cataract surgical problem
The first thing I would attempt is to reestablish the anterior capsule capture. This would solve both the refractive and the positional/fixation problems. Technically, this should not be overly difficult. Care must be taken that, with a bimanual technique, every force exerted on the capsular rim to distend it to enable “buttoning back” the lens optic be properly counteracted exactly opposite to avoid stressing the zonules.
The only problem one could encounter, although there is no indication of it in the figures, is a zonular defect or general loosening severe enough to make refixation not advisable. In this case, I would extract the loose capsular ring altogether. Thus, for optical correction, 2 possibilities remain: scleral suture fixation of a posterior chamber IOL in the ciliary sulcus or an AC IOL of modern design. I would opt for the latter. In addition to my general preference for AC lenses over sclerally suture-fixated PC lenses, there is another good reason to use an AC lens in this case: The patient apparently has high expectations for his UCVA; that is, for the precision of prediction of his residual refraction. His expectations appear to be considerably easier to fulfill with the AC IOL than with a sulcus-sutured PC IOL.© 2001 by Lippincott Williams & Wilkins, Inc.