99% of ophthalmologists (including me!) will not be able to figure out the surprise from this picture. If you want to guess, comment below before you keep reading!
This complex case presents a perfect storm of ocular pathology that requires a meticulous surgical plan. Behind the small pupil and extensive posterior synechiae, we discovered several markers of chronic inflammation including old keratic precipitates and a prior peripheral iridotomy. The real surprise is the presence of a phakic intraocular lens or ICL which was the primary driver of this persistent uveitis and the subsequent development of a mature white cataract. Our first step is to gently lyse the synechiae and expand the pupil to visualize the vault of the ICL. We must carefully explant the phakic lens before addressing the white cataract. Removing the source of inflammation while navigating these anatomical hurdles is the only way to restore clarity and quiet the eye for the long term.
