Eyeworld

EW NEWS & OPINION 26 April 2016 3.5 mm, which would still enable a view of the retina while decreasing glare. This purse string suture would only resolve the mydriasis, and the patient would still require spectacles for the +1.5 D of hyperopia. "The last option, and most inva- sive one, would be an IOL exchange with the pupilloplasty. Despite having glistenings and linear marks on the central optic, these may not induce much, if any, perceptible dysphotopsia. "Due to the size of the posterior capsulotomy and area of zonular loss, this has a high risk of vitreous prolapse, which would require an anterior vitrectomy and possible fixation of the IOL. With the iris issues that are pre-existing, suturing an IOL to the back of the iris is not a great choice. This means that the Agarwal 'glued IOL' method of in- trascleral haptic fixation would be a better choice. Such a surgery involv- ing the IOL explantation, anterior vitrectomy, IOL scleral fixation, and purse string pupilloplasty is complex and carries a higher risk than the other options. The patient should be warned that there is a chance he could be trading in tolerable vision for no vision." What was done The consultants bring up many points that I considered. I did not spend time experimenting with contact lenses because the patient was traveling from a distance and was more interested in an immedi- ate surgical solution to the prob- lem. I felt the dilated pupil and the scratched lens were issues causing problems and decided it would be best to fix both with 1 procedure. If I chose to do an iris cerclage and he was not happy, I'd have boxed in the old IOL and that would be checkmate. I decided to perform a combined IOL exchange for a 3-piece silicone lens that was optic captured in the rhexis, pars plana vitrectomy and iris cerclage. The pa- tient ended up plano-0.25 x 180 and had 1 line of improvement in his best corrected visual acuity. He was very happy with the visual outcome but even more so with the cosmetic outcome as he always hated the way his eye looked with the fixed dilated pupil. EW Contact information Chang: dceye@earthlink.net Devgan: devgan@gmail.com Donnenfeld: ericdonnenfeld@gmail.com Safran: safran12@comcast.net Sulewski: Michael.Sulewski@uphs.upenn.edu patient's dominant eye, but due to permanent macular damage and best corrected vision of only 20/40, this eye will no longer be the domi- nant eye, and this patient is relative- ly functionally monocular. I think his most compelling problem is the intractable glare, as the visual acuity will always be limited compared to the other eye, however, the glare will affect his overall binocular func- tion. Even though there are some blemishes on the IOL, and some degree of zonular damage, the IOL looks perfectly centered and there is no apparent pseudophakodonesis. Therefore, I would be inclined to leave the IOL alone at this point. I would try to fit this patient with a contact lens with shading and with the +1.5 refractive correction. If the patient is unable to tolerate the con- tact lens or if the glare symptoms are not improved to his satisfaction, then surgery is indicated. "I would concentrate on ad- dressing the glare issue by suturing the mydriatic pupil using either the sliding Siepser knot technique, the cerclage technique or the modified McCannel suturing method. The other possible option would be to use an artificial iris implant. I am not as concerned with the residual +1.5 postop refractive surprise as that could be handled with PRK or LASIK if necessary, and if you do an IOL exchange with an anterior or pars plana vitrectomy, there is no guarantee that you will hit the refractive mark as we can't always ensure where the effective IOL position will end up. Also, since the patient is functionally monocular with the macular scar, I don't have a problem asking him to wear polycar- bonate glasses with the +1.5 lens OD and plano OS since he should have protection for the healthy OS. He also needs to wear glasses anyway for reading. He is only 55 years old and I would not be in a hurry to suture or glue in another IOL now in anticipation of a future disloca- tion that may or may not happen. The long-term stability of fixating the haptics by sutured-in or glued methods into a scleral groove is not known." Uday Devgan, MD, Los Ange- les, commented, "I would approach this case in a step-wise pattern to find the least invasive remedy. The first step is determining whether he has symptoms other than intracta- ble glare, which is likely due to the chronic mydriasis. "Specialty cosmetic contact lens- es are available with a small central aperture to give an effective pupil size of 3 mm or so. This could also be ordered in the +1.5 D strength in order to correct the refractive error at the same time. Should this con- tact lens solve the majority of the patient's problems, further surgery may not be required. "If the contact lens solves the glare issue but the patient does not desire to wear them daily, a purse string suture can be placed in the iris to bring the pupil size down. The ideal balance is a pupil size of about further capsular dehiscence due to the traumatic zonulopathy, and after dissecting the optic free, the hap- tics should be amputated and left behind due to fibrosis around the bulbous haptic tip. Whether or not to exchange the IOL would depend on determining whether the optic scratches are causing severe enough radiating glare streaks." Michael Sulewski, MD, Phil- adelphia, noted, "This was the Scratched continued from page 24 NEW Our Family of Pre-Loaded CTRs Has Expanded Malyugin/Cionni & Henderson Capsular Tension Rings Now Pre-Loaded in Morcher EyeJets Malyugin/Cionni CTR • Eyelet at curved end is sutured to sclera • Unique design facilitates smooth introduction into capsule • The only injectable Cionni type CTR Henderson CTR • Scalloped design facilitates cortical removal • Maintains the desired stretch of the capsular bag Standard CTRs • Stabilize the capsule during surgery • Available in three sizes to accommodate various capsule bags Henderson CTR TYPE 10C Standard CTRs TYPES 14, 14A, 14C Malyugin/Cionni CTR TYPE 10G 800.932.4202 Visit FCI-Ophthalmics.com to watch the EyeJet informational video. For more information about our Pre-Loaded CTRs, please call us at 800-932-4202 Exclusively from

• Cover