This patient deserves further evaluation. We must know why the BCVA is limited to 20/50. Is the reason corneal, lenticular, or macular? Perhaps the recurrent iritis and surgery have caused cystoid macular edema (CME). An OCT evaluation can determine whether combined treatment with a topical steroid and NSAID is necessary. Surgery is not indicated until this issue is resolved.
Next, because there is the history of a prolonged shallow chamber, gonioscopy should determine the status of the angle. If significant peripheral anterior synechias are present, even though the IOP is within the normal range, the asymmetric pressure may be secondary and more stringent follow-up with visual fields and optic nerve photographs is warranted. The thicker cornea does not account for the asymmetry, although the relatively low IOP in the fellow eye may be due to the thin cornea. I would want to be assured that the pressure of 9 mm Hg is not associated with low-grade chronic iritis in the left eye. Bilateral uveitis mandates a systemic workup. Although the etiology is unknown in most cases, it can be identified and treated in others.
Ideally, the status of the corneal endothelium should be assessed. I would want an endothelial cell count before further manipulation. Perfluorocarbon is toxic to the endothelium. As it also mechanically interferes with vision, it should be removed. The remaining material in the posterior segment could still present anteriorly, but I would not take the extreme measures its removal would necessitate.
Regarding counseling, I would address the patient's concerns sequentially, starting with the Purkinje image. The commonly used IOL at the time of placement had the variable power on the back surface and a flat anterior surface, making reflective images off the acrylic material more obvious. Although newer IOLs have eliminated the planar front surface, the patient can expect some degree of glint in the eye, even with modern alternatives. I believe that exchanging the well-centered and functional IOL, particularly in the setting of an open capsule (even after vitrectomy), would be an unacceptable risk. The dilated and irregular pupil produces functional and cosmetic problems and deserves intervention. The bubbles in the front of the eye should be removed (although the posterior remnant might migrate forward and require attention later). The IOL tilt and optic capture by the pupillary margin and iridoplegia cause irregular astigmatism and glare. I would demonstrate with a slitlamp photograph. Although tilt can be analyzed with the Pentacam (Oculus, Inc.) or Visante (Carl Zeiss Meditec) system or by wavefront analysis, these tests are purely academic as optic capture can also promote iritis and therefore must be resolved. No comment was made about refractive error. If appropriate, the possibility of improving astigmatism can be considered; this would require topography if peripheral astigmatic keratotomy is incorporated into the surgical plan.
The patient must understand the risks of surgery, including infection and the possibility of recurrent iritis and its consequences, including CME. A perfect cosmetic result cannot be guaranteed.
Because the other eye is still the better eye, I would be inclined to advise resolving the ongoing issues in the right eye before performing cataract surgery in the left eye, in which I would implant a 1-piece acrylic blue-filtering aspherical IOL. The increased risk for retinal detachment in this fellow eye must be emphasized. I would argue against using silicone, although it causes less reflection. The timing of surgery should be at the patient's election based on her activities of daily living.
If the patient consents, my recommendation would be to plan surgery with peribulbar anesthesia once any CME is resolved. I would start topical NSAIDs 1 week before surgery, give 1 dose of oral moxifloxacin 3 hours before surgery, and administer the usual topical prophylaxis preoperatively and postoperatively. I would not use mydriatics.
Working through several paracenteses, I would first control the chamber with Viscoat, isolating the PFC bubbles for manual removal with a 26-gauge cannula on a syringe. Next, I would perform viscodissection to break the posterior synechias. The haptics are confirmed to be symmetrically located in the bag. Irrigation of Miochol E would allow me to see the miotic pupil shape and size. I would perform modified McCannel pupilloplasty with a 10-0 polypropylene suture and locking Siepser knot technique. I would suture the inferior iris well across the inferior part of the IOL to prevent recapture; 1 or 2 additional sutures might be necessary to “round” the pupil. Alternatively, depending on the miotic pupil size and shape, I would use a pursestring suture for a cosmetic outcome, making sure the pupil covers the inferior edge as recapture is possible without an adequate barrier. After manual removal of most of the OVD, I would irrigate a small amount of purified (preservative removed) triamcinolone acetate suspension into the anterior chamber to reduce postoperative inflammation. Once I ascertain that the paracenteses are secure, I would measure the IOP with an intraoperative Barraquer tonometer, leaving the pressure between 15 mm Hg and 22 mm Hg. One oral acetazolamide (Diamox) sequel would be prescribed immediately postoperatively.