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Consultation Section

May consultation #3

Zetterström, Charlotta MD, PhD

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Journal of Cataract & Refractive Surgery: May 2014 - Volume 40 - Issue 5 - p 845
doi: 10.1016/j.jcrs.2014.03.011
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This 79-year-old patient had cataract surgery many years ago, and the problem in the left eye appeared 23 years after surgery. The IOL implanted was an older rigid model, and it is likely that a complete anterior capsulorhexis was not performed during surgery. The IOL is placed in the sulcus; however, it is not stable. While it rotates, 1 loop has occasionally been seen in the iridectomy. The IOL is also decentered inferiorly and is slightly tilted. The IOL is probably too small for the sulcus, and thus the problem.

Stabilization of the existing IOL or an exchange would probably solve the problems. There are several options from which to choose.

Fixating the existing IOL to the iris with sutures is an option. However, in some cases this procedure can result in chronic uveitis or cystoid macular edema postoperatively. A more complicated solution is to glue the haptics to the sclera. This technique is described by Agarwal et al.1 Two scleral flaps are made 180 degrees apart, the haptics are externalized and placed under the flaps, and the haptics are glued to the scleral bed with biological glue. If this maneuver were successful, there would likely be fewer postoperative problems.

An IOL exchange is another option. Unfortunately, the incision has to be rather large for an exchange of an IOL with a hard PMMA optic. With the clear, untouched posterior capsule, a posterior capsulorhexis could be performed and a 3-piece acrylic IOL implanted with the loops again placed in the sulcus and the optic captured in the posterior capsulorhexis. With this maneuver, the IOL would remain stable.

The patient has a diffractive multifocal IOL in the other eye; however, the history does not say whether the patient uses glasses for near or far. With an IOL exchange, I would aim for emmetropia after having ensured that the patient can tolerate anisometropia.

Reference

1. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008;34:1433-1438.
© 2014 by Lippincott Williams & Wilkins, Inc.