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Consultation section

November consultation #9

Dick, Burkhard H. MD, PhD

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Journal of Cataract & Refractive Surgery: November 2014 - Volume 40 - Issue 11 - p 1935-1936
doi: 10.1016/j.jcrs.2014.09.012
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The patient’s main problem is increasing photophobia caused by the secondary extension of the zonular coloboma due to progressive shrinkage of the lens. The accident occurred at the age of 12 years, when binocular vision was already fully developed and the retina and macula look normal. Therefore, the chance of inducing binocular double vision because of postoperative exotropia or fusion problems is acceptably low.

If the risk for binocular problems were high (eg, because of different ALs between eyes) or if the patient wants to get rid of the photophobia problem only, I would perform brown tattooing of the cornea above the coloboma after making a local femtosecond laser–assisted circumscribed lamellar cut at 140 μm depth approximately 0.5 mm larger than the coloboma area using the surgical planning software of the laser system for creating the main cataract incision (Figure 4).

Figure 4
Figure 4:
Planning screen for femtosecond laser–assisted keratopigmentation of a large iridodialysis requiring intraoperative individualization based on the exact anatomy seen on spectral domain OCT.

If the patient seeks improved vision while accepting the increased risk for postoperative complications compared with standard cataract surgery, intraocular surgery would have to be performed. Because the vitreous has prolapsed into the anterior chamber, a vitrectomy is a must before the iridodialysis is closed.

Because the lens is hard and much altered in many aspects, my treatment of choice would be to take out the cataractous lens in toto via a superior sclerocorneal incision and prevent a dropped nucleus or lens material through the iridodialysis. This would be followed by an anterior 23-gauge vitrectomy. Especially in cases like this with uncertain biometry, real-time aphakic intraoperative aberrometry using a dynamic bidirectional applanation device can be of great help in confirming the AL measurements of the preoperative US biometry. Next, I would perform reversed implantation of an IOL that is fixated to the posterior surface of the iris (ie, retropupillary iris fixation; A constant 116.7) in the horizontal axis.1 The target refraction would be +3.00 D of hyperopia. I recommend starting the enclavation temporally, and I would use a blunt enclavation needle (Figure 5) to move the inferior and superior iris portions into the claws of this IOL to close the iridodialysis peripherally with minimal trauma and the most control.2 Although this IOL is also available for small (hyperopic) eyes with a 6.5 or 7.5 mm total diameter, I would choose the IOL with a total diameter of 8.5 mm and an optic diameter of 5.4 mm. Having constricted the pupil by injecting acetylcholine chloride, I would perform enclavation of the nasal iris. This would allow centration of the IOL optic on the pupil, which is actually decentered nasally.3 If the size of the tolerated coloboma opening were very small before the onset of the photophobia induced by the progressive extension of the iridodialysis, retropupillary implantation of a brown iris-fixated iris-reconstruction IOL available in various dioptric powers would be the alternative option.

Figure 5
Figure 5:
Scanning electron microscopy of the enclavation needle tip for iris-claw fixation shows that the tip is completely blunt.

References

1. Mohr A, Hengerer F, Eckardt C. Retropupillare Fixation der Irisklauenlinse bei Aphakie; Einjahresergebnisse einer neuen Implantationstechnik. Retropupillary fixation of the iris claw lens in aphakia; 1 year outcome of a new implantation technique, Ophthalmologe 2002;99:580-583.
2. Sminia ML, Odenthal MT, Gortzak-Moorstein N, Wenniger-Prick LJ, Völker-Dieben HJ. Implantation of the Artisan® iris reconstruction intraocular lens in 5 children with aphakia and partial aniridia caused by perforating ocular trauma. J AAPOS. 2008;12:268-272.
3. Kottler UB, Tehrani M, Dick HB. Impact of the line of sight on toric phakic intraocular lenses for hyperopia. J Cataract Refract Surg. 2004;30:1799-1801.
© 2014 by Lippincott Williams & Wilkins, Inc.