I would perform a gonioscopy to rule out angle closure not caused by pupillary block, which would not be relieved by an Nd:YAG laser iridotomy. If the gonioscopy shows an open angle, look for angle recession to anticipate late-onset postoperative glaucoma. A detailed indirect ophthalmoscopy should be done to rule out peripheral retinal tears. Anterior segment OCT (AS-OCT) should be performed focusing on the posterior capsule to exclude dehiscence in the posterior capsule, which could cause the nucleus to drop during hydrodissection or phacoemulsification.
In a shallow anterior chamber caused by a swollen lens, phacodonesis might not be visible in spite of zonular weakness. The operating surgeon might encounter zonular weakness for the first time during capsulorhexis. In such a situation, the condition might require implantation of a CTR or another sutured capsule-support device. A zero aspheric monofocal IOL has better tolerance to decentration and is preferred over a negative aspheric IOL in eyes with zonular weakness. Multifocal and accommodating IOLs are best avoided in such eyes.
In an eye with a preexisting posterior capsule defect, one may have to resort to a 3-piece PC IOL fixated in the sulcus. In an eye with both zonular dialysis and a posterior capsule defect, an iris-fixated IOL that preferably is fixated to the backside of the iris or a scleral-fixated PC IOL might be the only choices.
This patient’s eye should be monitored postoperatively for glaucoma and peripheral retinal tears.© 2015 by Lippincott Williams & Wilkins, Inc.