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segmentation and softening was partial; by augmenting this with chopping and phacoemulsification, the nucleus was removed. A 21.5 D Acrysof toric T9 intraocular lens (IOL) (Alcon Laboratories, Inc.) was implanted and dialed into the intended axis. Postoperatively, the corrected distance visual acuity was 20/30 and the toric IOL was wellcentered with a 360-degree capsule overlap (Figure 1, F).

DISCUSSION Manual capsulorhexis creation is especially challenging in cases in which an intumescent cataract coexists with an adherent leukoma. Under the operating microscope, even macular-grade scars are hard to visualize through because of light scatter and this makes it difficult to determine the status of the anterior capsule. Intraoperative AS-OCT was advantageous in our case as it was able to image through the scar and the advanced cataract. Although the laser treatment through a scar is poor, the ability to customize the laser to treat through central and paracentral clear cornea permitted a successful, albeit smaller, capsulotomy, enabling successful completion of the surgery. Femtosecond laser–assisted cataract surgery is contraindicated in cases with severe corneal opacities and corneal abnormalities. However, in eyes with a paracentral opacity where preoperative imaging can demonstrate that the extent of the scar lies outside the laser delivery zone, the femtosecond laser can be used and the capsulotomy position, depth, and energy parameters modified to successfully perform a capsulotomy while avoiding the area of the corneal scar as delineated by intraoperative imaging. This may, however, limit the size of the capsulotomy, as in our case. Intraoperative modifications are required to overcome the error messages during femtosecond laser treatment. In conclusion, femtosecond laser–assisted cataract surgery may be a useful adjunct in cases with mature white cataracts and corneal scars that can be excluded from the laser delivery zone.

Iris chafing syndrome after scleral-fixated intraocular lens implantation Mohammed G. Zayed, MB ChB, Stephen Winder, FRCOphth Intraocular lens (IOL)–related iris abrasion syndrome in relationship to anterior chamber IOLs was reported as early as 1977.1 Posterior iris chafing syndrome has been documented in relationship to sulcus-fixated IOLs.2 This is associated with transient visual obscuration, microhyphemas, intermittent spikes in intraocular pressure (IOP), and pigment dispersion.3 It is part of a spectrum of IOL-related iris abrasion syndromes, the first of which was described by Ellingson1 in relationship to anterior chamber IOLs (uveitis-glaucoma-hyphema syndrome). Scleral-fixation of an IOL has been associated with complications including suture erosion, a tilted or decentered IOL, fibrin reaction, and vitreous prolapse into the anterior chamber.4 We report a case of iris chafing syndrome after scleral-fixated IOL implantation using the Agarwal technique.5 CASE REPORT An 80-year-old woman presented with a 2-day history of a shadow over her right eye. The corrected distance visual acuity (CDVA) was hand motion (HM) in the right eye and 6/9 in the left eye. The patient had a history of uneventful phacoemulsification and IOL implantation in the right eye a few years earlier. On presentation, the right fundus examination showed rhegmatogenous macula-off retinal detachment. The eye was treated with vitrectomy, cryotherapy, and gas tamponade. One month postoperatively, the CDVA was 6/12 and the IOL was noted to be slightly dislocated. Three months later, the CDVA was 6/36 and examination showed a subluxated IOL and iris trauma. The IOL was removed and a secondary scleral-fixated IOL implanted using the Agarwal technique. Iris hooks were placed because of poor dilation, and sclerotomies for the haptics were placed 2.0 mm behind the limbus.

REFERENCES  Kra s A, nitz K, Filkorn T, Nagy ZZ. Intraocular 1. Szepessy Z, Taka femtosecond laser use in traumatic cataract. Eur J Ophthalmol 2014 Feb 10 [Epub ahead of print] 2. Conrad-Hengerer I, Dick HB, Schultz T, Hengerer FH. Femtosecond laser–assisted capsulotomy after penetrating injury of the cornea and lens capsule. J Cataract Refract Surg 2014; 40:153–156 nitz K, Takacs A, Filkorn T, Gergely R, Knorz MC. 3. Nagy ZZ, Kra Intraocular femtosecond laser use in traumatic cataracts following penetrating and blunt trauma. J Refract Surg 2012; 28:151–153 4. Grewal DS, Basti S, Grewal SPS. Femtosecond laser–assisted cataract surgery in a subluxated traumatic cataract. J Cataract Refract Surg 2014; 40:1239–1240 5. Schultz T, Ezeanosike E, Dick HB. Femtosecond laser-assisted cataract surgery in pediatric Marfan syndrome. J Refract Surg 2013; 29:650–652

Figure 1. Slitlamp picture of the right eye showing conjunctival injection, microhyphema, and iris trauma.

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Although there was an initial postoperative improvement in CDVA, at 3 weeks the CDVA was HM and cavity hemorrhage and diffuse hyphema were noted (Figure 1). After initial conservative management, cavity washout was performed. The CDVA improved initially, but the patient returned with an IOP of 36 mm Hg, hyphema, and cavity hemorrhage. She was again managed conservatively, but the IOP proved difficult to control and she became confused on acetazolamide. The diagnosis of posterior iris chafing syndrome was considered, and the IOL was removed. This resulted in resolution of the hyphema, cavity hemorrhage, and IOP. At the 6-month follow-up, the CDVA was 6/18 aphakic and the anterior chamber was quiet with a normal IOP on no medication.

DISCUSSION To our knowledge, this is the first report of posterior iris chafing syndrome in a patient with a scleralfixated IOL. Many patients are seen in outpatient clinics after scleral-fixated IOL implantation. Considering posterior iris chafing syndrome in cases of transient visual obscuration, microhyphemas, intermittent spikes in IOP, or pigment dispersion in pseudophakic patients can avoid unnecessary investigations and interventions associated with an incorrect diagnosis. REFERENCES 1. Ellingson FT. Complications with the Choyce Mark VIII anterior chamber lens implant (uveitis-glaucoma-hyphema). Am Intraocular Implant Soc J 1977; 3:199–201

2. Masket S. Pseudophakic posterior iris chafing syndrome. J Cataract Refract Surg 1986; 12:252–256 3. Ferguson AW, Malik TY. Pseudophakic posterior iris chafing syndrome [letter]. Eye 2003; 17:451–452. Available at: http://www.nature.com/eye/journal/v17/n3/pdf/6700322a.pdf. Accessed July 23, 2014 4. Evereklioglu C, Er H, Bekir NA, Borazan M, Zorlu F. Comparison of secondary implantation of flexible open-loop anterior chamber and scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg 2003; 29:301–308 5. Kumar DA, Agarwal A, Jacob S, Prakash G, Agarwal A, Gabor SGB, Prasad S. Sutureless scleral-fixated posterior chamber intraocular lens [letter]. J Cataract Refract Surg 2011; 37:2089–2090

Inadvertent intracorneal triamcinolone injection during cataract extraction Berna Akova-Budak, MD, Sertac¸ Argun Kıvanc¸, MD, Mehmet Baykara, MD Triamcinolone acetonide is currently being used for various purposes in ophthalmology. One purpose is to facilitate the management of posterior segment disorders and vitreous visualization in anterior segment surgery.1–5 Triamcinolone particles are trapped in and on the vitreous gel. The vitreous strands become visible, assisting identification and removal of vitreous in the anterior segment.6 Several complications have been reported with intravitreal and sub-Tenon injection of triamcinolone acetonide.5,7 Although adverse

Figure 1. Six-week clinical course of intracorneal triamcinolone acetonide. A: Brown cataract in the left eye. B: Inadvertent injection of triamcinolone into the corneal stroma. C: Persistence of triamcinolone particles in the corneal stroma. D: Partial dissolution of the particles at 3 weeks. E: Continued dissolution of the particles. F: No particles noted at 6 weeks. J CATARACT REFRACT SURG - VOL 40, NOVEMBER 2014

Iris chafing syndrome after scleral-fixated intraocular lens implantation.

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