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Consultation section

Cataract Surgical Problem

November consultation #1

Menapace, Rupert M. MD

Journal of Cataract & Refractive Surgery: November 2014 - Volume 40 - Issue 11 - p 1930-1931
doi: 10.1016/j.jcrs.2014.09.004
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An 80-year-old man sustained blunt contusional trauma to the right eye when he was manipulating a war explosive at the age of 12 years. He immediately lost vision in this eye. Vision partly recovered during the following months and deteriorated again to perception of light and hand movements. More recently, the patient has been increasingly bothered by photophobia.

Almost 70 years after the trauma, the patient presents because of increasing photophobia in the injured eye. Findings are as follows: a very dense nuclear cataract, a large iridodialysis and zonular defect along 3 clock hours temporally, and circumscribed vitreous prolapse into the coloboma (Figures 1 and 2). Through the pseudopupil thus created, a normal retina and macula can be seen, indicating good visual potential. The crystalline lens appears slightly shrunken, with a thin and brittle lens capsule (Figure 2) and an undulating exposed equatorial contour (Figure 3). Tapping on the limbus does not cause the lens to move or tremble. The endothelial cell count (ECC) is within normal limits, the intraocular pressure (IOP) is 14 mm Hg, and the corneal astigmatism is +2.00 @ 90. The left eye has +3.00 diopters (D) of hyperopia with normal corrected distance visual acuity. The patient reports significant impairment and strongly desires surgery that would relieve the increasing photophobia, which was obviously caused by the slow secondary extension of the coloboma along with the progressive shrinkage of the cataractous lens.

Figure 1
Figure 1:
Overview showing cataract and iridodialysis.
Figure 2
Figure 2:
Narrow slit-beam illumination highlights brittle capsule and dense nuclear cataract.
Figure 3
Figure 3:
Close-up view of the coloboma and undulated contour of lens equator.

With this very hard nuclear cataract, large temporal iridodialysis and zonular dehiscence, circumscribed vitreous prolapse, and good visual potential and with photophobia being the patient’s primary complaint, what approach would you consider and prefer?

© 2014 by Lippincott Williams & Wilkins, Inc.