Cases That Have Stuck with Me

OCULAR TRAUMA s SEVERAL SURGEONS SHARE CASES THAT HAVE THE STORIES BEHIND THE CASES STUCK WITH ME THEY’LL NEVER FORGET BY ALLON BARSAM, MD, MA, FRCOPHTH; MARK KONTOS, MD; SOOSAN JACOB, MD, FRCS, DNB; MICHAEL E. SNYDER, MD; AND ELIZABETH YEU, MD ALLON BARSAM, MD, MA, FRCOPHTH Severe Blunt Trauma | A positive outcome for a patient who had been told that nothing could be done. A few years ago, I treated a SURGICAL PROCEDURE the stabilization of the IOL –capsular 41-year-old man who had suffered After the creation of the main bag complex. severe blunt trauma to one eye many incision, I injected an OVD to Phacoemulsification was carried years earlier. The patient experienced tamponade the anterior hyaloid out with low flow settings. I used a severe glare as a result of the trauma, membrane in the region of the zonular stop-and-chop technique to ensure such that he had to wear sunglasses defect. A cohesive OVD was then that minimal force was placed on whenever he was outdoors or even injected, and three iris hooks were the already weak zonular structures in a well-lit room. Also, his vision had placed to keep the iris back and to (Figure 2). Using a Simcoe cannula, decreased progressively since the prevent propagation of the iridodialysis I performed manual irrigation and incident because of the development of during phacoemulsification. aspiration of the epinuclear shell and a traumatic cataract. Doctors advised I used a double-pass technique to soft lens matter to ensure that the force the patient that nothing could remedy create the capsulorhexis, centered exerted on the contents of the capsular the glare and that treating the cataract on the capsular bag instead of the bag was gentle. The tension on the would be too difficult and risky. pupil to ensure optimum size and CTS was reduced slightly to facilitate Upon seeing another ophthalmologist, centration. I sought to preserve as the removal of the soft lens matter however, the patient was referred to my much of the anterior capsular rim under the device if required. The CTS practice. as possible to facilitate placement of was released, the bag was filled with a a capsular tension segment (CTS). I cohesive OVD, and a capsular tension CLINICAL FINDINGS injected an OVD to create a space ring was placed in the capsular bag. An examination found a moderately between the dense cataract and An 8-0 double-ended PTFE suture dense cataract, iridodialysis, and trauma the anterior lens capsule. A CTS was placed through the eyelet into to the sphincter of the iris (Figure 1). was dialed underneath the anterior the capsular tension segment and The crystalline lens was subluxated, capsule. Next, a central iris hook was docked into a 25-gauge needle. I used and the equator of the lens was almost reversed 180º and used to pull the micrograspers to facilitate the docking. bisecting the visual axis. central eyelet of the CTS and ensure The suture was passed through the Figure 1. Traumatic cataract, iridodialysis, and trauma to Figure 2. Phacoemulsification was performed with low Figure 3. A one-piece aspheric IOL was placed. Figures 1-5 courtesy of Allon Barsam, MD, MA, FCROphth the iris sphincter. flow settings using a stop-and-chop technique to limit the force exerted on the weakened zonular structures. MAY 2020 | CATARACT & REFRACTIVE SURGERY TODAY EUROPE 27 s OCULAR TRAUMA Figure 4. Iridodialysis visible after iris hooks have been removed and OVD aspirated. Figure 5. One month after surgery, the IOL is well centered (left and right). bed of the scleral flap. The needle was (Miochol-E, Bausch + Lomb) into the complaint was a feeling of imbalance straightened, and a second pass was anterior chamber, dispersed it, and because of the refractive error of -3.00 D carried out adjacent to the central placed a cohesive OVD. in the contralateral eye. eyelet. The suture loops were then Next, I passed a 10-0 double-ended I performed LASIK on that pulled into the eye, and the CTS polypropylene suture through the eye to achieve emmetropia. After was directed into the capsular bag. iris roots using the micrograspers refractive surgery, UCVA was 20/10, I applied tension to centralize the for counter traction and a hand- and the patient was extremely capsular bag. I then used a slipknot to over-hand technique between the satisfied. allow tension to be titrated later on. micrograspers and the needle holders. s After implanting a one-piece I then pulled the suture inside the eye WATCH IT NOW aspheric IOL manufactured by and directed tension to reapproximate Rayner in the capsular bag (Figure 3), the iris root with the scleral wall. The I increased pressure on the CTS case concluded without incident. to ensure the centration of the IOL–capsular bag complex. OUTCOME I removed the iris hooks and One month after surgery, the IOL aspirated the OVD, revealing was well centered, and the patient the extent of the iridodialysis reported a resolution of glare symptoms (Figure 4). I then injected acetylcholine (Figure 5). UCVA was 20/16. His only BIT.LY/BARSAM0520 MARK KONTOS, MD The Psychological Toll of Ocular Trauma | A pellet gun injury changed the course of a young boy’s life. Managing patients with ocular accidentally shot with a pellet gun in did not result in a happy ending for the trauma is a pretty common occurrence the left eye at close range by his best young man. for most ophthalmologists. Most friend (a member of a prominent Initially, things seemed to go well, patients fade into the background of family in our community). It was clear and he seemed to be adjusting to the our memory. Some don’t though. Some on examination that the injury was new situation. One day, however, his we remember vividly. This case is one of severe and that the eye would not likely mom took me aside and said he was those to remember. recover useful vision. As I was talking to struggling in school and had become The injury itself was not so unusual, the mother, who was visibly distraught, socially withdrawn. Before the injury, a pellet gun shot to the eye of a I realized we were acquainted. She he was a smart, outgoing kid who was 12-year-old boy. It was the aftermath was a single mother who worked at very athletic and had been very popular and the consequences of the injury our country club. After several heroic in school. After the event, the injury for him that have stayed with me over attempts to save the eye by me, our resulted in a subsequent lawsuit that the years. cornea surgeon, and our retina surgeon, caused him to lose his best friend and I was called to the emergency room the eye was eventually removed, and a many of their common friends. He on a summer afternoon to see an prosthesis was placed with very good was no longer able to play organized eye injury to a boy who had been cosmetic results. Unfortunately, this sports because of his eye injury and 28 CATARACT & REFRACTIVE SURGERY TODAY EUROPE | MAY 2020 OCULAR TRAUMA s the associated loss of binocularity. His Over the next couple of years, he Oregon. She lost all contact with him dreams of playing football in high school seemed to be managing as well as could and had become very depressed over and being in the military had vanished. be expected, and I was no longer in close the situation. I too, was saddened by I started to notice the changes over contact with his family. His mother had the course his life was taking. time as well and felt he was at risk for left her job at the club, and I was seeing It was hard not to think that the depression and its consequences. He did him only for yearly examinations. When trajectory of his life would have been not have a father figure in his life, so I he missed an appointment, I contacted much different had that pellet just tried to do what I could to help without his mother. Unfortunately, the news grazed his face instead of doing the being too intrusive. I was able to get one was not good. He had dropped damage it did to his eye. He was a of the professional golfers at the club out of school and had developed a happy, well-adjusted young man with a to help, and we got the boy involved in significant drug addiction. After several life full of possibilities. That all changed golfing and the snowboarding camp at unsuccessful rehabilitation attempts, the day he lost his eye. And I remember our ski mountain. he left home and moved to Portland, it like it was yesterday. SOOSAN JACOB, MS, FRCS, DNB Traumatic Subluxated In–the-Bag IOL | Managing a complex case using the Jacob Paperclip Capsule Stabilizer. An interesting case that has stuck with me over the years is postoperatively. Intraoperatively, if required, capsular bag that of a middle-aged man who presented after sustaining ocular support can be increased by the translimbal placement of trauma from a shuttlecock while playing badminton. The patient capsular hooks that are removed after IOL implantation. had undergone cataract surgery a few years earlier. On examina- After first using this technique in this patient, I designed a tion, he had zonulodialysis and a subluxated in-the-bag IOL. modified version of the capsular hook: the Jacob Paperclip The traditional choice of treatment for this patient would Capsule Stabilizer (Morcher; Figure 6).

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