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Consultation section

cataract surgical problem

Section Editor(s): Masket, Samuel MD

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Journal of Cataract & Refractive Surgery: June 2004 - Volume 30 - Issue 6 - p 1155
doi: 10.1016/j.jcrs.2004.04.010
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A 48-year-old 1-eyed man is referred for management of a malpositioned posterior chamber intraocular lens (PC IOL). His history reveals that he had retinopathy of prematurity (ROP) that led to loss of his right eye, for which he wears a prosthesis.

The left eye has had several prior procedures for proliferative peripheral vitreoretinopathy, including scleral buckling and multiple vitrectomies. Fifteen years earlier, the patient had cataract extraction with placement of a 3-piece PC IOL with positioning holes in the optic. Subsequently, the IOL subluxated and 1 year ago he had attempted repositioning of the IOL by scleral suture fixation under the care of a vitreoretinal surgeon. Polypropylene sutures were fixated to the IOL loops and to the sclera. Furthermore, 1 suture loop was passed through an IOL fixation hole and scleral fixated. Unfortunately, according to the history, the patient had a stormy postoperative course that included a suprachoroidal hemorrhage. After a period of time, the eye recovered useful vision (20/60) but the patient was left with an irregular, enlarged, and fixed pupil and a firmly malpositioned IOL (Figures 1 and 2). In addition, and significantly, the ends of the scleral sutures have eroded through the scleral flaps, have been exposed, and have induced focal granulomata and giant papillary conjunctivitis (GPC).

Figure 1.
Figure 1.:
(Masket) Slitlamp photograph reveals conjunctival injection; suture-end exposure at the 10, 3, and 8 o'clock positions; and an irregular fixed pupil.
Figure 2.
Figure 2.:
(Masket) Red reflex view shows a malpositioned IOL with inflammatory deposits and a loop of polypropylene suture fixated through a superonasal positioning hole.

Although the patient has regained a good level of visual acuity, the enlarged irregular pupil limits his driving ability. He has been fitted with an aesthetic contact lens that improves his functional vision. However, the referring physician is concerned about the added risks of contact lens wear in the presence of suture exposure.

Given the above history and findings, how would you manage his condition?

© 2004 by Lippincott Williams & Wilkins, Inc.