Eyeworld

EW NEWS & OPINION 12 Roundtable discussion I approached a panel of experts, Brian Kim, M.D., John Hart, M.D., and George Beiko, M.D., to ask how they would proceed with this case. The first issue they all addressed is how to handle the implant. Dr. Kim said, "If this patient is very active and there is potential risk to the eye (tennis, basketball, mar- tial arts, etc.), plus the patient proba- bly has zonular disease due to post-vitreoretinal surgery, I think a sulcus-IOL alone would not be stable enough for this patient. Also, an ACIOL would not be ideal in this 48- year-old active man. I think a su- tured PCIOL would be best. An iris-sutured PCIOL would be prob- lematic since the pupil needs surgi- cal correction as well. I believe a scleral-fixated PCIOL would be the best way to afford secure PCIOL sta- bility without touching the iris. As far as IOL power, I would shoot for plano for best uncorrected vision. I would not offer intraocular sx to the other eye with pre-cataract due to the higher risk for RD. I would offer LVC of the good eye to give best un- corrected VA with the understanding that the patient may need a cataract surgery in the future." Dr. Hart said, "I would plan to fixate the IOL to the anterior capsule by removing the subcapsular fibrosis and enlarging the opening in the anterior capsule. I would place the IOL haptics in the ciliary sulcus and capture the optic through the open- ing in the anterior capsule. An at- tempt to remove the subcapsular fibrosis around the opening in the anterior capsule may be necessary for optic capture because the fibrotic opening in the anterior capsule would likely be too stiff to allow the optic through. Micrograspers and scissors work well for this task. If I was unable to fixate the optic in the anterior capsule and the IOL did not appear stable (it may be perfectly stable in the sulcus alone), I would plan to suture the haptics to the iris using 10-0 polypropylene and Siepser sliding knots." Dr. Hart further commented that his IOL choice would be a Tecnis ZA9003 aspheric IOL (Abbott Medical Optics, AMO, Santa Ana, Calif.), and he would target plano in this eye if the patient was willing to wear a contact lens in the other eye. Dr. Beiko also would attempt iris capture in this case. "Enlarge the an- terior capsulorhexis to 4-5 mm by making a small cut with scissors and extend with capsulorhexis for- ceps. My plan is to use optic capture of the IOL using the enlarged capsu- lorhexis (first described by Tobias Neuhann in 1992 and popularized by H. Gimbel). My IOL of choice would be a Tecnis three-piece acrylic IOL (AMO); this would ensure best possi- ble vision through correction of corneal asphericity and chromatic aberration, and not interfere if a sub- sequent silicone oil procedure is per- formed. I would target a refraction of –0.50 D (assuming he can tolerate a contact lens in his phakic eye)," Dr. Beiko said. Treatment My approach to placement of the implant was a hybrid of the ideas ex- pressed in the preceding comments. Like Dr. Kim I was concerned that simply placing a lens in the sulcus of this active young myope would not guarantee adequate stability. I was able to enlarge the opening in the anterior capsule, but I had to be careful to preserve the small bridge of tissue at 9:30 because if it were damaged the two openings in the anterior capsule would connect and the tear would go radial. After en- larging this opening I was able to buttonhole the optic through the opening in the anterior capsule leav- ing the haptics in the sulcus. I chose to suture fixate one haptic to sclera because I did not know how strong the zonules would be in this case. I felt this might reduce the risk of the lens dislocating down the road due to trauma or activity. I also felt the suture fixation might reduce stress on the remaining zonules over time in this very active individual. I used a Tecnis acrylic three-piece IOL in this case and targeted –2.5 to give good uncorrected near vision in the non-dominant eye, without making the patient completely contact lens dependent in the other eye. He is left eye dominant, and when he has cataract surgery in the second eye a target of plano to –0.5 will leave him with monovision. December 2011 by Steven G. Safran, M.D. Pupil playing possum A retroillumination image of the patient's eye A view of the patient's pupils in bright light. OD is fixed at 7 mm and completely non- reactive to bright light Source: Steven G. Safran, M.D. Day 1 slit lamp photograph Patient response to placing one drop of 0.25% pilocarpine in his right eye Source: Steven G. Safran, M.D. Case presentation T his is a 48-year-old attorney and avid athlete who was re- ferred to me for a secondary IOL and iris repair after previ- ous vitreoretinal surgery. He previously had a retina detachment in the OD that required multiple procedures including pars plana vitrectomy, endolaser, and lensectomy leaving him aphakic with a rim of intact anterior capsule. His poste- rior capsule is absent, and he has been completely vitrectomized. Looking at the image one can see a 3-mm central open- ing in the anterior capsule and an area of fibrosis in the capsule at 9:30 that forms a bridge between a second smaller trian- gular-shaped opening that points up to about 11:30. This is a long eye, just over 27 mm, and his other eye (the dominant OS) is 20/25+2 with a –4.75–0.75x50, slightly reduced due to 1+NS and early cortical changes. His pupil in the OD is fixed and dilated with no response to light. The retina surgeon asked me to avoid the use of a silicone IOL in case he needs silicone oil down the road. He has also asked me to avoid doing anything that would preclude viewing the periph- eral retina. The patient told me that he is active in tennis, basketball, and martial arts so he needs a very stable lens im- plant. The patient also requested an as- pheric lens as he is "averse to glare and requires a very high level of visual func- tion." He refracts to 20/20 in this eye, his macula OCT looks fine, his IOP is normal, and his endothelial cell count is excellent. Steven G. Safran, M.D., ASGR editor Anterior segment grand rounds Or view the video of this case 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

• Cover