JAN 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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12 EW NEWS & OPINION January 2012 Anterior segment grand rounds Reversal of misfortune by Steven G. Safran, M.D. rior angle of the iris and the exten- sive contact with the implant optic. Figure 4 is another image his is a 48-year-old gentleman who was referred to me for an IOL ex- change after he developed what was described as a recurrent "UGH" syn- drome (uveitis/glaucoma/hyphema) in the left eye. He was a myope who had a retina de- tachment in the OS that required a pars plana vitrectomy, which led to the development of a cataract. The referring cataract surgeon told me that a three-piece acrylic implant had been placed in the sulcus because of com- promise to the capsule and zonules. Although the eye had been quiet for 4 years after this, in the past 6 months the patient had three episodes of elevated pressure associated with inflammation and hyphema, and it was the most recent one that triggered his referral to my office. T Figure 1 Steven G. Safran, M.D., ASGR editor Figure 2 I saw the patient soon after his eye started "acting up" again. His vision was CF in the in- volved OS. IOP was 16 OD and 38 OS and the cornea had microcystic edema in the involved eye. A microhyphema was present and although the view was compro- mised I could see that the anterior chamber was very deep with the iris appearing bowed back with periph- eral transillumination defects. Figure 1 is a slit lamp view of the eye at presentation. Note the hazy view through the cornea and the periph- eral transillumination defects in the iris from 3:30 to 5:30. Figure 2 is a gonioscopy image. Note the blood in the angle and the extreme concavity of the iris. It appears very posteriorly angulated. At the time this case presented I was working with a very early proto- type lens to adapt the Spectralis (Heidelberg Engineering, Carlsbad, Calif.) to perform anterior segment OCT. Figure 3 includes OCT images where I attempted to determine the configuration of the iris in relation to the IOL. Note the extreme poste- demonstrating the iris configura- tion. Note the posterior bowing (there is an artifact in these images of an inverted cornea image pro- jected behind the iris). I presented this case to a stellar panel—Uday Devgan, M.D., Garry Condon, M.D., Daniel Goldberg, M.D., Baseer Khan, M.D., and Robert Nasser, M.D.— for discus- sion on how they would proceed in managing this patient. Dr. Devgan commented: "This is truly a challenging case in an eye with unusual anterior segment anatomy … If this patient has an open posterior capsule and in-the- bag placement is not possible then a scleral-fixated IOL could prove use- ful. Given the unusual iris configura- tion and the proclivity toward UGH syndrome, it may be wise to avoid any type of IOL that will interact with the iris including ACIOLs as well as iris-sutured PCIOLs." Dr. Nasser commented: "The an- terior segment depth and iris config- uration are puzzling to me. If the IOL was 13 mm or less in diameter it is likely mobile, causing iris trauma and hyphema … I have seen a hy- phema in a similar case potentiated by ASA or NSAID use and would be sure to stop those meds. I'd use med- ical therapy to lower IOP, and when (if) the cornea clears, re-evaluate the lens. I suspect it will need to be re- placed with a capsular fixed lens (best) or a longer lens sutured to the sclera. I would avoid suturing to the iris or an ACIOL. I'd delay glaucoma surgery if you can." Dr. Condon commented: "This is relatively weird! Is the capsular bag visible at all? Simple reposition- ing is not a likely option. You could elevate the IOL and do iris suturing but this may not alleviate the acute inflammatory problem. Exchange with scleral fix is a consideration. Removing the IOL and letting things quiet down and then going back later is probably what I'd favor. "In a similar case, I brought the three-piece IOL into the AC, rein- flated the bag, placed a ring in the bag, and then finally put the ENTIRE lens into the capsular bag." Unfortunately in this case the option of reinflating the capsular bag was off the table because the bag Figure 3 Figure 4

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