Before proceeding with surgical rehabilitation of this eye, the patient should be warned of the possibility of limited visual recovery, diplopia, and persistent photophobia as a result of removal of this dense cataract and restoration of vision. The patient and surgeon will be most comfortable with surgery performed under a peribulbar or retrobulbar block.
Repair of the iridodialysis should be performed first. A paracentesis placed at the inferonasal limbus will allow a dispersive OVD to be used to help reposition the prolapsed vitreous behind the lens equator. This would be preferable to a limited limbal or pars plana vitrectomy because the removal of vitreous would eliminate some of the posterior support for the lens and potentially encourage further zonular dialysis during phacoemulsification. If the vitreous cannot be pushed back, a limited bimanual vitrectomy will be required before the iridodialysis is repaired.
The dialysis can be easily repaired by creating a temporal corneoscleral pocket from a 350 μm deep temporal grooved incision. A double-armed 10-0 polypropylene suture on a long curved needle can be passed through the inferonasal paracentesis, passed through the iris root of the iridodialysis, and then passed out through the full thickness of the globe corresponding to the dissected scleral pocket (2.0 mm posterior to the limbus). Passing the 2 sutures through the iris edge so that each pass trisects the dialysis will allow it to close sufficiently to reduce the photophobia and keep the vitreous out of the anterior chamber during phacoemulsification. The sutures are tightened and tied after the needles are removed, and the suture ends are retrieved through the corneoscleral pocket opening with a small hook.A
Attention is then directed to the lens. The capsule should be stained with trypan blue dye by painting it on the lens surface. Lens removal can be performed using a bimanual or coaxial technique. Bimanual phaco would allow two 1.2 mm incisions to be placed at 7 o’clock and 10 o’clock. The capsulorhexis is performed with a microincision forceps and should be made as large as possible. Because of the history of trauma, the zonular dialysis, and the density of the cataract, it would be best to place a CTR and 3 capsule hooks designed with a broad point of contact at the capsular bag fornix to support the lens during the arduous phacoemulsification procedure. Placing 1 hook at the temporal location will support the bag equator with the missing zonular fibers and help block vitreous prolapse at this location. A large capsulorhexis will help prevent the capsule hooks from stressing the brittle anterior capsulorhexis and facilitate prolapse of lens fragments into the anterior chamber during phacoemulsification. A vertical chopping technique will work best for this dense lens. After successful lens removal, the temporal grooved incision is opened into the anterior chamber for toric IOL placement, with plano being the target. The hooks and OVD would then be removed. Additional pupilloplasty sutures could be placed after pharmacologic pupil constriction for corectopia created from the iridodialysis repair.
Other Cited Material
A. Hoffman RS. Iridodialysis repair through a scleral pocket [video]. Available at: http://www.finemd.com/videos/hoffman-video16.html
. Accessed August 30, 2014