Eyeworld

EW NEWS & OPINION March 2016 19 by Steven Safran, MD Patient seeks improved vision, but there are many complicating factors at play. Experts share their thoughts on how they would approach this situation D ean Ouano, MD, New Bern, N.C., commented, "I would hesitate to implant a toric IOL in this eye. The eye is buphthalmic with a huge capsular bag. Even by 'max- ing out' the astigmatic correction with an AcrySof SN6AT9 [Alcon, Fort Worth, Texas], you would only be able to correct a fraction of his keratometric astigmatism (about 8 D on topography). The rotational stability of a single-piece AcrySof To- ric IOL would be very suspect, even with a capsular tension ring (CTR). In addition, these buphthalmic eyes have a very unpredictable effective lens position (ELP) and pathologi- cally deep anterior chambers. With an axial length of 27.5 mm, does he have a posterior staphyloma? "I am a DMEK surgeon, but I would probably do a DSEK pro- cedure in this case. Being able to shallow the anterior chamber is almost a prerequisite for DMEK, and there's little chance of flattening his chamber enough. Some of my most frustrating DMEK cases involved axial myopes with deep anterior chambers. Maybe more experienced DMEK surgeons would think other- wise. "After the DSEK procedure, I would wait for keratometric stability and hopefully a clear cornea. The astigmatism may be mitigated by a 5.5 mm clear corneal or scleral tun- nel incision made at the steep axis. Biometric measurements will be a lot more reliable with a clear cornea. "Once the DSEK procedure was completed, I would consider cataract surgery, perhaps waiting 3 months. My preferred IOL in buphthalmic eyes is an MA50BM [Alcon] with a 6.5 mm optic. I would consider limbal or corneal relaxing incisions for residual astigmatism." Richard Schulze, MD, Savan- nah, Ga., said, "This is a 55-year-old monocular patient with a history of congenital glaucoma, buphthalmos, Big eye with big problems Figure 1. Cornea topography shows 8 D of regular astigmatism. Figure 2. Hazy corneal stroma and Haab's striae seen on slit lamp exam Figure 3. OCT of cornea shows thickened Descemet's membrane with Haab's striae. Haab's striae, high astigmatism, thickened Descemet's membrane, axial myopia, rosacea, and a cata- ract. The history does not mention it explicitly, but the eye is likely amblyopic as well, although vision of 20/50 in the remote past was recorded. Safety is paramount, and before proceeding I would want to treat the rosacea and try to maxi- mize the ocular surface. I also note the Placido rings on the topography Case presentation The patient is a 55-year-old bank CEO with a history of loss of the right eye due to congenital glaucoma as a child. His remaining OS is a buphthalmic eye with a very unusual cornea. He has 8 D of mostly regular cornea astigmatism, stromal haze, and a waxy thickened Descemet's mem- brane with Haab's striae that can be seen to be about 70 u thick on OCT. The eye is very large with an axial length of more than 27.5 mm and a white to white of more than 15 mm. His intraocular pressure is now controlled with just topical timolol and has an IOP of 15 with no evidence of glaucoma damage. He thinks he had a retinal detach- ment repair in this eye many years ago but does not remember the details. His vision has dropped to 20/200-1 from what he said used to be a best corrected vision of 20/50 at one point, and he wishes to have some- thing done to improve his vision as he can no longer drive safely. He also has marked acne rosacea. He has been referred in for cataract surgery by his ophthalmologist who believes that the vision has dropped mostly due to progression of the cataract. I consulted some colleagues to get their thoughts on how they would handle this case. Steven Safran, MD, ASGR editor continued on page 20 Anterior segment grand rounds (ASGR)

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