EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/115557
March 2013 A multifocal continued from page 15 n Dry Eye Lid Squeezers m ibu Me s er oll R ed os Cl * or ss e pr Ex C om pr es si on Fo rc ep s* * ™ in sk a :M 16 7 01 8- m bu ei M E io ss re xp Ey el id a Tecnis monofocal and the patient ended up 20/20 with minimal correction. After doing the surgery in the right eye it became clear to the patient that he much preferred the vision in the right eye with the monofocal Tecnis versus the multifocal Tecnis in the other eye, and he wished to have an IOL exchange done in the other eye. A decision was made to perform IOL exchange OS and to control the IOP doing a trabecular meshwork aspiration at the same time. I chose this surgical approach because of the dense pigment seen on gonioscopy. At surgery a cursory attempt was made to reopen the capsular bag in the left eye, but it was clear that this would not be possible. A simple IOL exchange was performed for a silicone Tecnis placed in the sulcus and at the same time trabecular aspiration was performed to clean out the angle. LRIs also were performed. The patient had excellent IOP throughout the postoperative period without drops to control the IOP and after a year requires dorzolamide-timolol only to keep the pressure in the teens OS. He is quite satisfied with the vision in both eyes now and does not mind wearing reading glasses at all. I think that this case highlights some important teaching points. This patient was a poor candidate for a multifocal lens from the start but doing the other eye first allowed me to get a better handle on how to move forward with the OS in question. It was important to challenge the diagnosis of "chronic iritis" here and recognize the masquerade syndrome caused by pigment/PXF. This allowed me to get the patient off of most of the drops that he was using that were causing ocular surface problems responsible for reducing his vision. Finally, I believe trabecular aspiration is an underutilized, minimally invasive surgical approach one can consider in situations such as this where pigment, pseudoexfoliation material, blood, cells, or other debris are elevating the intraocular pressure. EW 801 71 7: H ar dt en may have been present preoperatively so glaucoma may be an ongoing issue here. "The IOL either needs to be placed into the bag or exchanged. I might make a brief attempt at reopening the bag, but I would not push it at all as I think there is great risk of dislocating the bag. I would plan to exchange the lens for a three-piece IOL in the sulcus—probably the AQ 2010 [STAAR Surgical, Monrovia, Calif.]. I would expect to need to use iris hooks in order to achieve adequate dilation. One of the risk factors for inadvertently placing a one-piece into the sulcus is a small pupil, and that may have been a problem at the original surgery. I would prefer the hooks to a ring since they are more versatile and would be more helpful than a ring if there were further capsular issues uncovered or created at the next surgery. "Hopefully, the pressure will improve but the presence of underlying PXF may be associated with continuing glaucoma problems even if the pigment dispersion is eliminated," Dr. Brown said. In my approach to this case I felt that the patient did not have chronic iritis but rather pigment dispersion and PXF-related debris in the anterior chamber and angle that was masquerading as iritis. I felt the patient did not have significant inflammation and this did not need the chronic steroids that were likely adding to the pressure problems. I also felt that the glaucoma drops were causing much of the ocular surface problems that were dropping this patient's best corrected vision. My first order of business was to stop the steroids (which led to a drop in IOP), and then I was able to discontinue the brimonidine, which improved the ocular surface issues significantly. With the IOP down in the low 20s and the ocular surface much improved, the patient saw better and was somewhat out of the woods, but he still appeared to be achieving very little benefit from the multifocal lens. He was wearing glasses all the time to correct vision OD and astigmatism OS. After a long discussion with the patient about his options, we decided to do his cataract surgery in the OD with inthe-bag placement of a monofocal implant and to see how he liked this compared to the multifocal in the other eye. This would allow us to better determine how to proceed with the OS. The cataract surgery on the right eye was successfully performed using Meibum Expression Is Recommended As A Subsequent Procedure To Meibomian Gland Probing, Insuring The Patency Of Meibomian Glands. Call 800-637-4346 For More Information. Or Visit www.RheinMedical.com Editors' note: Dr. Brown has no financial interests related to this article. Dr. Myers has financial interests with AqueSys (Aliso Viejo, Calif.) and Glaukos. Dr. Safran has financial interests with Baush + Lomb. Contact information Brown: reaymary@comcast.net Myers: jmyers@willseye.org Safran: safran12@comcast.net #OME 3EE 5S !T !3#23 "OOTH 3360 Scherer Drive, Suite B, St. Petersburg, FL 33716 s 4EL s &AX %MAIL )NFO 2HEIN-EDICALCOM s 7EBSITE WWW2HEIN-EDICALCOM $EVELOPED )N #OORDINATION 7ITH 3TEVEN , -ASKIN -$ $EVELOPED )N #OORDINATION 7ITH $AVID 2 (ARDTEN -$ 1321 Rev.B 2HEIN -EDICAL 3TYLIZED %YE BABB