Eyeworld

EW NEWS & OPINION 15 Roundtable discussion I presented the case to Samuel Masket, M.D., Lisa Arbisser, M.D., and Michael Snyder, M.D. Here are their responses. Dr. Masket commented: "This case type, partial surgical zonulectomy, carries an excellent surgical prognosis, as the remaining zonular fibers are likely to be intact and strong. Once the contents of the bag have been removed, a standard CTR can be placed, as needed. Given that only two clock hours of the zonule have been removed, sutured devices are not necessary. Regarding the IOL, I would opt for an AcrySof Toric (Alcon, Fort Worth, Texas), likely the T6 model, after a full eval- uation of corneal cylinder. Management of the iris defect would require both iris repair and an artificial iris device. Because Morcher (Stuttgart, Germany) devices are not available in the U.S., a non- custom black silicone foldable iris diaphragm from HumanOptics (Erlangen, Germany) would be my choice management of the iris de- fect (after obtaining FDA permis- sion); it would require both iris repair and an artificial iris device. I would place it in the sulcus so as not to disturb the capsule bag alignment of the toric IOL. Because the pupil is blunted and irregular, I would close the iris defect in the manner of an iridodialysis. However, I would only tension the sutures enough to create a round pupil; this would leave a residual iris defect nasally, which would be 'covered' by the underly- ing artificial iris." Dr. Arbisser agreed with the use of a toric lens in this case and added her perspective on dealing with the iris defect. "This is the perfect case for the Morcher aniridia ring segment, which I have used for many years on a compassionate use basis as it is not FDA approved. The ring provides two functions: It blocks out the missing iris segment creating a black PMMA opaque area to prevent stray light and edge glare while at the same time providing a capsular ten- sion ring function. It is very cost-ef- fective. The FDA has recently stopped its compassionate use. When I had the Morcher ring avail- able a few months ago I would have by Steven G. Safran, M.D. A puzzle missing a few pieces November 2011 Case presentation A 65-year-old woman is status post iridocyclectomy in the left eye eight years previously for a ciliary body melanocytoma. She presents with the complaint of decreasing vision and glare in this eye presumably due to a progressive cataract and iris defect. She has 3 diopters of stable regular astigmatism in this eye and is missing the zonules com- pletely in the area of her previous surgery. She has 2-3+ nuclear sclerosis and a normal macula on SD-OCT. Steven G. Safran, M.D., ASGR editor A 65-year-old woman presented with a complaint of decreasing vision and glare in the left eye, presumably due to a progressive cataract and iris defect Source: Steve Safran, M.D. A custom-matched silicone iris prosthesis is placed in the bag with an IOL and a CTR in this post-iridocyclectomy patient. Top left: pre-op OS; top right: post-op OS; and bottom: mid-face post-op Source: Steve Safran, M.D. continued on page 16 If you have a case that you would like to send to Dr. Safran for consideration as a "case of the month" for the ASGR column please contact him at safran12@comcast.net. Anterior segment grand rounds Or view the video of the procedure at www.eyeworld.org/replay.php. Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) rePlay online content 11-23 News Update_EW November 2011-DL-3_Layout 1 11/4/11 11:50 AM Page 15

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