I would begin by staining the vitreous with dilute triamcinolone. I would first attempt to push back the prolapsed vitreous with a cohesive ophthalmic viscosurgical device (OVD). If this were unsuccessful, I would proceed with a limited anterior vitrectomy. The zonular gap is large enough that one could direct the vitrector through the defect, making sure to be posterior to the lens equator to pull the vitreous from the anterior chamber. However, I would favor a pars plana approach, taking only enough to remove the vitreous from the anterior chamber. A vitrectomy that is too aggressive could make the lens more mobile and deepen the anterior chamber, making later maneuvers more difficult.
Once the vitreous is removed, I would stain the anterior capsule. The lack of phacodonesis and the blunt shape of the lens indicate that the remaining zonular fibers are likely intact. It is important to begin the capsulorhexis by pulling toward the area of zonular dialysis, using intact zonular fibers for countertraction. A micrograsping forceps could also be used for countertraction if necessary. Sometimes the anterior capsule becomes fibrotic, which may necessitate cutting with microscissors. If this leaves an irregularity in the capsulotomy, it may preclude the use of a capsular tension ring (CTR) or capsular tension segment (CTS). Given the good dilation, I would consider femtosecond laser creation of the capsulotomy, although there is debate over the strength compared with a manual capsulorhexis.1,2
I would use viscodissection to free the lens and expand the capsule, especially in the temporal area, creating a pseudo-CTR. The lens in this area can be very adherent to the capsule, so it may take multiple attempts to free it completely. I would plan on chopping, avoiding maneuvers that would put further strain on the zonular fibers near the dialysis. During cortex removal, I would pull toward the zonular defect and tangentially, rather than centrally.
Once the lens is removed, a CTR can be placed. Zonular dialysis in these cases is often more than what can be seen clinically, so I would expect more than 3 clock hours of extension. However, there may be enough support that the lens is stable and well centered without further support. If not, an Ahmed CTS sutured to the sclera under a flap with 8-0 polytetrafluoroethylene (Gore-Tex) would stabilize and center the lens.3
I would close the iridodialysis to reduce glare and prevent diplopia from polycoria. I would use an ab interno approach with 10-0 polypropylene sutures; 3 sutures would likely be required for a defect this size.4 The external knots would be buried under a scleral flap. Alternatively, CTS suturing and iridodialysis repair could be performed through a Hoffman pocket.5
Assuming the case has gone as planned, a toric intraocular lens would be my choice for correcting the astigmatism. A discussion about the refractive target would have to occur before surgery to decide between mild hyperopia to avoid anisometropia or emmetropia with the plan of correction in the fellow eye in the near future.
1. Abell RG, Davies PEJ, Phelan D, Goemann K, McPherson ZE, Vote BJ. Anterior capsulotomy integrity after femtosecond laser-assisted cataract surgery. Ophthalmology
2. Friedman NJ, Palanker DV, Schuele G, Anderson D, Marcellino G, Seibel BS, Battle J, Feliz R, Talamo JH, Blumenkranz MS, Culbertson WW. Femtosecond laser capsulotomy. J Cataract Refract Surg
. 2011;37:1189-1198. erratum, 1742.
3. Slade DS, Hater MA, Cionni RJ, Crandall AS. Ab externo scleral fixation of intraocular lens. J Cataract Refract Surg
4. Snyder ME, Lindsell LB. Nonappositional repair of iridodialysis. J Cataract Refract Surg
5. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg. 32, 2006, p. 1907-1912, Available at: http://www.finemd.com/reprints/Scleral%20Fixation%20Without%20Conjunctival%20Dissection.pdf
. Accessed August 30, 2014.