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consultation section

cataract surgical problem

Worst, Jan G.F. MDa

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Journal of Cataract & Refractive Surgery: October 2001 - Volume 27 - Issue 10 - p 1540-1541
doi: 10.1016/S0886-3350(01)01139-7
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First, we should consider Hippocrate's statement, “Nil nocere” (ie, do no harm). However, the text says more than that; it says to give help and to not make things worse.

In view of the multiple traumas (ie, cataract surgery followed by functionally successful IOL implantation and blunt trauma), I would hesitate to do anything. However, efforts to improve the patient's condition are justified in view of the functionally optimal condition of the fellow eye, the bothersome reduced visual acuity, and in particular the “shakiness” of the IOL, which could be especially difficult for someone reading a musical score.

As the mobility of the IOL infers considerable displacement of the entire lens including the loops, removing it would be relatively easy. Both Figure 1, showing the eye before the trauma, and Figure 2, taken after, support this approach. However, any new incision for reimplantation must be done in an area that has not been used for previous surgery. Binkhorst stressed the importance of this in the early days, when almost all IOL (Binkhorst or Medallion type) implantations were performed secondarily.

I would implant an Artisan IOL, but with a modified technique in which the usual 12 o'clock approach is made from the temporal side. Figure 2 shows a significantly dilated pupil. Is this for photographic purposes, or is it an effect of the trauma? If it was a result of trauma, the Artisan lens should have a 6.0 mm diameter.

Astigmatism was mentioned, and I wonder whether it is moderate. Its presence means that a custom-designed Artisan IOL might be considered, although a technical limitation is that this lens requires accurate positioning. In view of the limited experience with this improvement, a low-powered toric Artisan IOL might be a good option.

If a 6.0 mm IOL does not cover the widened pupil, lenses with a black optic are available. However, fixation of loops of black material is more difficult than fixation of poly(methyl methacrylate) loops.

In recommending the Artisan systems approach, I am avoiding other systems that may be equally effective but with which I have no experience, with the exception of trans pars plana stitches. The incidence of CME is higher when the pars plana is involved.

The fixation of Artisan IOLs in eyes with a traumatized iris can be modified by the 3-point support system that avoids the defective areas of the iris.

© 2001 by Lippincott Williams & Wilkins, Inc.