After a blunt trauma to the globe, the most probable etiology of this very shallow anterior chamber is an extensive lesion of the zonular fibers with an anteriorly displaced lens, causing a ciliovitreolenticular block and angle closure. Before surgery begins, the 40 mm Hg IOP must be lowered by dehydration of the vitreous. To achieve this, I would give 200 to 400 mL of mannitol 20% and 500 mg of acetazolamide 2 to 4 hours preoperatively. In most cases, this regimen lowers the IOP enough that the anterior chamber then can be deepened using an OVD. If the crystalline lens shows abnormal movability during capsulorhexis, I would use iris retractors to stabilize the capsular bag and perform a very gentle, low-flow phacoemulsification with thorough hydrodissection, hydrodelineation, and chopping of the nucleus and would use a dispersive OVD to prevent aspiration of the floppy capsule. If the zonular dehiscence does not allow the implantation of a stable, well-centered posterior chamber IOL (PC IOL), I would use a CTR and fixate it with 1 or 2 transscleral polypropylene sutures. Using a long needle, the capsular bag can be penetrated without the risk for a large capsule rupture. Alternatively, a Cionni ring with an eyelet designed for scleral suture fixation can be used.
Keeping the capsular bag in place is preferable to removing it and implanting an angle-supported, iris-fixated anterior chamber IOL (AC IOL). Should the patient need filtering surgery later, an intact capsule–IOL diaphragm would be very advantageous because it would safely prevent vitreous prolapse into the anterior chamber or filtering site.© 2015 by Lippincott Williams & Wilkins, Inc.