CATARACT SURGICAL PROBLEM
October Consultation # 5
This case has some unusual features. There is huge anisometropia in the presence of similar axial lengths and keratometry readings. This suggests that the high myopia in this eye is the result of progressive nuclear sclerosis or anterior lens subluxation. The visibility of the edge of the lens in both eyes and the presence of iridodonesis suggest this patient has a form of ectopia lentis, possibly microspherophakia, and systemic associations should be sought. The history of trauma may be irrelevant.
Surgery in the left eye is fraught with potential problems. The surgeon may encounter an unstable zonular apparatus, which would make creating a capsulorhexis difficult; the ease or otherwise of creating a capsulorhexis is an indicator of how loose or stable the cataract is and whether an endocapsular tension ring might be needed. The second issue is the combination of a polar cataract with a dense nucleus.
I would perform standard coaxial phacoemulsification through a temporal clear corneal incision. Under OVD, I would carefully create a capsulorhexis, paying particular attention to the behavior of the capsule. I would then do hydrodelamination to separate the nucleus from the posterior polar plaque, followed by stop-and-chop phacoemulsification using lower parameters. The posterior polar plaque should be removed gently, ideally after the nucleus is removed. If at any time the capsular bag is perceived to be unstable, an endocapsular tension ring can be inserted, allowing safe completion of the procedure.© 2005 by Lippincott Williams & Wilkins, Inc.