Eyeworld

EW NEWS & OPINION 22 March 2016 Contact information Goldman: drdavidgoldman@gmail.com Ouano: ouanod@earthlink.net Safran: safran12@comcast.net Schulze: richardschulze@comcast.net Snyder: msnyder@cincinnatieye.com CTR injection was done easily and without resistance, immediately after injection a split in the posterior capsule was noted. Upon inspection after placing iris retractors, it could be seen that the split extended up and around the zonules to include the anterior capsule in a radial split of the capsular bag. At this point I realized that I had a radial tear in the capsular bag from anterior to posterior, but with no presentation of vitreous. I had to make a decision on how and where to place the IOL. I felt that sulcus placement would not be wise given the size of this patient's eye so I decided to try to place the lens in the capsular bag and position the haptics where there was capsular support. This was successfully done without extension of the tear. The patient ended up with a stable implant and an excellent postoperative refractive outcome of 20/25 with a correction of +0.5- 1.25 X 90 and uncorrected vision of 20/30. The implant has remained stable. EW What was done I originally booked this patient for cataract surgery, planning to do a toric T9 with a CTR, and if the lens showed signs of excess movement, I was considering reverse optic cap- ture. I also planned to do a DSAEK as a secondary procedure after the cataract surgery. However, a few days prior to the scheduled procedure I began having second thoughts about this approach and reconsidered the situation. I decided to have the pa- tient come in for dilated evaluation under a surgical microscope to see what the quality of the view during surgery would be. After doing this I came to the conclusion that my view would be so poor as to possi- bly compromise the safety of the planned cataract surgery. In addi- tion, I felt that this patient had both stromal and endothelial disease and thus would benefit from a full thick- ness cornea transplant to address his astigmatism, his stromal haze, his endothelial disease, and the issue of the compromised surgical view prior to any cataract surgery. I also felt I could probably reduce his astigma- tism significantly with a graft and potentially obviate the need for a toric lens. This would take the risk associated with lens rotation out of play. After extensive discussion with the patient, we cancelled the cataract surgery and instead planned penetrating keratoplasty (PK). The PK was done using an ad- justable running suture and was very successful. This was combined with a partial lateral tarsorrhaphy and use of autologous serum tears. The patient's vision improved to 20/40 a month after surgery, and he was given glasses to correct his myopia. After PK, his cornea astigmatism had dropped to a stable 1.5 D. Over the course of the next year, however, his vision dropped to 20/200 due to the progressive cataract and a decision was made to do cataract surgery, 1 year after his PK had been done. I also decided to leave the running suture in place to add whatever structural security it might provide, even though usually I remove these and wait for stabilization. I planned to do his cataract surgery with a CTR and a STAAR Sur- gical (Monrovia, Calif.) monofocal 3-piece IOL in the bag. The STAAR Surgical lens was chosen because of its longer 13.5 mm haptic length. As expected, the zonules were some- what lax and the anatomy a bit unusual, but surgery went extremely smoothly and without incident until insertion of the CTR. Although the Big continued from page 20 Watch videos from this case now at clinical.ewreplay.org Figure 4. One year post-PK with cataract Figure 5. Just prior to CTR insertion Figure 6. Split in posterior capsule just after CTR insertion; split can be seen running from 12:00 to 3:30, just below tip of Kuglen hook Figure 7. Radial tear in anterior capsule seen after placement of iris retractors Figure 8. Dr. Safran decided to try to place the lens in the capsular bag and position the haptics where there was capsular support. This was successfully done without extension of the tear. Figure 9. Day 1 postoperative slit lamp image Source (all): Steven Safran, MD Anterior capsule radial tear Posterior capsule tear

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