EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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16 EW NEWS & OPINION June 2012 Anterior segment grand rounds Taking the Y out of Zs and making them X: Part 1 by Steven G. Safran, M.D. n this and next month's ASGR columns, I'd like to examine Crystalens (Bausch + Lomb, B+L, Rochester, N.Y.) Z syndromes. While I've only had two Z syndromes occur as the result of my own cataract surgery (both early on in my use of the lens), I've had many of these referred to me by other surgeons for treatment. From these cases I believe I've learned a great deal about what causes the problem and how it can be avoided. I've selected six rep- resentative cases from my own practice, all of which were handled slightly differently, to highlight certain points that I feel can help surgeons to better avoid, detect, and treat this problem. We'll cover three cases this month and three cases next month. I've asked a panel of noted Crystalens experts, Jay Pepose, M.D., director, Pepose Vision Institute, St. Louis, and professor of clinical ophthalmology, Washington University School of Medicine, St. Louis; Jeff Whitman, M.D., president and chief I surgeon, Key-Whitman Eye Center, Dallas; Robert Weinstock, M.D., The Weinstock Laser Eye Center, Largo, Fla.; David Goldman, M.D., assistant professor of clini- cal ophthalmology, Bascom Palmer Eye Insti- tute, University of Miami Miller School of Medicine; Mark Gorovoy, M.D., Gorovoy M.D. Eye Specialists, Fort Myers, Fla., and James Khodabakhsh, M.D., Beverly Hills Vision Institute; to help me with the discussion of these cases. Steven G. Safran, M.D., ASGR editor C ase 1 is a 56-year-old with a short eye and steep Ks (21 mm eye but 49.5 D average Ks). She had un- eventful surgery with a Crystalens HD, and day 1 was 20.40 uncorrected with a refraction of –0.5. She showed up at 5 weeks with 20/200 vision and a refraction of –3.0–2.5X15. The lens is entirely within the confines of the capsular bag (Figures 1 and 2). Case 2 is a 50-year-old engineer who had Crystalens surgery bilater- ally 1 year ago with 6 D implants. He developed severe Z syndromes in both eyes, but we'll focus on his left eye here. This is a 30 mm eye, and his vision is 20/100 correcting to 20/50 with –1.0–1.0X105 (Figures 3 and 4). Case 3 is a 55-year-old woman who had Crystalens AO surgery OD a few months earlier. She developed a Z syndrome and was treated with multiple YAG lasers including a treatment under the nasal hinge with no improvement. When I saw her she refracted to 20/25 with –0.25–1.75X110 (mostly lenticular astigmatism). Her axial length in this eye was just shy of 22 mm (Figure 5 and 6). Case 1 discussion It is interesting that in my discus- sion with the expert panel, there was no consensus on how to handle any of these cases. In regard to case 1, Dr. Whitman commented that he would "YAG just behind the inferi- orly bowed hinge." Dr. Gorovoy would "treat all your cases first with extensive YAG and if unsuccessful then pars plana vitrectomy and cap- sulectomy. I would not recommend compensatory refractive laser or IOL exchange." Dr. Khodabakhsh would reposi- Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) Or view Dr. Safran's video at: http://youtu.be/G2CNmMYAGfo tion this lens and place a CTR. "When the patient is within the first 8-12 weeks after implantation with a Z syndrome, I tend to take the patient back to the OR, dissect and rotate the lens back to a good posi- tion, and place a CTR." Based on my examination of this patient I felt that the problem was posterior capsule fibrosis push- ing the anterior haptic forward. I did dilated gonisocopy to confirm that the haptic was properly positioned in the equator of the capsular bag under the anterior capsule. I felt that the Z was the combination of a larger rhexis that provides less ante- rior stabilization and posterior cap- sule fibrosis pushing the superior plate forward. I believe the fact that this was a very small eye played a role here. It has been my experience that the great majority of Z syn- continued on page 18 Figure 1. Note large rhexis and striae radiating down from 11:00 Figure 2. Note "Z" configuration of slit lamp beam reflecting off of the posterior capsule Figure 3. Note severe fibrosis and PC striae radiating from 6:00 Source (all): Steven G. Safran, M.D.