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EW INTERNATIONAL 110 September 2017 strated only a small amount of flare and Tyndall on biomicroscopy. As both haptics were outside of the capsular bag, Dr. Walsh chose an IOL exchange as her plan of action. To remove the IOL, Dr. Walsh first dislocated the proximal haptic to the anterior chamber and folded the device for removal. She replaced it with a three-piece IOL, which can be inserted into the ciliary sulcus because of its posterior vault. One year postoperatively, the patient was 20/20 with 14 mm Hg IOP without medication, and no anterior cham- ber reaction. "Similar cases have been de- scribed in the published literature with the use of either asymmetric or sulcus fixated IOLs, made of hydro- phobic/acrylic material," Dr. Walsh said. "These IOLs have square ante- rior and posterior optic and haptic edges, and no posterior vault, which means they are designed for in-the- bag implantation only. Cases have been reported of haptic induced recurrent vitreous hemorrhage and increased IOP with hydrophobic acrylic IOLs, which is just what we saw in this case. The simple con- clusion is that single-piece IOLs are designed for in-the-bag implantation only, and surgeons need to ensure that both haptics are securely im- planted in the capsular bag. Some- times the surgeon does not take the time to rotate the lens and make sure it is securely placed in the bag. If a haptic is left out of the capsular bag, it is usually under the main incision. In fact, most decentrations result from one haptic being left out of the bag. Recurrent uveitis is often diagnosed instead of displaced IOLs and is frequently confused with pigmentary dispersion syndrome. Sometimes you need someone to take a fresh look at a problem to identify it." Simply overwhelming A second challenging case study pre- sented at the symposium described a seemingly hopeless clinical scenario characterized by ocular pain and re- duced visual acuity in a patient who underwent multiple eye surgeries. by Stefanie Petrou Binder MD, EyeWorld Contributing Writer presented to Dr. Walsh complaining of symptoms that were so severe that he was unable to work and needed a second opinion. On examination, Dr. Walsh found that his best corrected visual acuity was 20/25 and IOP was 40 mm Hg. Biomicroscopy showed severe Tyndall and flare in the anterior chamber, as well as a nasal transillumination defect. She observed an open chamber angle, a significant amount of pigment compared with the fellow eye, and no goniosynechiae on gonioscopy. After pupil dilation, Dr. Walsh saw a nasally decentrated single-piece IOL with both haptics embedded in the ciliary sulcus. The posterior capsule was intact, and fundoscopy showed a normal macula and optic nerve. Dr. Walsh treated the patient with prednisolone acetate 10 mg every 2 hours, brimonidine tartrate, timolol maleate, and oral acetazol- amide. Within 5 days the patient's IOP was 24 mm Hg, and he demon- symptoms, if what should be a sim- ple diagnosis is overlooked. Accord- ing to Aileen Walsh, MD, Gama Filho University, Rio de Janeiro, Brazil, these situations are common and often result from not seeing what's right in front of you. "The misdiagnosis of a simple dislocated IOL can cause unneces- sary discomfort and reduced vision for months if not years if not iden- tified. We decided to present a case study to highlight how important it is not to miss even a simple diagno- sis," Dr. Walsh said. The case involved a 46-year-old male patient with recurrent episodes of blurred vision, severe ocular pain, and headache, that persisted for 3 years after uncomplicated cataract surgery. The surgery and subsequent diagnostic tests and treatments were not performed at Dr. Walsh's clinic. The diagnosis the patient received was idiopathic anterior uveitis, and he was treated accordingly. However, symptoms persisted and the patient Symposium highlights case studies that show how the right diagnosis and treatment choice can make all the difference W hen a clinician hits a brick wall, it may take fresh eyes or a fresh approach to diagnose and handle a prob- lem. Two Brazilian surgeons shared two very different case studies in which their best efforts required tenacity, ingenuity, and open eyes, during the "Symposium of Chal- lenging Cases," sponsored by the Brazilian Association of Cataract and Refractive Surgery (BRASCRS) at the 2017 ASCRS•ASOA Symposium & Congress. Simply baffling Sometimes a dislocated IOL can cause some of the most baffling Diagnoses and solutions Presentation spotlight Dr. Walsh presents at the "Symposium of Challenging Cases" at the 2017 ASCRS•ASOA Symposium & Congress. Source: ASCRS

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