Eyeworld

EW CATARACT 82 March 2018 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer Presentation spotlight Taking the right steps in managing a traumatic eye injury can make all the difference in restoring good vision E ye trauma can be hard to handle, with many mov- ing parts that require the ophthalmologist's close attention. In a case presen- tation shown as an e-poster at the XXXV Congress of the ESCRS, visual acuity was restored through careful handling of the damaged tissues and implantation of a multifocal IOL following a perforating eye injury involving an intraocular foreign body with resultant traumatic cata- ract. The author of the poster, Anca Tomi, MD, Emergency Eye Hospi- tal, Bucharest, Romania, discussed her thought process in treating the traumatic, perforated eye and what helped her decide on a multifocal IOL implant. Case description The case study described a young male patient, 20 years old, who in- jured his left eye while hammering, 2 days prior to presentation at the Emergency Eye Hospital. Dr. Tomi suspected an intraocular foreign body (IOFB), which she confirmed in the course of a thorough ocular examination. Fortunately, the IOFB was smooth, passing through the cornea and into the eye without causing extensive corneal damage. Dr. Tomi explained, "The IOFB was a metallic, small, and sharp splinter. It probably entered the eye with high velocity and caused small and clear-cut perforations in the cornea, iris, anterior capsule, and posterior crystalline capsule. You can hardly notice the small, self-sealed corneal wound, paracentrally at 4 o'clock on the cornea. Because of the paracen- tral location, the wound itself did not affect vision, and the patient delayed presentation at the clinic until the cataract developed, 2 days after the injury." Upon presentation, the patient's left eye had a visual acuity of 0.2, and his IOP was 14 mm Hg. There was a small, self-sealed corneal wound, just off center at 4 o'clock. The anterior chamber was present, and there was evidence of a rup- tured pupillary sphincter, ruptured anterior capsule, as well as cataract. IOFB extraction was performed through a pars plana sclerotomy using a magnet. Dr. Tomi performed cataract surgery on the patient 2 weeks after presentation. "A delay of 2–4 weeks may allow central corneal heal- ing and reduce the inflammatory response. It may sometimes even be preferable to do a multi-step proce- dure, after control of inflammation, with adequate corneal clarity and an appropriate IOL power calculation," she said. The patient's visual acuity was counting fingers, and there was an absence of inflammatory signs. Dr. Tomi carried out B and A scan ultrasonography and keratometry readings. The patient's preoperative left eye biometry was as follows: axial length (AL) 23.45 mm, R1 7.98 mm/42.29 D @ 151 degrees, R2 7.64 mm/44.18 D @ 61 degrees, spherical equivalent (SE) 43.23 D, cylinder –1.89 D @ 151 degrees, R 7.81 mm. She opted for the implanta- tion of a multifocal IOL (ReSTOR, Alcon, Fort Worth, Texas). In-the- bag implantation was possible with good centration, despite the anterior capsule not being intact and a hole that she discovered intraoperatively in the posterior capsule. "I decided to implant the MF- IOL intraoperatively, after assess- ing the 'damages' to the capsular bag and only when I anticipated a good centration and stability of the MFIOL in the bag. The integrity and stability of the capsular bag can only be evaluated intraoperatively. The option to implant a multifocal IOL in this patient was considered because of his age, 20 years, his strong desire for a multifocal im- plant, and the possibility to obtain accurate biometry measurements. We should take other options into consideration when performing cataract surgery in cases like these, such as a three-piece IOL implanted in the sulcus or sutured at the sclera. Sometimes a two-step approach is necessary, with delayed IOL implan- tation," Dr. Tomi explained. The surgery achieved good visu- al outcomes. Dr. Tomi followed the patient regularly for 9 months post- operatively. "The postop VA OS was 1, for far and near. Postop refraction in the right, uninjured eye was +0.25, and it was 0.50 in the left, injured eye. The SE was 0.00. At the 3-month follow-up visit, the VA OS was 0.8 and there was mild posterior capsule opacification (PCO). By 9 months after surgery, the VA OS was 0.3, and there was considerable PCO requiring YAG laser capsulotomy," she said. Management of injury and surgical approach Physicians confronted with perfo- rating eye injuries need to respond to the problem at hand. There is no blueprint for managing trauma, however, certain guidelines can help to plan the course. For the manage- ment of perforating eye injuries, Dr. Tomi performs a complete evalua- tion of the damage to the intraoc- ular structures. She recommends first dealing with the repair of the cornea, iris, or scleral wound. Next, careful extraction of the foreign body allows the physician a better MFIOL implantation in a traumatic eye Anterior capsular tear, cataract Well-centered multifocal IOL 1 day postop Source: Anca Tomi, MD

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