Eyeworld

EW NEWS & OPINION 24 April 2016 by Steven Safran, MD "I would begin by giving the patient a +l.5 D cosmetic contact lens with a normal-sized pupil that resolved the issue of the fixed iris. This would resolve 2 of the 3 prob- lems and would allow the surgeon to assess the contribution of these issues to the patient's symptomatol- ogy. If the cosmetic contact lens significantly resolved the patient's glare and halo, he could be offered this treatment as a permanent solu- tion. If a contact lens was not the patient's treatment of choice, a purse string iridoplasty to bring the pupil down to a normal size or an artifi- cial iris would be excellent choices. While the surgeon was in the eye, the 'scratches' could be assessed and if possible polished and resolved. LASIK or PRK at a later date could resolve the residual refractive error. "If the cosmetic contact lens does not resolve the patient's symp- toms, after an extensive informed consent, I would perform an IOL exchange, carefully opening up the capsular bag with dispersive viscoelastic on a 30-gauge needle, placing viscoelastic behind the IOL to tamponade the vitreous face, and placing the appropriate power, zero aberration 3-piece IOL behind the original IOL prior to bisecting the acrylic IOL and removing it from the eye. The new IOL could then be placed in the sulcus and centered with a posterior capture. The purse string iridoplasty would bring the pupil down nicely." David Chang, MD, Los Altos, California, said, "Differentiating whether the intractable glare is due to the traumatic mydriasis or the op- tic scratches is crucial. The scratches would likely cause specific symp- toms of radiating lines from point sources of light. Trying a painted contact lens might be useful. If this significantly improved his symp- toms, it would argue for doing an iris suture cerclage procedure. Two oppositely placed interrupted 10-0 Prolene sutures at the pupil margin will create a nicely rounded smaller pupil. Exchanging the IOL prior to iris suturing is possible. Although it would likely entail an anterior vitrectomy, there is a good anterior capsular platform to fixate a 3-piece IOL in the sulcus. An additional benefit might be improvement of his refractive error and anisometro- pia. The main danger would be Scratched and sniffing T his is a 55-year-old active male who had blunt trauma to the OD. He developed a traumatic cataract and subsequently had cataract surgery. Since the surgery, however, he has been bothered by intractable glare in this, his dominant right eye. He was referred to me for an opinion on what can be done to fix his glare problem. His refractive outcome in this eye is +1.5. The other eye is phakic and plano. On exam the eye has a fixed and dilated pupil. The images included have been taken without dilating drops placed in the eye. His pupil is fixed in this position and does not budge with bright light or pilocarpine. He has an AcrySof lens (Alcon, Fort Worth, Texas) with a series of smudges or scratches cen- trally, moderate to severe glistenings in the optic, and he had extensive YAG capsuloto- my treatment extending almost to the edge of the optic 360 degrees. On gonioscopy it can be seen that there is a diffuse, patchy loss of zonules, mostly associated with his blunt trauma and previous surgery. The patient's best corrected vision in this OD (his dominant eye) is limited to 20/40 because of the macula damage associated with his trauma. He's also very bothered by glare and light sensitivity. Steven Safran, MD, ASGR editor Yellow arrow shows smudges in optic; red arrow shows edge of capsulotomy Atonic fixed dilated pupil Patient's eye 1 week postoperative Source: Steven Safran, MD Patient seeks to fix a glare problem after surgery E ric Donnenfeld, MD, Rockville Centre, New York, said, "This patient has 3 significant problems that are all likely contributing to his problem of glare and halo: IOL opacifications, hyperopic refractive error, and a fixed dilated pupil. The cataract surgery was otherwise done well and the 1-piece acrylic IOL is in the bag. The decision tree should be based on which of the problems is most contributing to his poor quality of vision and then develop- ing a treatment plan based on risk and reward. An IOL exchange is the obvious first solution, but the trauma and zonular weakness, open posterior capsule, and IOL firmly ad- herent to the capsular bag make IOL exchange the highest risk procedure. continued on page 26 Anterior segment grand rounds (ASGR) Watch a video from this case now at clinical.ewreplay.org

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