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Consultation section

November consultation #8

Schmickler, Stefanie MD

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Journal of Cataract & Refractive Surgery: November 2014 - Volume 40 - Issue 11 - p 1934-1935
doi: 10.1016/j.jcrs.2014.09.011
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The patient’s eye was injured at the age of 12 years, which means the eye might have become amblyopic. Furthermore, the patient might have lost stereopsis.

It is surprising that the glare is worse now than the year before. The temporal iridodialysis might explain these symptoms, although the glare has been present since the injury occurred. The case description says this may be due to the progressive shrinkage of the lens and the consecutive extension of the coloboma.

The primary aim of surgery should be to decrease glare because the potential of visual improvement might be small. Surgery should be performed under general anesthesia. For difficult cataract cases such as this one, I prefer to use a femtosecond laser to create the capsulorhexis and fragment the nucleus. I would use a temporal sclerocorneal tunnel incision because it could be enlarged later in the surgery if necessary. Then, I would inject a dispersive OVD and carefully perform hydrodissection and phacoemulsification for lens removal. If the capsular bag remains stable, I would implant a 3-piece IOL rather than a 1-piece IOL and then remove the prolapsed vitreous by anterior vitrectomy.

Should zonular support be insufficient due to the missing zonules, I would deliver the nucleus in toto after enlarging the incision. The vitreous must then be removed.

Next, I would fixate the iris to the limbus with 2 sutures while instilling a dispersive OVD to keep the anterior chamber formed. I would leave a residual peripheral coloboma because the iris tissue will not be sufficiently distensible due to the longstanding iridodialysis.

If I had to remove the capsular bag with the lens in toto, I would not implant an IOL in the same surgical session because the whole procedure would put too much burden on the corneal endothelium. After some weeks and with a clear cornea, I would implant a reversed iris-claw IOL in the posterior chamber and fixate it on the rear side of the iris.

If the patient does not desire surgery because of the risks, an iris-print contact lens can be used to protect against glare.

© 2014 by Lippincott Williams & Wilkins, Inc.