CONSULTATION SECTION

Cataract Sur

gical ProblemEdited by Samuel Masket, MD

Figure 2. Gonioscopic view of the superior angle of the right eyeshows a basal iridectomy. The slitlamp beam passes across thesupport loops of the IOL and creates the false impression of discon-tinuity of the central aspect of the loop. The loop is intact; however,the peripheral portion of the support loop and the footplate havepassed through the iridectomy, allowing the IOL to decentersuperiorly.

A 73-year-old man was referred for management ofmarked difficulty with nighttime driving after cataractsurgery in the right eye 2 years previously. Accordingto the history, cataract surgery was complicated bycapsule rupture, vitreous loss, and iris sphincterdamage as a result of the interoperative floppy-iris syn-drome (IFIS); the patient had used both tamsulosin(Flomax) and over-the-counter saw palmetto for symp-toms associated with prostate enlargement. At the ini-tial surgery, an anterior chamber intraocular lens (ACIOL) was placed after anterior vitrectomy and a supe-rior basal iridectomy were performed. The IOL decen-tered postoperatively and was repositioned surgicallyon 2 occasions. As a result of the difficult surgery inthe right eye, the patient is reluctant to consider sur-gery in the left eye, even though the eye has a signifi-cant cataract. However, given his great difficultydriving at night, the patient now requests visualrehabilitation.

Current findings include the following: corrected dis-tance visual acuity, 20/20 in the right eye and 20/50 inthe left eye; retinal acuity meter measurement, 20/20in the left eye; brightness acuity test results, 20/80 inthe right eye and 20/100 in the left eye, and applana-tion tonometry, 11 mm Hg in both eyes. The endothe-lial cell count (ECC) is 1957 cells/mm2 in the right eyeand 2410 cells/mm2 in the left eye and the pachymetry,546.0 mm and 528.0 mm, respectively.

Figure 1.Anterior segment view of right eye. Note the superonasallysubluxatedAC IOL and irregular pupil with damage to the temporalaspect of the sphincter. The inferior footplate is visible on the irissurface.

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Anterior segment examination of the right eyeshows evidence of previous cataract surgery with a su-periorly placed limbal incision, moderate nasal and su-perior decentration of an AC IOL, and a defect in thetemporal aspect of the pupil margin (Figure 1). The re-sult is that the temporal edge of the AC IOL is bared,likely contributing to nighttime glare symptoms. A di-lated view shows little to no residual capsule remnantand no vitreous in the anterior chamber. On gonios-copy, the superior peripheral support loop and foot-plate pass through the basal iridectomy (Figure 2).The posterior segment examination is unremarkable.

Examination of the left eye is normal with the excep-tion of a significant mixed cortical, nuclear, and poste-rior subcapsular cataract.

Given the patient’s complaints and findings, howwould you manage this case?

- Although the patient is understandably reluctant, Iwould encourage him to have cataract surgery in theleft eye first. Because there was significant difficultlywith IFIS in the first eye during surgery, I would usethe epi-Shugarcaine technique1 and a Malyugin ring.2

If the pupil dilates better than expected, I would use

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1798 CONSULTATION SECTION

the 7.00 mm ring. Otherwise, I would use the 6.25 mmring, which is large enough and is easier to remove.

Because the IOL in the right eye has become dislo-cated a third time, I believe itmaybeundersized.There-fore, I would measure the white-to-white distancepreoperatively and use a dispersive ophthalmic visco-surgical device (OVD) intraoperatively toprotect the al-ready traumatized corneal endothelium. I would beginby repairing the sphincter tear, closing thepupilmarginwith a 10-0 polypropylene suture on a long, curvednee-dle.3 A more peripheral iris suture might also be re-quired, although based on Figure 1, I do not believethis would be necessary. The dislocated IOL gives bet-ter exposure to the tear,making it easier to repair beforethe IOL is repositioned. Iwould thencarefully rotate thehaptic out of the iridectomy, rotating the IOL90degreesinto a horizontal direction. This could be done throughsmall incisions. If the IOLweremobile in this position, Iwould explant it through a temporal incision, avoidingthe already traumatized superior cornea, and replace itwith a larger IOL. At this point, I might consider ex-change for a 3-piece PC IOL sewn to the iris with 9-0 polypropylene sutures on a long, curved needle.4 Ifthe IOL were stable in the horizontal position, I wouldplace a 9-0 polypropylene or 11-0 polyester fiber sutureona short, curvedneedle to anchor1haptic to the sclera.This could be done with a scleral groove, or the suturecouldbeplacedthrough the internal lipofaparacentesisover the haptic. Iwould remove theOVDwith a biman-ual technique and watch the patient carefully after sur-gery for intraocular pressure spikes.

Postoperatively, I would have the patient weara protective shield to prevent eye rubbing, whichcould destabilize the AC IOL.

David Crandall, MDDetroit, Michigan, USA

REFERENCES1. Schulze R Jr. Epi-Shugarcaine with plain balanced salt solution

for prophylaxis of intraoperative floppy-iris syndrome [correspon-

dence]. J Cataract Refract Surg 2010; 36:523

2. Chang DF. Use of Malyugin pupil expansion device for intraoper-

ative floppy-iris syndrome: results in 30 consecutive cases. J Cat-

aract Refract Surg 2008; 34:835–841

3. Cionni RJ, Karatza EC, Osher RH, Shah M. Surgical technique for

congenital iris coloboma repair. J Cataract Refract Surg 2006;

32:1913–1916

4. Condon GP, Masket S, Kranemann C, Crandall AS, Ahmed K II.

Small-incision iris fixation of foldable intraocular lenses in the ab-

sence of capsule support. Ophthalmology 2007; 114:; 1311–1138

- Although this patient has excellent Snellen acuityafter a fairly complex surgical course, unacceptable

J CATARACT REFRACT SURG -

glare has prompted the patient to seek further visualrehabilitation. As far as which eye to address first,we are not told whether the primary symptom ofnight-driving complaints is stimulated more by thecataractous left eye or from edge glare from the decen-tered AC IOL in the right eye. This information is cru-cial in determining which eye to treat first.

If the previously operated right eye is themost symp-tomatic, several options exist.We are not providedwithgonioscopic positioning of the inferior footplates, al-though from the slitlamp picture, it appears as thoughthe inferior footplate and loopmaybe restingonperiph-eral cornea, notwithin the angle. If so, IOLexchangewillbe required to prevent progressive endothelial cell lossirrespective of the presence or absence of symptoms.An exchange seems a better option than another reposi-tioning of the AC IOL, which is likely inappropriatelysized for this anterior segment. In the setting of analready compromised and flaccid iris, I would not usethe iris as a fixation element. I would exchange the ACIOLwith a posterior chamber (PC) IOL that is passivelysulcus fixated if adequate capsule support remains or,alternatively sclerally sutured, ideallywith 4-point fixa-tion. I would select an IOLwith rounded haptic and op-tic edges. In viewof the IFIS during the first procedure, Iwould use flexible iris retractors to stent the iris to thelimbus for the IOL exchange procedure and to preventfurther damage. The sphincter damage may not beproblematic with a well-centered PC IOL, althougha10-0 polypropylene repair suture placed using theSiepser sliding-knot technique could be placed afterIOL fixation to reappose the frayed edges.

For the cataract surgery in the left eye (before or afterthe issues in the right eyeare addressed), Iwouldplan tostent the iris for the procedure. If the pupil were poorlydilated initially, iris retractors or aMalyugin ringwouldbe suitable alternatives. If thepupil dilateswell at thebe-ginning of the case, I would use iris retractors from thestart. Although a ring will dilate a small pupil, it cannotprevent a large pupil from constricting intraoperatively.AMalyugin ring requires anaperture smaller than its in-ner diameter for placement, and inserting it mid-proce-dure can be more challenging, potentially causingcapsule damage and poorer visualization.

Michael E. Snyder, MDCincinnati, Ohio, USA

- Each eye should be addressed separately. In theright eye, the decentered AC IOL and temporal pupilmargin defect are causing night-vision problems.Based on the low endothelial count, AC IOL loop

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