This 42 year old patient sustained an airbag injury to his face a few months ago. He noted cloudy vision in his left eye, which has since worsened. He is seeing you for consultation and the view is shown in this picture.
His right eye is completely normal and sees 20/20. The left eye has vision of Count Fingers at 1 meter. There is no afferent pupillary defect. The pressure is 19 mmHg in the left eye and gonioscopy shows a normal angle without evidence of damage. The left cornea is clear and has a normal endothelial cell count and pachymetry. The pupil does not dilate despite maximum topical mydriatic medicines. The lens shows a whitish cataract with nuclear and cortical changes. There is a large area of posterior synechiae with three clock hours of iris adherent to the anterior lens capsule. There is a very hazy view of the posterior segment but the B-scan ultrasound looks reasonable without any gross abnormalities.
What is your approach for the cataract surgery?
Before you answer, let me show you one more photo taken at the slit-lamp microscope:
This photo shows that there is a large gap between the superior iris and the lens. When we place the patient in the supine position with the iris parallel to the floor of the room, we look using the indirect ophthalmoscope and the crystalline lens tilts back deeper into the vitreous cavity. It appears that the only thing holding the cataract in place is the area of posterior synechiae.
Now what is your approach?
My approach was to send the patient to a trusted vitreo-retinal colleague who performed a pars plana vitrectomy and pars plana lensectomy. He also noted a small area of rhegmatogenous retinal detachment which he repaired. Finally, an acrylic IOL with four loop haptics (B&L Akreos AO60) was secured to the sclera with Gore-Tex.
Sometimes, the best surgical approach is referring the patient to a colleague.
Please leave a comment below to give your input and explain your surgical approach.
That was probably the best management done.A closed chamber management of nucleus in such a case is the best option with all the tools vit cutter and frag to deal with any prob what so ever.A management from anterior approach would have lead to a nucleus drop for sure provided it was just attached through a PS. Had this case been with me at my centre,the only difference in approach would have been a glued fixated 3 piece IOL as the gore-tex is not easily available in India.
excellent. thank you for contributing
I also believe that this approach is much more intelligent than an ICCE, not for the risk of a nucleus but also for the risk of the vitrous base manipulation during the loop assisted delivery of a deep located lens.