CONSULTATION SECTION

- Treating this very challenging case should include reducing the photophobia with iridodialysis repair and restoring good visual acuity. It seems possible to safely manage the eye through a modern small-incision surgery approach. The crystalline lens can be managed by a small-incision technique considering the arc length of the zonular defect. Depending on the surgical findings, the capsular bag might have to be fixated to the scleral wall using a modified CTR or CTS with fixation elements to the scleral wall. The pupil should be fully dilated for surgery. Ideally, anterior vitrectomy without infusion would be performed after injection of triamcinolone to allow visualization of the vitreous in the area of the iridodialysis. At this step, the placement of 2 iris retractors on the pupillary margin of the displaced iris would provide good exposure of the lens. The capsulorhexis would be centered on the lens. During or at the end of opening the capsule, a capsule hook would be placed in front of the zonular defect to stabilize the capsular bag and secure further maneuvers. Viscodissection would separate the cortical material from the capsule fornix before CTR implantation. There are 2 options at this step depending on whether the capsular bag will be fixated to the scleral wall. A simple CTR should be sufficient based on the arc length of the zonular defect (approximately 3 clock hours [25%]). If the zonular defect appears to be longer, a Cionni modified CTR would be fixated to the scleral wall. The ring would be inserted under attentive observation and control of the stress placed on the zonular fibers. At the end of this maneuver, the capsule retractor hook would be removed. A chop technique in which a central groove is created while stress on the zonular fibers is minimized would be the best option for lens removal. The cortex removal must be performed with low aspiration or with a cortex cannula to avoid traction on the capsular bag, especially in the area of the zonular defect. Careful complete lens epithelial cell aspiration from the anterior capsule leaf is an important step to reduce secondary fibrotic changes. A single-piece hydrophobic IOL would be primarily implanted in the anterior chamber, after which the haptics would be carefully maneuvered into the bag to minimize traction on the zonular fibers. Injection of triamcinolone at this step should ensure the absence of vitreous. The pupil would then be constricted and the iris prepared under OVD for suturing. A scleral flap starting 2.0 mm back from the limbus would be dissected, extending over 3 clock hours. A 10-0 polypropylene suture double-armed with straight or curved 13.0 mm needles would be used to repair the iridodialysis. Two fixation points

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would be necessary. Entry through the main incision using a curved needle would allow comfortable suturing under the scleral flap. At the end of the procedure, the conjunctiva could be sutured or glued. Dominique Pietrini, MD Paris, France

- This patient presents with 2 major problems; that is, photophobia and poor visual acuity in an eye that sustained blunt trauma in his late childhood. Due to good vision in his early childhood and the normal retinal and macular appearance, the potential for visual acuity restoration is good. Comparison of the axial length (AL) between the eyes will add another clue regarding the visual potential of the eye. Both problems can be addressed in the same surgery. The first step would be an intense discussion with the patient so he will have realistic expectations regarding the surgery results. Topical nonsteroidal antiinflammatory drug (NSAID) drops 3 days before surgery would be prescribed. The first step of the surgery would be to push the prolapsed vitreous posteriorly using a dispersive OVD. If this were not possible, a limited anterior vitrectomy would be performed using triamcinolone to stain the vitreous. Next, the iridodialysis would be assessed to determine whether it would interfere with the cataract extraction to follow. If so, at this point, it would be fixated in a scleral pocket with 10-0 polypropylene sutures using Richard Hoffman’s technique for fixation of subluxated IOLs. The next step would be to address the advanced cataract. With a stable capsular bag and limited segmental zonular defect, a segmental capsular stabilization device should be available. It is recommended to use the device as late as possible but as early as needed to stabilize the area of the missing zonular fibers. Due to the advanced cataract, dye may be required for capsule staining. A soft-shell technique using a combination of dispersive OVD and cohesive OVD is recommended for corneal endothelial cell protection, and a phacoemulsification technique that will minimize the use of the ultrasound (US) energy and zonular damage should be used. My preferred technique would be vertical chopping. Intraocular lens selection would be dependent on the posterior corneal astigmatism. Because the posterior astigmatism is negative with high with-the-rule (WTR) posterior corneal astigmatism, it may be sufficient to plan the surgical incision at 90 degrees; with low WTR posterior corneal astigmatism or against-the-rule posterior corneal astigmatism, a toric IOL may be considered.

J CATARACT REFRACT SURG - VOL 40, NOVEMBER 2014

November consultation #5.

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