Cataract surgical problem: Reply
Assuming the iris could not be easily reconstructed by gently breaking the synechias in the inferior angle, an incision would be placed through the bridge of iris tissue occupying the visual axis. High-molecular-weight hyaluronate (Healon5®) would be an ideal agent to inject to viscodilate the new “pupil” and retract the iris during the capsulorhexis, hydrodelamination, and slow-motion phacoemulsification procedure.
Next the implantation of an AcrySof IOL and 2 Morcher Type 50C prosthetic iris rings would be performed, using the viscoelastic agent to create special planes within the capsular bag. I have implanted these devices anterior to, posterior to, and even straddling the IOL under different circumstances. Effective glare reduction is the desired goal, which can be achieved by rotating these pigmented interdigitating plates until a continuous iris diaphragm is formed.
The management of the glaucoma is less clear; even the members of our glaucoma team expressed divergent opinions about this case. The more aggressive recommendation would be to combine the cataract surgery with a filtering procedure using antimetabolites and releasable sutures. The more conservative opinion would be in favor of performing the cataract surgery without a fistulizing procedure but leaving a temporal paracentesis track marked with methylene blue for easy identification in case an urgent reduction of an IOP spike were necessary in the early postoperative course. Should medical therapy fail to control the pressure, surgical intervention as a second-stage procedure could be done later.© 2000 by Lippincott Williams & Wilkins, Inc.