CONSULTATION SECTION

- Considering the clinical picture, this is a case with an unstable sulcus-fixated IOL with friction to the back of the iris (pigment epithelium and blood vessels). This is causing recurrent attacks of secondary glaucoma. I would like to ask the patient whether she has a history of trauma to the eye. Considering the older age of the patient and the displacement of the IOL inferiorly, as seen in Figure 1, a cause could be an inferior zonulysis. Another possible cause is a bend in the superior IOL haptic near the haptic–optic junction. Also, there is a small iridodialysis at 3'clock, which could indicate a somewhat compromised angle. I would add gonioscopy to the clinical examination to study the angle and, after dilation, to examine the haptics. My surgical approach would aim at stabilizing the IOL or exchanging it. Using topical anesthesia and with a fully dilated pupil, I would start with a temporal 20-gauge paracentesis. This would allow easier manipulation and better visualization. I would then inject a cohesive OVD to fill the anterior chamber and open the sulcus for 360 degrees. Using a push– pull hook, I would examine the ciliary sulcus and posterior capsule all around and deliver the superior haptic into the anterior chamber to examine it for a bend or fracture. If the problem is inferior zonulysis, I would go ahead with scleral fixation of the superior haptic at 12 o'clock using the Hoffman reversed scleral pocket technique,1,2 starting in the corneal periphery at the base of the iridectomy. The superior iridectomy would allow perfect visualization of the needle during its passage to exit the sclera. Next, 10-0 or 9-0 polypropylene sutures mounted on double-armed long curved needles would be used. The IOL would be rotated so the superior haptic is at the 12 o'clock position. The temporal paracentesis would be enlarged to a 2.0 to 2.4 mm incision to allow introduction of the first needle with a microforceps. I would pass the needle behind the haptic and exit it 2.0 mm behind the limbus through the conjunctiva. A high-viscosity OVD would help open the space between iris and capsule and protect the latter from being punctured. Then, the second needle would be passed in front of the haptic and exited at the same location. Using a Sinskey hook, I would retrieve the suture ends through a scleral pocket after cutting the needles, tighten a triple knot to fixate the haptic in the proper position, and bury the knot in the pocket. I would wash out the OVD, hydrate the wound, and inject an intracameral antibiotic. This technique would provide the least amount of manipulation and induction of wound-related astigmatism, if any, keeping in mind the patient had only 0.5 D of astigmatism and excellent visual potential.

847

If the haptic is markedly damaged, the IOL would have to be exchanged after the wound is enlarged (PMMA, 6.0 mm optic). A new IOL with an overall diameter of 13.0 mm would be implanted in the sulcus and suture fixated to the sclera. Finally, the wound would be closed with 2 interrupted 10-0 nylon sutures. Yehia Salah Mostafa, MD Cairo, Egypt REFERENCES 1. Hoffman RS, Fine IH, Packer M, Rozenberg I. Scleral fixation using suture retrieval through a scleral tunnel. J Cataract Refract Surg 2006; 32:1259–1263. Available at: http://www.finemd.com/ reprints/Scleral%20Fixation%20Using%20suture%20Retrieval% 20Through%20a%20Scleral%20Tu.pdf. Accessed March 3, 2014 2. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg 2006; 32:1907–1912. Available at: http://www.finemd.com/reprints/Scleral%20Fixation %20Without%20Conjunctival%20Dissection.pdf. Accessed March 3, 2014

- There are 3 points to consider regarding this case; that is, the implantation of the IOL in the ciliary sulcus; the obvious rotation, shown by the haptic's intermittent presentation in the iridectomy; and the material and design of the haptics. Immediately after implantation of an IOL in the ciliary sulcus, the IOL can rotate if its diameter does not fit the sulcus dimensions. Twenty-three years after implantation, IOL rotation or decentration can occur only if the structure of the sulcus and/or the capsule changes. I believe 2 situations are the most likely causes of the problem. First is erosion of the peripheral zonular fibers or a zonulysis by the haptic, especially if the material is polypropylene. If the end of a haptic finds its way through such a defect, it may cause slight IOL decentration and bleeding or pigment dispersion from the iris or ciliary body. With 1 loose haptic within a zonular defect, backward and forward IOL rotation can occur after abrupt movements of the head or eye. Concomitant bleeding might cause an increase in IOP. The second situation is that after years, a polypropylene haptic can break, causing IOL decentration and bleeding if the end of the haptic penetrates the iris or ciliary tissue. Bleeding may also result from posterior synechiae between the iris and capsule passing through the positioning hole. After abrupt head movements, the synechiae may rupture and cause bleeding. With UBM, it may be difficult to detect the real position of the haptic end. Another option, although invasive, is to use an endoscope designed for endocyclophotocoagulation for diagnostic purposes if the patient agrees to a surgical solution of the problem

J CATARACT REFRACT SURG - VOL 40, MAY 2014

May consultation #6.

May consultation #6. - PDF Download Free
46KB Sizes 2 Downloads 3 Views