Eyeworld

M y question is how to best manage this pa- tient given that he is on maximal medica- tion for his glaucoma and thus needs something done to stop this cycle of pigment dispersion while controlling his IOP. I called a few colleagues to get their thoughts on this case. Mark Gorovoy, MD, Gorovoy MD Eye Specialists, Fort Myers, Fla., was the first to respond. "Cause [is] a bit uncertain as this syndrome is typically from single-piece acrylic IOLs and not 3- piece silicone. Also, is it from optic or haptics? That should be more vis- ible from transillumination defect location, which I could not see in the photos. [Author's note: No frank transillumination defects were seen at the slit lamp in this thick, darkly pig- mented iris.] That info is key. The other history I need is if this lens is stable or mobile in the posterior chamber. If mobile [there is an] easy answer: lens exchange with possible staged shunt if IOP remains high more than 2 to 3 months. The other unknown is, even with IOL surgery to correct iris chaffing, will [the] IOP come down fast enough to stabilize glaucoma?" "Assuming the IOL is stable, there are a few options. Option 1 is shunt alone (I prefer over trab) with- out any IOL surgery since no CME and excellent visual acuity in high myope. This also avoids all vitrec- tomy risks with IOL reposition (opening bag or relocating the entire IOL behind the bag in scleral tun- nels). Option 2 is to replace with a new 3-piece such as the STAAR Surgical 3-piece lens [Monrovia, Calif.]. There's no guarantee this lens would be better and if not done with a glaucoma procedure, it might not solve the main issue of high IOP. Option 3 is commit to reposition the IOL in the bag and if not successful, reposition in the PC with scleral tunnel. This [option is] most aggres- sive as it requires vitrectomy." "In conclusion, if the IOL is loose, replace [it] with a longer hap- tic-to-haptic 3-piece. It is also possi- ble to fixate this in the PC anterior to the capsule via scleral tunnels. The goal is to eliminate lens motion. My guess is that he still may need glaucoma surgery within several by Steven G. Safran, MD Rubbin' me the wrong way BABD 1347 Rev.B 3360 Scherer Drive, Suite B, St. Petersburg FL 33716 s 4EL s &AX %MAIL )NFO 2HEIN-EDICALCOM s 7EBSITE WWW2HEIN-EDICALCOM 1 $EVELOPED )N #OORDINATION 7ITH *UAN & "ATLLE -$ $EVELOPED )N #OORDINATION 7ITH %LIE ' +HOURI -$ 3 $EVELOPED )N #OORDINATION 7ITH 3TEVEN , -ASKIN -$ 0ATENT 0ENDING 4 $EVELOPED )N #OORDINATION 7ITH $AVID 2 (ARDTEN -$ Background, Expressed Lid Image 08- 0171 8 B a tlle 1 Ey elid Co m pr ession Forceps 08-01719 Khouri 2 Eyelid Squeegee 08- 0171 6 M ask in 3 Meib um Expressor 08 -01 7 17 Hardte n 4 Ey eli d Co m pression Forceps -EIBUM %XPRESSORS Case presentation This is a 68-year-old gentleman who happens to be the uncle of the referring ophthalmologist. He had cataract surgery in both eyes a little over a year ago. Both eyes are 20/20 uncorrected, but whereas the left eye has a normal IOP on no medication, the right eye has severe glaucoma and is uncontrolled on maximal medication. He presents to me with an IOP of 28 on four topical drops and oral acetazolamide. He has evidence of early cupping in the right eye, some early glaucomatous field damage and corresponding changes on OCT of the OD, while the left eye is normal in all these areas. On examination he has evidence of severe pigment dispersion syndrome in the right eye. His trabecular meshwork OD is seen to be severely pigmented on go- nioscopy with only light pigment OS. The iris has evidence of diffuse pigment loss in this eye relative to his other eye, and there is a pigment on the corneal endothelium OD. He has 11 D Tecnis Z9002 silicone in- traocular lenses (Abbott Medical Optics Santa Ana, Calif.) in both eyes, but while the implant is in the capsular bag in the left eye, the right eye has the implant placed in the sulcus. There is a large radial tear in the anterior capsule with a defect in the anterior capsule extending from 2 o'clock to 5 o'clock, and the capsular bag is com- pletely collapsed and fibrosed behind the IOL. The central iris appears to be in con- tact with the IOL surface and upon dilation, there appears to be a distinct and relatively sharp edge to the IOL that is in contact with the posterior iris. I did not see any frank pseudophakodonesis of the IOL at the slit lamp even though I tried to elicit this by tapping the eye. While most of the cases of pigment dispersion glaucoma that we see caused by sulcus-placed IOLs appear to be associ- ated with single-piece acrylic lenses, in this case we have a 3-piece silicone IOL that one would normally expect to be well toler- ated that is causing a severe problem. Steven G. Safran, MD, ASGR editor Anterior segment grand rounds continued on page 14 clinical.ewreplay.org

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