A healthy 66-year-old man, 6 weeks after AcrySof ReSTOR 1-piece IOL implantation in the bag in the right eye and ciliary sulcus in the left eye, has a “runaround” tear in the posterior capsule with some vitreous prolapse through the tear. The patient is happy with the vision in the right eye but is bothered by reduced and fluctuating vision in the left eye.
On examination, there is a 1+ cellular reaction in the anterior chamber. The IOL in the left eye is slightly nasally displaced in the sulcus. A bolus of vitreous is herniated anteriorly through the capsule defect inferotemporally, and some pigment debris is noted in the anterior vitreous. Although there is no macular edema on OCT, this patient is at risk for cystoid macular edema (CME), which would further compromise his vision.
The retinal acuity meter shows a retinal visual potential of 20/20 in the left eye, although the best corrected distance acuity is only 20/40. Corneal topography would be helpful to assess the presence of regular and irregular astigmatism. A rigid gas-permeable contact lens refraction would further help identify the presence of astigmatism. Despite the presence or absence of astigmatism in this eye, the complaint of fluctuating vision and cellular reaction in the anterior chamber would lead me to discuss with the patient the option of exchanging the IOL.
Centration is critical when placing multifocal IOLs. The IOL is 1 piece; thus, recentering it may not be the best option for this patient. Because of the presence of a multifocal IOL in the fellow eye, I would replace the decentered lens with a 3-piece MN60D3 AcrySof ReSTOR IOL. At the time of lens exchange, I would perform a limited anterior vitrectomy, taking care not to extend the posterior capsule tear. Because the 1-piece AcrySof ReSTOR IOL is in the sulcus, the haptics could be rotated into the anterior chamber; with the anterior chamber filled with OVD, the lens could be folded in the anterior chamber and removed through a clear corneal wound. If possible, I would capture the optic under the anterior lens capsule, leaving the haptics in the sulcus oriented perpendicular to the posterior tear.
Another option would be to exchange the IOL with a monofocal lens; however, this might necessitate bilateral IOL exchange, which would be less than ideal. This should be discussed with the patient.