This patient has a dense brunescent cataract and an iridodialysis. Cataract surgery seems appropriate given the complaint of increasing photophobia and the findings shown in the photographs.
Unless the patient sustained commotio retinae or traumatic optic neuropathy at the time of the injury, his eye may have good visual potential. He was 12 years old when it happened.
Appropriate preoperative testing includes entoptic imaging to assess gross macular function or dark room pinhole testing through the dilated pupil or iridodialysis to assess fine macular function. If an optical coherence tomography (OCT) image can be obtained through the cataract, it would be helpful for evaluating gross macular anatomy. If the entire retina cannot be visualized ophthalmoscopically, B-scan ultrasonography should be performed to rule out peripheral detachment.
Surgical issues to be considered include the corneal astigmatism, iridodialysis, vitreous prolapse, zonular loss at the site of the iridodialysis, possible diffuse zonular laxity elsewhere, and cataract density.
Preoperative planning is critical. I would hope to place a toric IOL in the capsular bag to address the corneal astigmatism but would have a suitable spherical backup IOL available for sulcus implantation. I would fashion a Hoffman pocket at the site of the iridodialysis before entering the eye. I would also have an Ahmed CTS and a 13.0 mm CTR available. The 2 separate devices are easier to manipulate than a single Cionni modified CTR.
I would start surgery by making a superior clear corneal incision. This location reduces stress on the zonular fibers in the area of dehiscence during the phacoemulsification and CTR insertion. I would inject a dispersive OVD over the iridodialysis to push back the prolapsed vitreous. I would repeat as often as necessary to avoid vitreous aspiration. I would then inject a highly cohesive OVD to maximize my working space. Trypan blue dye might be necessary to improve visualization for creating the capsulorhexis. After hydrodissection, phacoemulsification must be performed gently to avoid further damage to the zonular fibers. After cortex removal, I would reinflate the capsular bag with a highly cohesive OVD and inject more dispersive OVD over the iridodialysis.
I routinely polish the anterior capsule with Shepherd capsule polishers to eliminate postoperative fibrosis and capsulorhexis phimosis. After topping off with a little more OVD, I would inject a CTR in the direction of the zonular dehiscence. I would then assess whether an Ahmed CTS were needed to center the capsular bag. If so, I would implant and secure it to the temporal sclera inside the Hoffman pocket.
After implanting a toric IOL, I would remove most of the OVD, making sure the IOL remained on axis. Then I would constrict the pupil, inject a little additional cohesive OVD, and repair the iridodialysis using a double-armed 10-0 polypropylene suture in a horizontal mattress fashion.
Finally, careful OVD removal would ensure that the toric IOL remains on axis.