Eyeworld

EW CATARACT 32 February 2017 Anterior segment grand rounds (ASGR) by Steven Safran, MD Mixed and not matched T his is a 68-year-old woman who came in for a second opinion. She is post-cataract surgery in both eyes, 1 year previously. She is perfectly happy overall with her left eye, which has a ReSTOR (Alcon, Fort Worth, Texas) in the capsular bag with a near plano refrac- tive outcome, but very unhappy with the outcome of her dominant right eye, which had a toric IOL placed. She complains of chronic pain in the right eye and claims it hurts if she touches it. She feels that her distance vision is poor in this eye and that her near vision without glasses is nowhere near as good as the other eye with the ReSTOR lens. She has been told she needs a YAG laser treatment in the right eye and wanted another opinion before she had that procedure performed. On examination, the left eye has a ReSTOR IOL well-positioned in the capsular bag. The right eye, however, has an Alcon T3 toric IOL oriented at 6 to 12. In this eye she has 1 D of with-the-rule corneal astigmatism, and the refraction is –0.75–0.5X90 correcting to only 20/25 because of posterior capsule opacity. She has tenderness to touch at the superior limbus. Upon dilation it can be seen that the inferior haptic is in the capsular bag adjacent to a radial tear in the capsule (Figure 1), while the rest of the IOL and the superior haptic is lodged in the sulcus with the capsular bag collapsed and fibrosed closed underneath it. She has no evidence of glaucoma or transillumination defects of the iris. Steven Safran, MD, ASGR editor Figure 1. Yellow arrows point to radial tear margins; inferior arrow points to capsule edge lying above IOL, and superior arrow points to capsule edge lying below IOL and fused to posterior capsule A year after cataract surgery in both eyes, patient experiences chronic pain in one eye I asked the participants on the EyeConnect cataract listserv and the Kera-net cornea discus- sion group for their opinions on how they would approach this patient's problem. Mark Gorovoy, MD, Fort Myers, Florida, responded: "There are several points in your case that design. Optic capture through a posterior rhexis would prevent the possibility of iris issues but would be more difficult and probably unnec- essary." Robert Lyons, MD, Southlake, Texas, said, "My opinion is that the IOL in the sulcus is causing some clinical symptoms and eye pain when rubbing. There is no evidence yet of UGH syndrome, but the likelihood of this happening down the road is high given the 'in-the- bag' IOL, which is not in the bag. In this situation, I think an exchange would be quite easy. Since the posterior capsule is not violated yet and most of the lens is in the sulcus, there would need to be very little dissection done, and if you wanted to leave the bag alone, amputate the IOL haptic that is in the bag and leave it there. The rest of the IOL should come out fine. Then a true sulcus IOL could be placed, perhaps even a ReSTOR three-piece to match the fellow eye. A 'primary' posterior capsulotomy could be attempted with reverse optic capture, or the IOL could be placed and then a YAG capsulotomy could be performed shortly afterward. A very aggressive surgeon could even perform the YAG capsulotomy before the exchange, and do reverse optic capture a little easier. "Once everything heals up and you can get a true manifest refrac- tion, any remaining cylinder can be touched up with excimer laser or LRI as desired by the patient." Yuri McKee, MD, Mesa, Ari- zona, noted, "I would agree with the approach of IOL explant and replacement with a three-piece IOL in the sulcus. Our first goal must be the health of the eye, and we know that acrylic haptics in the sulcus are not healthy. Along this line of thought, I would leave the posterior capsule intact and do a YAG later as this is probably the approach with the least risk. Intentionally violating the posterior capsule during surgery could give access to the vitreous of inflammatory factors stirred up during surgery, thus increasing the risk of CME. I do not think that an optic capture is worth the increased risk. "As to what three-piece IOL to use, it's a tough call, but a three- piece multifocal is an option. The patient needs to fully understand the staged nature of an IOL ex- change, then full healing, then YAG cap, then a waiting period, then a corneal refractive procedure. This is a marathon, not a sprint, and there will be costs incurred by the patient. Proper patient expectations are as important as good surgical skills here." Russ Van Norman, MD, Shreve- port, Louisiana, commented, "I think this lens should be replaced, as one-piece acrylics are not toler- ated in the sulcus. My first choice deserve comment. First, the haptic in the sulcus is a problem that must be addressed, not ignored. There are several options, but at the end of the day, they all must eliminate iris chafing, which if not already oc- curring will occur and will result in severe glaucoma down the road. The options include haptic amputation, IOL exchange vs. reposition, or a novel approach I have used—suture the offending haptic with a prolene lasso suture, positioning it posterior- ly to the iris (i.e., off the iris). I think this problem takes priority. "Second, while this is tangential to the real problem above, mixing and matching IOLs was an idea I never liked or made sense to me. Every patient compares one eye to the other, and unless its known monovision, he or she will think one eye is inferior. It's asking for trouble. So in this case, which is unusual in that the multifocal is the better result, the second eye, if an exchange is selected, can get a three- piece multifocal (ReSTOR vs. Tecnis [Abbott Medical Optics, Abbott Park, Illinois]). "Third, the quick response of many surgeons in complaining patients is to YAG. This case illus- trates that this simple procedure can make the more definitive procedure needed riskier. This is especially true in patients who complain immedi- ately after surgery when the capsule is clear but somehow the frustrated surgeon blames the capsule and there is still an unhappy patient now with an open capsule." Robert Dale Pilkinton Jr., MD, Nashville, Tennessee, commented, "I would do an IOL exchange, possibly amputating the haptic that is in the bag as the radial tear would make me less aggressive in attempting to reopen the bag. Knowing the power of this lens improves your chance of emmetropia with an IOL exchange, and I would adjust accordingly. The cylinder will not be an issue as the T3 overcorrected her in the first place, and you could always do a touch-up LRI if needed. I do not do a lot of multifocals, but if she likes the quality of vision of the ReSTOR, she will likely have made up her mind and nothing else will do. I would put the three-piece ReSTOR on the shelf and do a PI to minimize the chance of pigment dispersion and UGH from this square edge

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