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Consultation section: Glaucoma

Managing an unstable subluxated intraocular lens with uncontrolled intraocular pressure and progressing glaucoma

July consultation #1

Samuelson, Thomas W. MD

Journal of Cataract & Refractive Surgery: July 2016 - Volume 42 - Issue 7 - p 1098-1099
doi: 10.1016/j.jcrs.2016.06.010
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An 88-year-old woman with exfoliative glaucoma presented with increasingly frequent headaches and extremely variable vision in the right eye. The patient’s intraocular pressure (IOP) was 45 mm Hg in the right eye with a central corneal thickness of 495 μm. She had moderate visual field loss (Figure 1) and in-the-bag subluxation of an intraocular lens (IOL) in the right eye (Figure 2). Maximum medical therapy lowered the IOP to 28 mm Hg; however, the patient was unable to tolerate the medications and the right visual field loss had progressed from previous examinations. Although her corrected distance visual acuity measured 20/30, the patient’s vision fluctuated considerably and there were times when her vision was very poor in the affected eye. There was moderate pseudophacodonesis in the left eye; however, the IOL had only mild decentration (Figure 3) and the patient’s visual acuity was “pretty good,” measuring 20/25 in the left eye. The IOP in the left eye was controlled and stable.

Figure 1
Figure 1:
Moderate visual field loss in both eyes with recent progression in the right eye and a stable left eye.
Figure 2
Figure 2:
Visually significant IOL subluxation in the right eye.
Figure 3
Figure 3:
Mild, asymptomatic IOL subluxation in the left eye.

Please discuss your recommended treatment of the right eye in terms of IOL management as well as glaucoma management. The patient’s only previous ocular procedure was cataract surgery in each eye 9 years earlier. She has not had laser or surgical glaucoma procedures. The right IOL was highly mobile in the retropupillary space, although there was no visible vitreous anterior to the IOL–capsule complex. Also, please comment on how you would manage the left eye, which had moderate pseudophacodonesis, although the IOL was reasonably well centered. The patient was in generally good health and was not taking any anticoagulants and her life expectancy was considered favorable.

© 2016 by Lippincott Williams & Wilkins, Inc.