Eyeworld

EW CATARACT 36 November 2016 he decide that he wants to improve his vision further. This case demonstrates how when dealing with post-traumatic cataract situations, you don't know what you are going to find until you get in the eye. One needs to be flexi- ble in the approach to accommodate the anatomic realities found during the surgery and modify the surgical plan accordingly to achieve the best possible outcome. EW Editors' note: The physicians have no financial interests related to this article. Contact information Hart: Aiophth@aol.com Hester: hesterchristianc@gmail.com Safran: safran12@comcast.net Rosenthal: kr@eyesurgery.org pre-existing defect in the posterior capsule, and a pars plana vitrectomy was carried out after staining with Triesence once again. The vitrector was used to create a central open- ing in the posterior capsule as it was clear that the lens could not be placed in the capsular bag by this time. Once this was completed the anterior capsule opening was ex- panded a bit to make it large enough for optic capture. However, during this maneuver there was some dis- continuity seen in the anterior cap- sule edge that could make it prone to a tear-out during an optic capture maneuver, so a decision was made to suture one haptic to sclera and to buttonhole the optic through both the anterior and posterior capsule opening to better stabilize the IOL— an Aaren EC3 Pal 21.5 D lens (Aaren Scientific, Ontario, California). This was successfully achieved. Even though a radial tear did extend in the nasal anterior capsule, the poste- rior capsule opening was continuous in this region and so helped stabi- lize the optic on that side, and the sutured haptic was further insurance against any dislocation. The next day the patient had a quiet eye and good 20/25 uncor- rected vision despite the presence of more than 3 D of cornea astigma- tism. The lens was perfectly cen- tered, and he was very happy with the outcome of his surgery (Figure 3 and Figure 4). A discussion was had about his residual astigmatism, and the patient was informed that PRK would be an option to correct his astigmatism down the road should "If the posterior capsule is minimally damaged I would con- sider placing a toric IOL in the bag. If there was any question about sufficient capsular support, I would place a three-piece monofocal IOL with the haptics in the sulcus and optic capture—as much as the anterior capsule would allow given the traumatic opening. If I could not place a toric IOL at the time of sur- gery, I would plan to perform PRK to correct the remaining refractive error about 3 months after cataract surgery." What was done The case was performed under general anesthesia. Diluted Triesence was used at the beginning of the case to stain the vitreous strand adherent to the cornea and this was cut with a vitrector. The adhesions between the iris and the capsule were then cut with an MST forceps and the anterior capsule stained with trypan blue. The opening in the anterior cap- sule was expanded using a curved vitreoretinal scissor as the thick, fibrotic anterior capsule could not be torn manually. The residual lens material was removed with separate I/A handpieces, and it was found that most of the lens material had been reabsorbed. The anterior and posterior capsule were found to be fused on the temporal side near the traumatic opening in the posterior capsule, and this fusion could not be lysed without risking further damage to the capsule. During this part of the proce- dure vitreous presented through the John Hart, MD, West Bloom- field, Michigan, noted: "From the pictures I would suspect that the posterior capsule was breached, especially since there is a vitreous strand incarcerated in the corneal wound. Where you have the blue pointer, it appears to be pigment from the iris (posterior synechiae). The white cataract appears at least partially reabsorbed, and from what I can see, there appears to be a round hole in the anterior and posterior capsules. There appears to be subcapsular fibrosis beneath the anterior capsule. "I would plan for a pars plana vitrectomy using Triesence in the anterior chamber to ensure com- plete removal of vitreous from the anterior segment. I would start the case by filling the anterior chamber with VISCOAT [Alcon] and then retracting the iris to determine the full extent of the damage. I would lyse any posterior synechiae. Then I would perform the pars plana vit- rectomy. I would stain the anterior capsule with trypan blue. The cap- sular leaflets are likely fused where the nail pierced the lens. I would attempt to perform a capsulorhexis by initiating the rhexis away from the nail hole. Puncture of the ante- rior capsule may be difficult if there is subcapsular fibrosis. Subcapsular fibrosis may also require scissors for completion of the rhexis. If the lens was significantly reabsorbed, I would inject VISCOAT beneath the anterior capsule to create space after the initial entry into the capsule. The lens material will likely be soft, therefore I would remove it with I/A. Perforated continued from page 35 Figures 3 and 4. Day 1 slit lamp images of operative eye with well-centered PC IOL captured behind anterior and posterior capsule Source (all): Steven Safran, MD Watch a video of this case at EyeWorld Clinical rePlay, clinical.ewreplay.org.

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