cataract surgical problem
▪ The last attempt at repositioning the IOL had a very stormy postoperative period with suprachoroidal hemorrhage. The best vision he has is a reasonable 20/60. His current problems are inability to drive due to the irregular enlarged pupil and the decentered IOL and his scleral sutures have eroded through and are causing GPC. The good potential for functional vision has been proved with the cosmetic contact lens trial. Improving his functional vision would require a centered IOL and a small, round pupil. Ideally, this should be achieved without any scleral sutures because the last time this was attempted, there were serious sight-threatening complications and because the scleral sutures have eroded through within a year and are causing GPC. This leaves us with a limited choice of IOL fixation sites. An anterior chamber (AC) IOL (angle supported or iris fixated) could provide a reasonable option, but the patient is young and one has to consider the risks of long-term corneal decompensation. Furthermore, a penetrating keratoplasty (PKP) in this setting will carry a high risk for failure. A lens replacement procedure will require a large scleral or corneal incision and carry a significant risk within the setting of this particular eye that has had so many previous surgical procedures. Any such procedure will have to be combined with a pupilloplasty to reduce the pupil size.
My personal recommendation would be to recenter the current IOL combined with pupilloplasty. The IOL will be fixated by its optic fixation holes onto the iris and, at the same time, the pupil size can be reduced. The actual technique would be to use a variation on McCannel sutures. I would start by making paracentesis at 2, 5, and 10 o'clock meridians. McCannel sutures will be used to achieve a small pupil and secure the IOL to the peripheral iris through all 4 IOL optic fixation holes. The big pupil will allow easier visualization of these holes and thus, the IOL McCannel sutures will have to be in place before the McCannel sutures to reduce the pupil size are secured. If it is felt that the IOL is still quite mobile, further McCannel sutures can be placed to secure the IOL haptics to the peripheral iris. The current scleral sutures can be removed completely. The iris appears to be quite normal and should hold these sutures quite well. Postoperative steroids, nonsteroidal antiinflammatory drugs (NSAIDs), and antibiotics would be adequate for 4 to 6 weeks.
This technique provides an elegant solution for this patient and meets all of the treatment objectives. It is the least invasive of all the options with a reduced risk profile.© 2004 by Lippincott Williams & Wilkins, Inc.