EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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April 2012 Anterior segment grand rounds A case for cerclage by Steven G. Safran, M.D. EW NEWS & OPINION 15 Case presentation T his is a 49-year-old woman who is 4 years status post- LASIK. She had a macula-off retina detachment that was treated by the retina specialists with pars plana vitrectomy and silicone oil. After re- moval of the silicone oil she had an air fill and went into acute angle-closure glau- coma that was successfully treated by deepening the anterior chamber with viscoelastic at the slit lamp. (Her presenta- tion and treatment for the narrow angle situation is described and detailed in "Facing interface fluid after LASIK, RD repair" on page 12.) Although her IOP normalized and her angle remained open, she presented to me a few months later with a dense cataract, zonular defects, and an atonic dilated pupil that did not respond to light or pilocarpine. Her other eye was always about –2.0 myopic so LASIK was done only in this eye, her dominant right eye for monovision, which she performed well with until her retina detachment occurred. Steven G. Safran, M.D., ASGR editor Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) Or view the video of Dr. Safran's procedure at http://youtu.be/PkYpnRzh2iQ. We want your cases! Have a particularly interesting anterior segment case you'd like to share with ASCRS colleagues? Send it to Dr. Safran for consideration as a "case of the month" for the ASGR column. Please contact him at safran12@comcast.net An image of her eye after receiving 2% pilocarpine T here are many questions here regarding the handling of the cataract surgery and the issue of what to do with the iris. Roundtable discussion Brandon Ayres, M.D., Cornea Serv- ice, Wills Eye Institute, Philadelphia, commented: "This is a very interest- ing case with three major issues: 1) what intraocular lens and power to use for the case given the patient is status post-laser refractive surgery; 2) how to handle the very high likeli- hood of zonular instability during lens removal; and 3) how to deal with an atonic pupil. "I traditionally stay away from presbyopia-correcting lenses in com- plex cases. … My personal prefer- ence is a one-piece acrylic lens targeting plano. This patient is al- ready using monovision and will likely be happy with good distance vision in the operative eye. "With any luck there is only a small area of zonular loss that can be corrected with placement of a capsu- lar tension ring. If more than two or three clock hours of zonular weak- ness are noted I like to place capsu- lar support hooks early in the case, preventing further zonular damage, and then place a CTR later in the case. When greater than four to five clock hours of dehiscence are noted, a capsular tension segment can be sutured into place or held in place with a flexible iris retractor. "Assuming the cataractous lens is removed and an IOL is placed, I would fix the pupil using a cerclage The patient's post-op appearance 1 month after surgery Source (all): Steven G. Safran, M.D. suture. I like to use four to five para- centesis sites and intraocular forceps to place the suture. I find it easier to run a baseball-style suture around the pupillary margin, trying to get as many bites as possible (minimum of 16), or you may see areas at the pupil margin that have been skipped. I also use a viscoelastic can- nula to help guide the suture out of the eye at each paracentesis to pre- vent grabbing small, almost invisible fibrils of cornea. Once the entire su- ture is placed it can be tied either in a McCannel fashion or tied in the eye using microforceps. I try to leave about a 4-mm pupil in these cases. "I would use an iris prosthesis only if the iris were so atrophic that she had persistent glare. I usually try to fix the iris if possible; if not possi- ble then use the iris prosthesis." Garry P. Condon, M.D., chair- man, ophthalmology department, Allegheny General Hospital, Pitts- burgh, had similar thoughts regard- ing this case but would stage the surgery if possible. "With a mydri- atic pupil like this and added dilat- ing agents, performing a careful slit lamp exam by angling your view and using a gonio mirror to help, it's possible in many cases to get a good idea of the extent of zonule loss. A UBM pre-op might help to give you a clue about the extent of zonule disruption as well. In any case I'd plan to have trypan blue dye, cap- sule retractors/hooks, an Ahmed seg- ment, and a standard CTR available. Supporting the bag where needed with retractor/segment and early placement of a standard CTR are often two steps I take prior to phaco that have been useful in my hands. If there's greater than about 160 de- grees of missing zonules, I would add and suture an Ahmed segment at the end of the case if a CTR is in place already. "In a patient like this, iris cer- clage can produce a beautiful cos- metic and functional result. That said, if I have an expansile ring in the bag, I usually opt to come back another day to do the cerclage be- cause of my concern for nicking the rhexis edge with the long curved needle. I have personal experience in that regard, and it isn't pretty watching the CTR/bag splay open to completely undo a great case. Inter- rupted McCannel sutures are fine too but not as pretty." Treatment My thoughts regarding this case were similar to those expressed here by Drs. Ayres and Condon. I ended up performing phaco using trypan blue to stain the capsule. I like to place the CTR as late in the proce- dure as possible, and in this case about three clock hours of zonular weakness were found between 8:00 and 11:00 o'clock (best seen at the end of cortical cleanup on the video). A CTR was placed to help stabilize this just prior to placing the IOL. A three-piece Tecnis Acrylic im- plant (Abbott Medical Optics, Santa Ana, Calif.) was chosen with a re- fractive target of about –0.5 selected to ensure that she would not end up hyperopic. An iris cerclage was done at the same time as the cataract sur- continued on page 16