CASE FILES s DENSE, DISLOCATED, BRUNESCENT CATARACT Approaching cataract surgery in a monocular patient.

BY ASHVIN AGARWAL, MS; MARJAN FARID, MD; P. DEE G. STEPHENSON, MD, FACS; AND AUDREY R. TALLEY ROSTOV, MD

CASE PRESENTATION

An 84-year-old Russian woman presents for a cataract surgery evaluation. The patient has a history of a failed graft, retinal detachment, and in her right eye. Visual acuity is light perception in her right eye and count- ing fingers in her left. A slit-lamp examination of the patient’s left eye finds a dense cataract, an inferiorly dislocated lens, loose zonules, and phacodonesis (Figure). The cornea is clear, and endothelial cell density is normal. B-scan ultrasonography shows no retinal detachment. The IOP measures 15 mm Hg. Examination reveals no other significant findings. How would you proceed? What form of anesthesia would you use? What would your preferences be in terms of surgical technique and IOL?

—Case prepared by Audrey R. Talley Rostov, MD

Figure. Examination of the patient’s left eye shows a dense cataract and loose zonules.

I would begin by making a conjuncti- were well tucked into the Scharioth val peritomy at the 3 and 9 clock hours tunnels, I would seal them with glue. I and two partial-thickness scleral flaps would end the case with pupilloplasty located 180º apart. I would also create to optimize the outcome. the SICS tunnel but leave it unopened. ASHVIN AGARWAL, MS After performing continuous curvilinear capsulorhexis, in order to ensure that Because the patient is almost blind the zonules were manipulated as little as and her right eye has undergone mul- possible, I would pull the lens into the tiple , I would first attempt to anterior chamber. Next, I would open restore some vision in her left eye. It the SICS wound and extract the lens MARJAN FARID, MD has a diseased bag-lens complex and using a viscoexpulsion technique, which, a progressive condition that threatens in my experience, minimizes stress on A controlled plan of action would the longevity of the bag-IOL complex. the zonules. Examination with iris hooks be extremely important in this My procedures of choice would be might then be warranted. case. The first steps would be to set manual small-incision cataract surgery I would use the space under each realistic expectations for the patient (SICS) to explant the cataractous lens, scleral flap to make a sclerotomy, and to select the correct approach followed by intrascleral haptic fixation which I would then use to perform to anesthesia. I would explain to the of an IOL (glued IOL technique) under anterior and externalize the patient the severity of her situation and peribulbar anesthesia. haptics. After ensuring that the haptics make sure she understood that a second

OCTOBER 2018 | CATARACT & REFRACTIVE SURGERY TODAY 27

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n AUDREY R. TALLEY ROSTOV, MD AUDREY R. TALLEY ROSTOV, MD Editorial Advisory Board Editorial Advisory Board TALLEY ROSTOV, MD TALLEY ROSTOV, MD CRST CRST WHAT I DID: AUDREY R. R. WHAT I DID: AUDREY Cataract surgery was uneventful, was surgery Cataract Owing to some medical issues, theissues, medical some to Owing Financial disclosure: Consultant (Allergan, Bio- Founder, Stephenson Eye Associates, Venice, Florida Member, [email protected] Financial disclosure: None Private practice, Northwest Eye Surgeons, Seattle Medical advisory board, SightLife, Seattle Member, [email protected] Executive Director and Chief of Clinical Services, [email protected] Financial disclosure: None Director of Cornea, Cataract, and Refractive [email protected] Tissue, CorneaGen, Johnson & Johnson Vision, Kala Tissue, CorneaGen, Johnson & Johnson Vision, Kala Pharmaceuticals, Shire) Dr. Agarwal’s Eye Hospital, Chennai, India Surgery; Vice-Chair of Ophthalmic Faculty; Director of the Cornea Fellowship Program; and Associate Professor of Ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine Financial disclosure: Consultant (Alcon, Bausch + Lomb) + Bausch (Alcon, Consultant Financial disclosure:        n P. DEE G. STEPHENSON, MD, FACS n n n n reflects my concern that potential futurepotential that concern my reflects implant. the disturb could surgery retinal UCVA 20/40 had patient the and postoperatively. SECTION EDITOR n n n n n ASHVIN AGARWAL, MS n n n MARJAN FARID, MD n n patient waited 4 months before schedul before months 4 waited patient thepoint, that At surgery. cataract ing into entirely dropped had nucleus lens com medical the on Based vitreous. the andissues cardiac (eg, case the of plexity theanesthesia), general about concerns cata observe to decided specialist jointa schedule than rather surgery ract cham anterior an selected I procedure. preferencethe also was which IOL, ber IOLof choice My surgeon. retina the of - - - - -

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CASE FILES P. DEE G. STEPHENSON, MD, FACS P. DEE G. STEPHENSON, MD, FACS I would have more than one surgicalone than more have would I If I was able to safely remove theremove safely to able was I If The degree of zonular laxity and lossand laxity zonular of degree The plan ready. No matter the technique, Itechnique, the matter No ready. plan requireto execution its expect would be needed to create 360º stability of stability 360º create to needed be preferenceMy complex. capsule the itsbecause IOL three-piece a be would someprovide would haptics spring-like three- A capsule. the within tension orscleral allow also would IOL piece needed. if fixation iris anterior approach, I would then usethen would I approach, anterior SegmentTension Capsular Ahmed an FCIdistributor US Morcher, (CTS, to fixation scleral with Ophthalmics) someIn capsule. intact the stabilize mayCTSs three even or two cases, minimize trapping of cortical materialcortical of trapping minimize whichequator, capsular the around withremove to difficult be then can aspiration. and irrigation anthrough entirety its in nucleus disassembly with a slow and deliberateand slow a with disassembly carefulbeing technique, chopping remainingthe on stress minimize to ringtension capsular A zonules. areaslocalized stabilize to help might toprefer I but weakness, zonular of topossible as late as device the insert laser to create a capsulotomy centeredcapsulotomy a create to laser nuclearperform to and lens the on capsularemploy would I fragmentation. lens-capsulethe center help to hooks centrationits maintain and complex nuclearperform would I stability. and safely removed via an anterior approach. anterior an via removed safely on available colleagues retina Having idea. good a be would standby overallthe determine ultimately will anterioran through case this of success femtoseconda use would I approach. surgery with a team of retina doctors will doctors retina of team a with surgery becannot cataract the if necessary be CATARACT & REFRACTIVE SURGERY TODAY

CATARACT SURGERY CATARACT 28 s