EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/176967
September 2013 Refractive challengesFebruary 2011 and innovations EW FEATURE 51 Refractive amblyopia case: What would you do? by Erin L. Boyle EyeWorld Senior Staff Writer AT A GLANCE • The case was a 29-year-old female patient born with congenital cataracts, with 4.3 D of with-therule astigmatism in the right eye and a posterior polar cataract. • The patient reported that her vision had declined in the last two years. • Dr. Berdahl performed femtosecond laser-assisted cataract surgery, and the physicians interviewed agreed with this choice. • The capsular bag tore during lens insertion, but the patient still had a successful toric IOL implantation. • The patient was "very satisfied" with the surgical outcome. A young patient presents with multiple issues, and the question of how to treat the case is posed to several surgeons, including the treating physician A 29-year-old female came in for an exam at the office of John Berdahl, MD, Sioux Falls, S.D. The patient was born with congenital cataracts and had a history of amblyopia in her right eye, from either the cataract or her high level of astigmatism. Her best corrected visual acuity was 20/150, and on examination, she had a posterior polar cataract. The remainder of her eye exam was normal on the right eye, and the left eye exam was normal with uncorrected vision of 20/20. Her topography showed 4.3 D of with-the-rule astigmatism in the right eye. She stated that her vision had become increasingly worse over the last two years. What Dr. Berdahl did Dr. Berdahl performed femtosecond laser-assisted cataract surgery and the cataract and all cortical material was successfully removed. Upon inserting the intraocular lens, the capsular bag tore. Dr. Berdahl explained what he did next: "I proceeded to place the toric intraocular lens in the eye given her high amount of corneal astigmatism. The femtosecond lasercreated capsulotomy was very helpful because she had a perfectly round and well-centered capsule, which allowed me to place the haptics in the capsular bag and perform a reverse optic capture so that the optic was above the capsular bag. "I was then able to carefully rotate the intraocular lens so it was oriented in the proper axis," he said. After surgery, the patient had 0.5 D of astigmatism and uncorrected vision of 20/40 and was "very satisfied" with the outcome, according to Dr. Berdahl. Cataract surgery? Gary Wortz, MD, Koffler Vision Group, Lexington, Ky., said he appreciated Dr. Berdahl's decision-making process and would have made similar surgical decisions, including performing cataract surgery. He said the case is an interesting one because of multiple factors, such as the fact that the patient had a great deal of astigmatism, a torn posterior capsule, and a toric lens implanted in the eye. "You're in a position, surgically, where you have to say, 'What's the best thing to do right now? What's the lesser of all the evils?'" he said. "There's no perfect scenario at that point and you have to make a judgment call. Those are the things that, as a surgeon, are intriguing to me, because I put myself in that situation and think, what would I do? What's the best possible outcome we can have here?" "From my standpoint, I think it's a conundrum that we could all see ourselves being faced with, and it makes us think," Dr. Wortz said. William Wiley, MD, Brecksville, Ohio, also would have performed cataract surgery in this case, and said he has experienced great success with cataract surgery/IOL implantation for refractive amblyopic cases. "We typically see an objective improvement in best corrected visual acuity, and the patients always note improvement in their subjective vision," he said. According to Sumit (Sam) Garg, MD, vice chair of clinical ophthalmology, medical director, Gavin Herbert Eye Institute, University of California, Irvine, Calif., choosing cataract surgery was a reasonable option in this case because the patient was becoming steadily more symptomatic with reported visual loss. "Of course, she needs to understand the potential risks of surgery and uncertain level of improvement," he said. "A discussion of continued on page 52 BUBBLE LEVEL MARKER • Stephens Bubble Level Axis Marker helps align the marker with the horizontal axis • Easily removable and replaceable lightweight bubble level • Designed and engineered to meet the needs of sterilization • Crisp edges create a fine demarcation • Length of marks accommodate both limbal and corneal markings • Marker is made of matte finished stainless steel • Replacement bubble level cylinders are available individually • Overall length is 120mm, with an 11mm wide blade and 2mm wide marking surfaces S9-2070 Bubble Level Axis Marker 2500 Sandersville Rd., Lexington, KY 40511 USA Phone: 800-354-7848, 859-259-4924 Fax: 859-259-4926 E-Mail: stephensinst@aol.com www.stephensinst.com