As important as the surgical approach is the discussion of expectations and risks with the patient. The patient must understand the risk for recurrent iritis and retinal detachment if the decision is made to proceed with an operation. My sense is that cosmetics are important to her, but this should be balanced against issues of visual function. I would also involve the vitreoretinal surgeon in the decision-making process because removal of the PFC is a consideration.
Any surgical intervention carries the risk for reactivating the uveitis. If the patient elects to proceed with surgery, I would initiate topical therapy (eg, prednisolone acetate [Pred Forte] 4 times a day or every 2 hours for 1 to 2 weeks before surgery) and deliver sub-Tenon's or intraocular triamcinolone acetate (Kenalog) at the time of surgery. Postoperatively, an extended course of steroids and probably an NSAID would be appropriate.
Despite the statement in the case report that the IOL is in the capsular bag, it is obvious that the inferior portion of the optic is outside the bag. The photographs do not allow visualization of the anterior capsule, but I presume the initial capsule tear was larger than the optic and the anterior and posterior capsules are now fused beyond the edge of the optic.
Options for dealing with the IOL include repositioning it or an IOL exchange. Given the previous Nd:YAG laser capsulotomy, I would favor leaving the existing IOL. I would perform careful synechialysis to relieve the adhesions. Use of viscodissection could help reduce the need for blunt and sharp dissection and thus minimize the risk for postoperative uveitis. If the anterior capsule opening were smaller than the optic, it would be useful to reopen the bag to allow complete optic capture within the bag. However, I think the opening is too large in this case. To prevent future optic capture, the pupil should be constricted with interrupted polypropylene sutures or an iris cerclage.
An alternative that avoids suturing the iris would be to exchange the IOL and place an IOL with a larger optic (eg, AcrySof MA50BM with 6.5 mm optic) in the sulcus. An open posterior capsule makes this a riskier proposition, but use of viscodissection may facilitate this approach.
The PFC should not be left in the eye for an extended period, so I would perform the operation in conjunction with a PPV. This would be performed by a vitreoretinal colleague to remove the PFC from the posterior chamber. Endolaser or a buckling procedure may be warranted depending on the status of the retina.