EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/220233
November 2013 EW NEWS & OPINION 13 Anterior segment grand rounds Shpilkes in the sulcus by Steven G. Safran, MD T his is a 72-year-old gentleman who is referred in four months status postcataract surgery with a dislocated silicone three-piece lens in the sulcus of his left eye. The patient dilates poorly, has mild PXS and a collapsed capsular bag with fusion of the anterior and posterior capsule and capsular fibrosis. The lens is dislocated inferiorly and the top of the optic crosses the pupil. The patient is highly myopic with a 28.2 mm eye. This implant is a 9.5 diopter SofPort AO lens (Bausch + Lomb, Rochester, N.Y.), and according to my calculations would leave the patient slightly hyperopic if it were placed either in the capsular bag or the sulcus (I calculate for a 10.5 in the bag). The other eye has had successful and uneventful cataract surgery with a plano outcome. Given this constellation of findings— poor dilation, possible weak zonules, high myopia, a dislocated lens in the sulcus with a collapsed and fibrosed capsular bag behind it—what would the preferred approach to handling this case be given that there are so many potential therapeutic options? Steven G. Safran, MD, ASGR editor Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) I consulted with Garry Condon, MD, chairman, Department of Ophthalmology, director, glaucoma division, Allegheny General Hospital, associate professor of ophthalmology, Drexel University College of Medicine, and clinical assistant professor of ophthalmology, University of Pittsburgh; Ken Rosenthal, MD, surgeon director, Rosenthal Eye Surgery, New York and Great Neck, N.Y.; and Tal Raviv, MD, assistant professor of ophthalmology, New York Medical College, Valhalla, N.Y., New York Eye and Ear Infirmary, and founding partner, New York Laser Eye, to get their thoughts on this case. Dr. Condon at first was very succinct in his response: "Iris capture, McCannels—goodbye. YAG later. Rationale: low risk here, no vit, historically great outcomes." In my email reply to Dr. Condon, I agreed that this was a very reasonable option and one that many surgeons would likely choose but on further consideration this option "would leave the patient a bit hyperopic. Also, the silicone lens may get pitted a bit when you do the YAG because the PC haze is quite dense with the AC and PC fused (also the patient doesn't dilate). I'm also concerned about vitreous prolapse in this very high myope once you do the inevitable YAG capsulotomy given that the IOL is not completely in contact with the vitreous face to tamponade it. I think that there are a lot of people who would take the same approach that you would here but I'm not a big fan of iris fixation so I did not choose that option. Any other thoughts?" Dr. Condon's response: "I had a patient something like this—high myope with three-piece IOL too short for his big eye and resulting in windshield-wiper syndrome producing secondary pigmentary glaucoma. He had a +1.0 D IOL to start. I did not attempt to open up the fused capsule (felt it would be futile) but went straight to (creating a new) rhexis and IOL exchange for a slightly higher diopter IOL with optic capture." Dr. Rosenthal gave a detailed analysis outlining a few different options: "The first question to be answered is: Why is the IOL dislocontinued on page 14 Patient at presentation. The top of the IOL can be seen to cross the mid pupil (arrow tip). Patient after maximum dilation. Note the fused anterior and posterior capsule behind the dislocated implant. The patient only dilates to about 3.5 mm. The blue arrow points to the top of the IOL. Here is a postoperative image taken at one week. The implant is perfectly centered and the cornea is clear. Source (all): Steven G. Safran, MD