Eyeworld

EW CATARACT 30 April 2018 by Steven Safran, MD Management of patient with pseudoexfoliation syndrome 10 years post- cataract surgery who is now functionally aphakic and has a symptomatic cataract in the other eye I asked my colleagues on Keranet and the ASCRS listserv, "What would you do for this patient and in what order would you suggest doing it?" Here are some of the responses I received. Steven Rosenfeld, MD, Delray Beach, Florida, said, "I would rec- ommend a cataract extraction with a three-piece silicone IOL (LI61AO, Bausch + Lomb) in the right eye, since the left eye with the dislocated PC IOL and capsular bag complex has 20/25 vision with an aphakic Going from "pseudoexaphakia" to exaphakia T his is an active, healthy, 79-year- old woman. She has been referred for a dislocated IOL capsular bag complex in the left eye and is 10 years out from her original cataract surgery in which a hydrophilic acrylic one-piece lens with four loop haptics (Akreos A060, Bausch + Lomb, Bridgewater, New Jersey) was placed. In this eye, she has a history of pseudoexfoliation glaucoma and has an IOP of 21 on topical timolol and travoprost drops. On slit lamp exam the eye appears to be aphakic with no IOL or capsular bag visible, but after being maximally dilated the top of the IOL/ bag complex can be visualized bobbing around in the anterior vitreous (Figure 1). She is currently wearing an aphakic soft contact lens with which she sees 20/25, but she has difficulty putting it in and taking it out. Her endothelial cell count is excellent in both eyes, and she has no significant glaucoma damage on OCT imaging of the optic nerves. In the right eye she has a 20/70 cataract and evidence of pseudoexfoliation syndrome as well (Figure 2). Steven Safran, MD, ASGR editor Figure 1. Dislocated Akreos lens in capsular bag complex OS Figure 2. Pseudoexfoliation cataract in OD Anterior segment grand rounds (ASGR) CL. Once the right eye is healed with stable vision, I would remove the Akreos IOL/capsular bag com- plex and perform a vitrectomy, in- sert a three-piece PC IOL, and secure it in the sclera without sutures using intrascleral haptic fixation." Matthew Ward, MD, Provo, Utah, commented, "I presume she is tolerating the aphakic SCL OK. If so, I would focus on the cataract eye first and would perform phaco/IOL with CTR; she appears to dilate well enough not to require a Malyugin ring. I like the CTR there as it makes suturing easier in case she starts to dislocate. I would not preemptively support the capsule with a sutured device unless there is significant lens mobility during surgery. "If all goes well with the cata- ract surgery, I would proceed with IOL exchange in the other. I would lay the patient back in the exam lane to see if I can tell whether there is posterior migration of the IOL in a supine position. If the IOL drifts posterior, I would involve a vitreo- retinal colleague to retrieve the IOL from the back. I wouldn't attempt to suture the existing Akreos IOL, but would remove it and suture in an enVista IOL [Bausch + Lomb] using 7-0 Gore-Tex." Richard Schulze, MD, Sa- vannah, Georgia, observed, "This is a challenging case of an active 79-year-old with pseudoexfoli- ation in both eyes, a dislocated IOL/capsule complex in the left, a cataract in the right, and glaucoma secondary to pseudoexfoliation in both eyes that is apparently well controlled without any evidence of optic nerve damage on OCT. I would focus my efforts on rehabili- tating the left eye before addressing the cataract on the right. As I see it, there are three reasonable alterna- tives for reestablishing pseudopha- kia in the left eye. "First, perform four-point scleral suture fixation of the Akreos IOL through Hoffman pockets or a scler- al groove. This might be my first choice since the loops of the Akreos are already there, virtually crying out to be supported with sutures. "Second, exchange the Akreos for an EC-3 PAL [Carl Zeiss Meditec, Jena, Germany] placed via a Yamane technique. "Last, exchange the Akreos for an anterior chamber lens. Although an AC IOL may perhaps not be ideal, one must recognize that not every surgeon has the necessary skill for a sutured posterior chamber lens. Attempting an infrequently used technique with unfamiliar instru- mentation can lead to unanticipated problems that can make things far worse, thus violating the first rule of medicine: Do no harm. If sized properly, an AC lens can be well tol- erated, provide excellent vision (no dysphotopsias), and has the virtue of simplicity, falling well within the skill set of the average surgeon. One must remember to place a PI at the time of AC IOL insertion. A PI can easily be placed with a vitrector in IA/cut mode using a super slow cut speed and one snip. Alternatively, if no vitrectomy is performed (it is possible to do a case like this with- out needing a vitrectomy if disper- sive OVD is used to tamponade the vitreous prior to removing the exist- ing IOL), a Fugo blade can be used to perform a clean PI without risk of hemorrhage since the plasma energy of the Fugo provides hemostasis." Kamran Riaz, MD, Chicago, noted, "I would first ask her which eye bothers her more. I suspect it would be her right eye given the VA and the fact that she sees reasonably well with her CL in the left eye. "I would proceed to do CE + IOL with CTR placement in the right eye. I would preemptively place an EC-3 PAL in the bag as it is a three-piece IOL, and if the bag/IOL

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