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Consultation section

Cataract Surgical Problem

December Consultation # 1

Masket, Samuel MD

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Journal of Cataract & Refractive Surgery: December 2007 - Volume 33 - Issue 12 - p 2013
doi: 10.1016/j.jcrs.2007.10.003
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A healthy 66-year-old man is referred for management of the following problem: Approximately 6 weeks earlier, he had bilateral cataract surgery with implantation of a 1-piece AcrySof ReSTOR diffractive multifocal intraocular lens (IOL) (Alcon Laboratories). Surgery in the right eye, performed first, was uneventful and the IOL was placed in the capsular bag. However, in the left eye, in which surgery was performed 1 week subsequently, a “runaround” anterior-to-posterior capsule tear occurred and the 1-piece AcrySof ReSTOR IOL was placed in the ciliary sulcus. The patient notes acceptable vision in the right eye but is bothered by reduced and fluctuating vision in the left eye. There is no other meaningful ocular history.

Ocular examination of the right eye shows a well-healed temporal clear corneal incision and a centered 1-piece AcrySof ReSTOR IOL; the anterior chamber is quiet, the posterior capsule is intact and clean, and posterior segment examination is unremarkable. Anterior segment examination of the left eye shows a healed temporal corneal incision, a clear cornea, a 1+ cellular reaction, and a sulcus-placed and somewhat mobile 1-piece AcrySof ReSTOR IOL, which was decentered nasally at the moment the photograph (Figure 1) was taken. The underlying lens capsule, as seen in the figure, has a radial tear in the anterior capsule at the 4 o'clock position that extends peripherally around the equator to include a large defect in the posterior capsule. A small bolus of vitreous is herniated anteriorly through the capsule defect inferotemporally, and some pigment debris is noted in the anterior vitreous. Posterior segment examination is normal, and macular optical coherence tomography (OCT) shows no edema.

Figure 1
Figure 1:
Slitlamp photomicrograph of the left eye shows that the IOL is nasally displaced and outside the capsular bag. A tear in the anterior capsule at the 4 o'clock position extends to the posterior capsule.

Current findings include the following: uncorrected distance visual acuity, 20/40 in the right eye and 20/100 in the left eye; best corrected distance visual acuity, +0.75 −0.75 × 130 (yields 20/20) and −1.00 −0.50 × 45 (yields 20/40), respectively; retinal acuity meter, 20/20 in the left eye; corneal diameter, 13.00 mm in both eyes; intraocular pressure (IOP), 17 mm Hg in the right eye and 16 mm Hg in the left eye.

Given the above, what would you suggest is the best course of management?

© 2007 by Lippincott Williams & Wilkins, Inc.