Eyeworld

EW CATARACT 62 March 2017 by Steven G. Safran, MD into the rapidly dwindling stash of STAAR AQ5010v IOLs (STAAR Surgical, Monrovia, California) and place a zero power lens in the sulcus. If not available, a Staar CQ2015v (collamer) or silicone SofPort AO (Bausch + Lomb, Bridgewater, New Jersey) of zero power to be placed as a piggyback IOL in the sulcus may be a reasonable choice. Given the fibrosis and PXF history, I'd prefer an option that avoids IOL exchange and further manipulation of the capsular bag, especially since the ob- jective vision is 20/20, and the goal is to improve the subjective visual disturbances." Yuri McKee, MD, Mesa, Arizo- na, noted, "There are a few consid- erations here: First, what is the likeli- hood of a successful IOL exchange with an intact capsule in this case? Probably low considering the pseu- doexfoliation. Even if surgery was successful, I would think that she would be at an increased risk of late IOL/bag dislocation in the future. Likewise, for a piggyback IOL, I would be worried about the long- term integrity of the zonules and their ability to support a second IOL. So, are we resigned to just do a pars plana vitrectomy and explant the entire lens bag complex followed by intrascleral haptic fixation (ISHF)? Perhaps not, but in any case, I think the surgeon should be prepared for that option if they choose to operate in this case. With practice, I have found that ISHF is actually easier than all of the gymnastics associated with sutures, ring segments, capsular tension rings (CTRs), etc. "There might be another op- tion, but this is absolutely theoreti- cal and way outside of the box: Use a femto to make a circular opaque bubble layer within the IOL just in- side of the rhexis (or even to expand the rhexis). This opacity may disrupt the total internal reflection that could be casting the shadow on the peripheral retina. Of course, I would try this in the wet lab and measure the effects before ever considering it in a patient." Samuel Masket, MD, Los Angeles and Nicole Fram, MD, Los Angeles, weighed in together and Anterior segment grand rounds said, "Although always a worthy consideration, nonsurgical means for dealing with symptomatic chron- ic ND often fail. Those include phar- macologic mydriasis (may induce glare and aesthetic deformity) and spectacles with thick temple pieces (patients often desire freedom from glasses). That said, I generally offer those methods, albeit with little success. "Management of ND that persists beyond 6 months is surgical in our experience. At the outset, I have a lengthy conversation with the patient about the enigma of the condition, the fact that it occurs only with what we consider to be anatomically 'perfect' surgery, and I discuss our experience with surgical approaches. Typically, the patient has seen (several) other colleagues who have not been sympathetic to their problem, and the patient must be reassured that they are sane and indeed have a debilitating problem. Patient in need of cataract surgery in second eye will not have it until first eye is "fixed" C live Novis, MD, Springs, South Africa, commented, "Before offering her any surgery, I would give her a trial of Mydriacyl (tropi- camide, Alcon, Fort Worth, Texas). If this does not work, I would next offer her spectacles with broad dark temples. Only if these two conser- vative measures fail would I go on to surgery (which in this case would be a piggyback sulcus IOL as my first option before lens exchange as my last option)." Kamran Riaz, MD, University of Chicago, said, "I would try to dig Getting beyond a shadow of doubt T his is a 78-year-old nurse who had cataract surgery in her left eye 18 months previously. She is referred in for persistent negative dysphotopsia (ND) in this eye. She has a 20/50 cataract in her right eye (OD), and her left eye (OS) is 20/20 uncorrected with an Akreos A060 (Bausch + Lomb, Bridgewater, New Jersey) in the capsular bag. She is extremely unhappy because of persistent severe ND affecting this eye. She has a history of pseudoex- foliation syndrome in the left eye with a poorly dilating pupil. The lens appears to be well-fibrosed in the capsular bag. She refuses to have cataract surgery in the right eye until the left eye is "fixed." She is very intelligent and reasonable but much more bothered by the ND in her OS than the poor vision in her OD. I consulted the members of both the Keranet and ASCRS cataract online com- munities to get their thoughts on how to approach management of this case. Steven G. Safran, MD, ASGR editor OS maximally dilated showing Akreos AO60 in capsular bag

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