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Consultation section

November consultation #6

Kleinmann, Guy MD

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Journal of Cataract & Refractive Surgery: November 2014 - Volume 40 - Issue 11 - p 1933-1934
doi: 10.1016/j.jcrs.2014.09.009
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This patient presents with 2 major problems; that is, photophobia and poor visual acuity in an eye that sustained blunt trauma in his late childhood. Due to good vision in his early childhood and the normal retinal and macular appearance, the potential for visual acuity restoration is good. Comparison of the axial length (AL) between the eyes will add another clue regarding the visual potential of the eye.

Both problems can be addressed in the same surgery. The first step would be an intense discussion with the patient so he will have realistic expectations regarding the surgery results.

Topical nonsteroidal antiinflammatory drug (NSAID) drops 3 days before surgery would be prescribed. The first step of the surgery would be to push the prolapsed vitreous posteriorly using a dispersive OVD. If this were not possible, a limited anterior vitrectomy would be performed using triamcinolone to stain the vitreous. Next, the iridodialysis would be assessed to determine whether it would interfere with the cataract extraction to follow. If so, at this point, it would be fixated in a scleral pocket with 10-0 polypropylene sutures using Richard Hoffman’s technique for fixation of subluxated IOLs. The next step would be to address the advanced cataract. With a stable capsular bag and limited segmental zonular defect, a segmental capsular stabilization device should be available. It is recommended to use the device as late as possible but as early as needed to stabilize the area of the missing zonular fibers. Due to the advanced cataract, dye may be required for capsule staining. A soft-shell technique using a combination of dispersive OVD and cohesive OVD is recommended for corneal endothelial cell protection, and a phacoemulsification technique that will minimize the use of the ultrasound (US) energy and zonular damage should be used. My preferred technique would be vertical chopping.

Intraocular lens selection would be dependent on the posterior corneal astigmatism. Because the posterior astigmatism is negative with high with-the-rule (WTR) posterior corneal astigmatism, it may be sufficient to plan the surgical incision at 90 degrees; with low WTR posterior corneal astigmatism or against-the-rule posterior corneal astigmatism, a toric IOL may be considered. If measurement of the posterior astigmatism is not possible, I would use the Baylor nomogram1 or the new Barrett calculator available at the American Society of Cataract and Refractive Surgery web site.A

If the surgery can be completed without fixation of the iridodialysis, it would be the time to close it as detailed above. Anterior vitrectomy, if necessary, should be completed at this time.

Postoperatively the patient would be treated with antibiotic and steroid topical drops, similar to regular cataract extraction surgery. However, NSAID topical drops would also be prescribed for an extended period (approximately 2 months).

Reference

1. Koch DD, Jenkins RB, Weikert MP, Yeu E, Wang L. Correcting astigmatism with toric intraocular lenses: effect of posterior corneal astigmatism. J Cataract Refract Surg. 2013;39:1803-1809.

Other Cited Material

A. Barrett toric calculator. Available at: http://www.ascrs.org/barrett-toric-calculator. Accessed September 3, 2014
© 2014 by Lippincott Williams & Wilkins, Inc.