cataract surgical problem
The patient is largely relying on his monocular “near distance” vision as a piano player. In addition, his eye had previous complicated surgery as well as recent trauma. Thus, minimal surgery is advised. I would recommend carefully dialing the lens in the ciliary sulcus clockwise until the haptics reach the 8 to 2 o'clock position. In this position, the optic should again be captured by the anterior capsule.
The rationale is that the maximum extension of the initial posterior capsule tear seems to direct from the 5 to 10 o'clock position. Here, the tear is likely to involve the equatorial aspect of the capsular bag and, especially at 5 o'clock, the zonular apparatus. Thus, the blunt injury released the optic capture, leading to the sunset phenomenon seen at the postinjury examination. To get the maximum posterior capsule remnant and zonule support, the 8 to 2 o'clock position seems advisable. The anterior capsule opening, although larger than before the injury, seems sufficient for an optic capture maneuver.
An exchange for an IOL with a larger optic and large loops in the sulcus or placement of an AC IOL is another option. However, the surgical trauma and the risk of cystoid macular edema (CME) would be greater with an angle-supported AC IOL, and the risk of secondary open-angle glaucoma would increase.© 2001 by Lippincott Williams & Wilkins, Inc.