had maximum reflectivity. Selection of an IOL that has a higher amount of power on the anterior surface would reduce the reflection from the third Purkinje–Sanson image, reducing the perceived reflection. Alternatively, an IOL with a lower index of refraction would also mitigate this cosmetic issue, although I would be reluctant to place a silicone-based IOL in an eye with a history of retinal detachment and iritis. Whether the altered anterior surface of a presbyopia-correcting multifocal IOL would reduce the cosmetic reflections has not been studied, although it is an interesting potential speculation to discuss with the patient if she is otherwise inclined toward such an IOL. The cataract in the fellow eye should be addressed only after the issues in the first eye have been satisfactorily resolved. In the second-eye cataract surgery,
J CATARACT REFRACT SURG - VOL 33, OCTOBER 2007
tension ring and a symmetrically biconvex IOL with an optic diameter of at least 6.0 mm. Oliver Findl, MD, MBA London, United Kingdom
REFERENCE 1. Cauchi P, Azuara-Blanco A, McKenzie J. Corneal toxicity and inflammation secondary to retained perfluorodecalin. Am J Ophthalmol 2005; 140:322–323
- This patient deserves further evaluation. We must know why the BCVA is limited to 20/50. Is the reason corneal, lenticular, or macular? Perhaps the recurrent iritis and surgery have caused cystoid macular edema (CME). An OCT evaluation can determine whether combined treatment with a topical steroid and NSAID is necessary. Surgery is not indicated until this issue is resolved. Next, because there is the history of a prolonged shallow chamber, gonioscopy should determine the status of the angle. If significant peripheral anterior synechias are present, even though the IOP is within the normal range, the asymmetric pressure may be secondary and more stringent follow-up with visual fields and optic nerve photographs is warranted. The thicker cornea does not account for the asymmetry, although the relatively low IOP in the fellow eye may be due to the thin cornea. I would want to be assured that the pressure of 9 mm Hg is not associated with low-grade chronic iritis in the left eye. Bilateral uveitis mandates a systemic workup. Although the etiology is unknown in most cases, it can be identified and treated in others. Ideally, the status of the corneal endothelium should be assessed. I would want an endothelial cell count before further manipulation. Perfluorocarbon is toxic to the endothelium. As it also mechanically interferes with vision, it should be removed. The remaining material in the posterior segment could still present anteriorly, but I would not take the extreme measures its removal would necessitate. Regarding counseling, I would address the patient’s concerns sequentially, starting with the Purkinje image. The commonly used IOL at the time of placement had the variable power on the back surface and a flat anterior surface, making reflective images off the acrylic material more obvious. Although newer IOLs have eliminated the planar front surface, the patient can expect some degree of glint in the eye, even with modern alternatives. I believe that exchanging the well-centered and functional IOL, particularly in the setting of an open capsule (even after vitrectomy), would be an unacceptable risk. The dilated and irregular pupil produces functional and cosmetic problems
1685
and deserves intervention. The bubbles in the front of the eye should be removed (although the posterior remnant might migrate forward and require attention later). The IOL tilt and optic capture by the pupillary margin and iridoplegia cause irregular astigmatism and glare. I would demonstrate with a slitlamp photograph. Although tilt can be analyzed with the Pentacam (Oculus, Inc.) or Visante (Carl Zeiss Meditec) system or by wavefront analysis, these tests are purely academic as optic capture can also promote iritis and therefore must be resolved. No comment was made about refractive error. If appropriate, the possibility of improving astigmatism can be considered; this would require topography if peripheral astigmatic keratotomy is incorporated into the surgical plan. The patient must understand the risks of surgery, including infection and the possibility of recurrent iritis and its consequences, including CME. A perfect cosmetic result cannot be guaranteed. Because the other eye is still the better eye, I would be inclined to advise resolving the ongoing issues in the right eye before performing cataract surgery in the left eye, in which I would implant a 1-piece acrylic blue-filtering aspherical IOL. The increased risk for retinal detachment in this fellow eye must be emphasized. I would argue against using silicone, although it causes less reflection. The timing of surgery should be at the patient’s election based on her activities of daily living. If the patient consents, my recommendation would be to plan surgery with peribulbar anesthesia once any CME is resolved. I would start topical NSAIDs 1 week before surgery, give 1 dose of oral moxifloxacin 3 hours before surgery, and administer the usual topical prophylaxis preoperatively and postoperatively. I would not use mydriatics. Working through several paracenteses, I would first control the chamber with Viscoat, isolating the PFC bubbles for manual removal with a 26-gauge cannula on a syringe. Next, I would perform viscodissection to break the posterior synechias. The haptics are confirmed to be symmetrically located in the bag. Irrigation of Miochol E would allow me to see the miotic pupil shape and size. I would perform modified McCannel pupilloplasty with a 10-0 polypropylene suture and locking Siepser knot technique. I would suture the inferior iris well across the inferior part of the IOL to prevent recapture; 1 or 2 additional sutures might be necessary to ‘‘round’’ the pupil. Alternatively, depending on the miotic pupil size and shape, I would use a pursestring suture for a cosmetic outcome, making sure the pupil covers the inferior edge as recapture is possible without an adequate barrier. After manual removal of most of the OVD, I would irrigate a small amount of purified (preservative removed) triamcinolone acetate suspension into the anterior chamber to
J CATARACT REFRACT SURG - VOL 33, OCTOBER 2007
1686
CONSULTATION SECTION
reduce postoperative inflammation. Once I ascertain that the paracenteses are secure, I would measure the IOP with an intraoperative Barraquer tonometer, leaving the pressure between 15 mm Hg and 22 mm Hg. One oral acetazolamide (Diamox) sequel would be prescribed immediately postoperatively. Lisa Brothers Arbisser, MD Bettendorf, Iowa, USA Rock Island, Illinois, USA Salt Lake City, Utah, USA
proposition, but use of viscodissection may facilitate this approach. The PFC should not be left in the eye for an extended period, so I would perform the operation in conjunction with a PPV. This would be performed by a vitreoretinal colleague to remove the PFC from the posterior chamber. Endolaser or a buckling procedure may be warranted depending on the status of the retina. Tim Johnson, MD Iowa City, Iowa, USA
Dr. Arbisser has honoraria and research grants from Alcon and AMO.
- As important as the surgical approach is the discussion of expectations and risks with the patient. The patient must understand the risk for recurrent iritis and retinal detachment if the decision is made to proceed with an operation. My sense is that cosmetics are important to her, but this should be balanced against issues of visual function. I would also involve the vitreoretinal surgeon in the decision-making process because removal of the PFC is a consideration. Any surgical intervention carries the risk for reactivating the uveitis. If the patient elects to proceed with surgery, I would initiate topical therapy (eg, prednisolone acetate [Pred Forte] 4 times a day or every 2 hours for 1 to 2 weeks before surgery) and deliver sub-Tenon’s or intraocular triamcinolone acetate (Kenalog) at the time of surgery. Postoperatively, an extended course of steroids and probably an NSAID would be appropriate. Despite the statement in the case report that the IOL is in the capsular bag, it is obvious that the inferior portion of the optic is outside the bag. The photographs do not allow visualization of the anterior capsule, but I presume the initial capsule tear was larger than the optic and the anterior and posterior capsules are now fused beyond the edge of the optic. Options for dealing with the IOL include repositioning it or an IOL exchange. Given the previous Nd:YAG laser capsulotomy, I would favor leaving the existing IOL. I would perform careful synechialysis to relieve the adhesions. Use of viscodissection could help reduce the need for blunt and sharp dissection and thus minimize the risk for postoperative uveitis. If the anterior capsule opening were smaller than the optic, it would be useful to reopen the bag to allow complete optic capture within the bag. However, I think the opening is too large in this case. To prevent future optic capture, the pupil should be constricted with interrupted polypropylene sutures or an iris cerclage. An alternative that avoids suturing the iris would be to exchange the IOL and place an IOL with a larger optic (eg, AcrySof MA50BM with 6.5 mm optic) in the sulcus. An open posterior capsule makes this a riskier
- This patient’s unfortunate situation is multifactorial. Clearly, her downgaze complaints stem from the PFC in the anterior chamber. This can be addressed by removal, most preferably at the slitlamp, before other interventions, as the PFC will likely migrate in the posterior segment with the patient in the reclining position and would require a combined approach with the vitreoretinal team to remove. With a small retained bubble posteriorly, a combined vitreoretinal and anterior segment approach is reasonable, although it often comes with logistical challenges. The recurrent iritis might be exacerbated by the sharp anterior edge of the AcrySof MA30BA IOL rubbing against the iris surface. This could be addressed by synechialysis, performed bluntly or using intraocular 23-gauge microscissors, as needed, combined with repositioning the IOL optic through the posterior capsule opening, IOL exchange for a round anterior edge IOL, or both. Pupil cerclage would prevent subsequent optic capture of the iris. The reflections off the anterior surface of the IOL may be less cosmetically disturbing with a pupil repair procedure, reducing the aperture by pupil cerclage (or imbricating) sutures, IOL exchange, or both. The AcrySof MA30 series IOLs had only 5.0 diopters of power on the anterior surface and thus had maximum reflectivity. Selection of an IOL that has a higher amount of power on the anterior surface would reduce the reflection from the third Purkinje–Sanson image, reducing the perceived reflection. Alternatively, an IOL with a lower index of refraction would also mitigate this cosmetic issue, although I would be reluctant to place a silicone-based IOL in an eye with a history of retinal detachment and iritis. Whether the altered anterior surface of a presbyopia-correcting multifocal IOL would reduce the cosmetic reflections has not been studied, although it is an interesting potential speculation to discuss with the patient if she is otherwise inclined toward such an IOL. The cataract in the fellow eye should be addressed only after the issues in the first eye have been satisfactorily resolved. In the second-eye cataract surgery,
J CATARACT REFRACT SURG - VOL 33, OCTOBER 2007