EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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16 EW NEWS & OPINION September 2012 Anterior segment grand rounds Taking the Y out of Zs and making them X: Part 2 by Steven G. Safran, M.D. I n this month's column we will consider another three cases of Z syndrome that were referred to my practice for management (see part 1 in the June issue of EyeWorld). I am grateful to have an esteemed panel of Crystalens (Bausch + Lomb, Rochester, N.Y.) experts, Jay Pepose, M.D., director, Pepose Vision Institute, St. Louis, and professor of clinical ophthalmol- ogy, Washington University School of Medicine, St. Louis; Jeff Whitman, M.D., president and chief surgeon, Key-Whitman Eye Center, Dallas; Robert Weinstock, M.D., The Weinstock Laser Eye Center, Largo, Fla.; David Goldman, M.D., assistant professor of clinical ophthalmology, Bascom Palmer Eye Institute, 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, Calif., to help me with the discussion of these cases. Steven G. Safran, M.D., ASGR editor C ase 1 is a 76-year-old woman who had a Crystalens HD placed 5 months earlier. Initially she was happy with her vision, but it dropped after a few months. In response, the surgeon performed a YAG capsulotomy, which did not help. She presented to me with a refraction of –0.5–3.0 X30 degrees (all lenticular astigma- tism due to her lens tilt), and she was extremely upset with her vision. She did not care if she needed reading glasses but simply wanted her vision to be "normal" again. Her endothelial cell count was only about 1,050 cells/mm3 in this eye (Figures 1 and 2). Case 2 is a 32-year-old ICU nurse who had Crystalens surgery OS 3 months earlier. When her vision dropped a month after her surgery, her cataract surgeon per- formed a YAG capsulotomy for pos- terior capsule opacity, but her vision continued to worsen. She presented to me for a fifth opinion about her situation. She had 5 diopters of lenticular astigmatism due to severe tilt of the implant. There was an opening in the posterior capsule. Her eye was just shy of 22 mm long (Figures 3 and 4). Case 3 is a 53-year-old health- Watch the videos on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) care professional who had successful Crystalens surgery in her dominant right eye and was thrilled with it. The second eye subsequently had Crystalens surgery, and although she was initially doing well, she woke up with sudden onset of decreased vision 5 weeks after her surgery and was discovered to have a Z syndrome. The surgeon cyclopleged her and used topical steroids, but after 3 weeks of no improvement, he referred her to me for surgical man- agement. She was very happy with the Crystalens outcome in the other eye and wanted a succesful Crystalens in this eye too, if possi- ble. Gonioscopy demonstrated that the lens was completely within the bag. This was a 14.5 diopter implant, and my calculations showed that if this implant were in perfect posi- tion, she'd end up with a refractive outcome of about +0.25 in this, her nondominant eye. She would like to be able to read her computer with this eye without glasses (Figures 5 and 6). Figure 1. Here is the image of the patient's left lens. Note the open posterior capsule and the forward tilt of the upper temporal hinge. The lens is also tilted around the vertical axis as the temporal plate sits more posterior than the nasal plate Figure 2. Here we can see that the temporal plate is inserted anterior to the equator with the hinge acutely flexed back. The upper part of the hinge is also tilted forward relative to the bottom, creating some of the astigmatism that we see Figure 3. Here we can see the severe posterior tilt of the temporal half of the implant in this left eye. There is significant capsule fibrosis, and the PC has been opened with YAG laser