EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/115557
rePlay online content March 2013 EW NEWS & OPINION 15 Anterior segment grand rounds A multifocal masquerade by Steven G. Safran, M.D. A n 80-year-old gentleman is referred by his optometrist because he is unhappy with his cataract surgery in the non-dominant OS done by another surgeon one year ago. He has chronic "iritis" and glaucoma in this eye. He is on maximum medical therapy here for his elevated IOP (brimonidine/dorzolamide-timolol/latanoprost OU) but also loteprednol QID in this eye because of chronic "cells and flare" noted in the postop period that have persisted despite the use of steroids. His vision in this eye is 20/80 best correcting to 20/40-2 with +0.25-1.25X85 (which matches his topographic cylinder). He has punctate keratopathy (which I felt was the cause of his limited vision in this eye, especially given that he has a multifocal implant) and pigmented cells floating in the anterior chamber. There is a Tecnis multifocal (Abbott Medical Optics, Santa Ana, Calif.) in this eye, which happens to be placed in the sulcus with the capsular bag collapsed and fibrosed behind it, and the IOP is 16 OD and 31 OS. VF testing as well as OCT of the optic nerve and macula are completely normal OU. The other eye has a dense 3++ NS cataract with marked pseudoexfoliation syndrome, a pupil that dilates to only 4 mm, and 20/50 best corrected vision. Gonioscopy shows an open angle OU but there is 2-3++ pigment OD and 4++ pigment OS in the angle. The posterior capsule appears to be intact in this eye (although at first it is difficult to even see because it is so clear behind the implant). Steven G. Safran, M.D., ASGR editor Click on the video to watch this patient under go an IOL exchange and trabecular aspiration for glaucoma. I asked Jonathan Myers, M.D., glaucoma service, Wills Eye Institue, Philadelphia, and Reay Brown, M.D., glaucoma specialist, Atlanta Ophthalmology Associates, Atlanta, advice on how they would approach this patient with multifactorial problems. Dr. Myers commented: "This 80year-old gentleman with exfoliation syndrome has a significant cataract in the right eye and a multifocal lens implant in the sulcus causing pigment release and elevated pressure in the left eye. Attention should first be directed to the left eye given that eye's worse vision and elevated IOP. The OCT and fields are fine here, but if significant concern existed regarding IOP control, glaucoma surgery could be performed at the time that the IOL situation is addressed. An off-label iStent [Glaukos, Laguna Hills, Calif.] might work well here or perhaps canaloplasty. A tube shunt may have greater odds of long-term success than trabeculectomy when performed with other surgery, especially if extensive anterior segment work is performed. ECP and Trabectome [NeoMedix, Tustin, Calif.] are probably less ideal, given the inflammation. "There are many options to address the IOL in the left eye. If he is no longer as concerned with uncorrected reading vision, or is willing to consider monovision, an exchange for a three-piece, sulcus IOL would be a relatively simple procedure. A fibrosed, intact capsule can be reopened to allow in-the-bag positioning of this or another IOL. However, in an 80-year-old gentleman with exfoliation syndrome and a year of fibrosis in which the original surgery's difficulty and stress to the zonular fibers is unknown, the challenge and potential for complications is greater. When the left eye has been stabilized, the right eye is a candidate for cataract surgery, with the full array of options (other than sulcus placement of a one-piece acrylic IOL)." Dr. Brown commented on this case: "This is pigmentary glaucoma caused by a one-piece lens in the sulcus in a complex patient with pseudoexfoliation (PXF). The circulating cells are pigment and that is why treatment with steroids was not helpful. Theoretically, the capsular bag could be opened and the multifocal lens placed into the bag. However, it is one year out from surgery and the bag has fibrosed. PXF is associated with higher degrees of capsular phimosis and attempts to reopen the bag would challenge zonules that may already be weakened. Pigment dispersion is common with PXF generally—even in phakic eyes—and a sulcus one-piece IOL obviously makes that much worse. PXF glaucoma continued on page 17 Both eyes after maximum dilation has been achieved—first the OD with PXF and cataract then the OS Postop image of the OD The eye day one postop Source (all): Steven G. Safran, M.D.