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Consultation Section

Cataract surgical problem: Reply

Wilson, Richard P. MD

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Journal of Cataract & Refractive Surgery: March 2000 - Volume 26 - Issue 3 - p 317-318
doi: 10.1016/S0886-3350(00)00336-9
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This patient is in the older age range to be presenting with ICE syndrome. That, accompanied by her relatively good vision, healthy nerve, and medically controlled IOP, suggests that her endothelial disorder is not overly aggressive.

In this type of patient, I have been surprisingly successful with straightforward filtration surgery with modest use of mitomycin-C in a previously unoperated eye and with more aggressive mitomycin regimens in triple procedures and in patients with conjunctival scarring.

As the patient in question has a cataract, I would proceed with a combined cataract extraction, injectable IOL, and trabeculectomy with 3 minutes of a wide area with a 0.4 mg/cc mitomycin-C soak. Because of her endothelial disease, I would cushion the cornea well with a viscoelastic agent during phacoemulsification and use minimal energy as far away from the cornea as safely possible. A pupilloplasty would be necessary to remove the cataract and should also improve postoperative vision.

If the patient had exhibited more aggressive endothelial disease signified by a young age at onset, progressive iris changes during observation, and more difficult IOP control, I would have strongly considered placing an aqueous shunt combined with temporal clear corneal phacoemulsification and IOL implantation.

The necessity for IOPs in the under 15 mm Hg range would sway me more toward a trabeculectomy, which I expect would result in lower IOPs than an aqueous shunt. Early corneal decompensation, suggesting that PKP will be required in the foreseeable future, would also point me to a trabeculectomy. A review of the literature suggests that corneal grafts in the presence of aqueous shunts have a higher failure rate than in the presence of trabeculectomies.

Overall, this patient's prognosis is guarded, but I would expect her to do well in the near future.

© 2000 by Lippincott Williams & Wilkins, Inc.