Eyeworld

EW GLAUCOMA 60 December 2017 by Steven Safran, MD Patient with glaucoma and high myopia has a dislocated IOL 1 month after cataract surgery I asked some colleagues how they would manage this case. Baseer Khan, MD, Toronto, said, "Two issues have been identified as problematic in this case. The first is the patient's glaucoma, and the second is the malpositioned toric lens with its associated zonular instability. "In addressing the first issue, the IOP is stated to be under control on drops, though postoperatively, there will likely be retained viscoelastic so I would place the patient on acetazolamide for 1 week postop to prevent IOP spikes. "In regard to the malpositioned implant, given that this patient is 1 month out, it should be relatively easy to open the bag a little, enough to hook the anterior capsule and then inflate the bag with sodium hyaluronate. "I would use a capsule tension segment (CTS) temporally to support the bag once there was enough inflation to fit one in. Further in- flation would allow the placement of a capsule tension ring (CTR) and realignment of the IOL to the cor- rect position. Once that was done, I would suture the CTS into position using a double armed 9-0 Prolene suture. "I would also be prepared to completely explant the zonular/IOL complex if I was unable to open up the bag. In that case I would suture a three-piece IOL to the iris aiming for a myopic outcome, then do an excimer enhancement after a few months to manage the cylinder." Kamran Riaz, MD, Chicago, commented, "It appears that this patient has had nasal zonular dehis- cence and a malpositioned intraocu- lar lens that is further worsening the astigmatism. One interesting wrinkle to this present state of affairs is that while the intended refractive target was –0.5 in the surgical eye, the current spherical equivalent in the surgical eye is –1.5, and the spherical equivalent in the previously oper- ated eye is –3.75. Had the intended refractive target been achieved in the surgical eye, the patient may have been bothered by aniseikonia secondary to anisometropia. So while the present refractive state was not the target, it may be having a beneficial effect in terms of the spherical equivalent balance to minimize anisometropia between the two eyes. If this were the only issue at hand, non-surgical manage- ment with glasses, contact lenses, or excimer laser correction could be offered. "However, there is more than the refractive issue at hand here— namely, what is the best way to approach this malpositioned intra- ocular lens. It is fortunate that this patient is presenting early before fi- brosis of the anterior capsule occurs. There is marked zonular dehiscence of 5 clock hours and pseudophaco- donesis; there also may be vitreous coming forward in this area. This is not a stable situation, and it is high- Philosopher's dilemma T his is a 78-year-old active university professor of philosophy who has been referred in for a dislocated intraocular lens 1 month after cataract surgery. He has a history of glaucoma and high myopia (–7.0) and had a 16 D Tecnis Toric ZCT150 lens (Johnson & Johnson Vision, Santa Ana, California) placed to correct 1.5 D of corneal astigmatism. It was intended to be placed at 180 degrees but instead is at 75 degrees and is thus adding to, rather than subtract- ing from, his astigmatism. He currently has 3.0 D of astigmatism in the refraction. Furthermore, he has severe pseudophaco- donesis and a large zonular dehiscence with collapse of the capsular bag from 7 to 11 o'clock as seen in Figure 1. He also has glaucoma with VF loss and is on dorzolamide/timolol and latanoprost with good pressure control. The other eye had phaco/trabeculectomy in the past with a standard three-piece IOL and has a refraction of –3.0–1.5X90. This eye was targeted for –0.5 with a 16.0 ZCT150, but he currently is plano–3.0X90. He is unhappy with his refractive outcome and the con- stant "jiggling" of the lens as it affects his vision. Steven Safran, MD, ASGR editor continued on page 62 Anterior segment grand rounds Figure 1. Zonular dehiscence with collapse of capsular bag seen from 7 to 11 o'clock (blue arrow) Watch a video of this case on EWAR

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