A now-17-year-old girl was reportedly born with no pupil formed in her right eye. In her first week of life, she underwent attempted pupilloplasty at a foreign institution. Surgery was reported to have been complicated and followed by vitreous hemorrhage. Nine months later, the eye was reevaluated at another institution and the presence of primary persistent hyperplastic vitreous noted. Secondary widening of the artificial pupil was performed. She now presents with a slit-shaped pupil and a very dense nuclear cataract (Figure 1). She now desires removal of the cataract to regain the temporal visual field and at least some residual vision as well as reformation of the pupil for cosmetic reasons.
Slitlamp examination shows superficial corneal scarring around a corneal incision and corneal sutures superiorly with iridocorneal synechiae between 10 and 12 o'clock confirmed on gonioscopy. It appears that a primary inferiorly displaced pupil was enlarged, and the iris shanks pulled up and incarcerated in the corneal incision, resulting in a slit-shaped cat's eye pupil. Intraocular pressure was 10 mm Hg. Light perception is uncertain but definitely positive on transillumination, and ultrasound reveals the retina to be fully attached (Figure 2).
How would you counsel this girl, and what would be your surgical approach? Which specific techniques would you consider for removal of the cataract and reformation of the pupil?