CASE PRESENTATION
A 50-year-old white male presented to our office. He was a truck driver who had been struck in the right eye by a hooked rubber tie-down strap when adjusting a payload. Over the course of the first week after the injury, the patient had persistent, elevated intraocular pressures (IOPs) in the mid-30s, angle recession, traumatic mydriasis, iritis, and zonular dialysis with phacodonesis over the entire inferotemporal quadrant. Follow-up was sporadic, and 6 months after his injury, he returned to the clinic with 20/300 vision, an IOP of 50 mm Hg, traumatic cataract, and a superonasally subluxed lens. A vitreous strand was present in the inferotemporal quadrant of the anterior chamber. The optic nerve demonstrated cupping of 0.5, whereas it had been normal at the 1-month follow-up visit. Over the 6-month course, the patient had used numerous glaucoma medications with variable success. Currently, he was taking latanoprost, dorzolamide eyedrops, and acetazolamide, but had recently gone a number of weeks without using medication. With an IOP of 50 mm Hg, medical management of the glaucoma had clearly failed. Correcting for a 3 D myopic shift, the patient's BCVA was now 20/50. His commercial driver's license and livelihood were at stake.
1. How would you address the glaucoma?
2. How would you extract the subluxed lens?
3. Which type of implant lens would you use?
4. Does the presence of vitreous in the anterior chamber change your plan?
SURGICAL COURSE
The patient consented for combined phacotrabeculectomy with planned anterior vitrectomy. Because his zonules were torn inferotemporally and the capsular integrity was doubtful, I decided to use a capsular tension ring (DOMILENS GmbH, Stuttgart, Germany). I performed IOL calculations for both anterior and posterior chamber lenses, using the IOLMaster (Zeiss Humphrey Systems, Dublin, CA) and traditional A-scan technology with correlation to the unaffected eye.
We usually prefer to use topical anesthesia, and similar cases have been successfully performed with topical, subconjunctival, and intracameral lidocaine. However, the patient expressed a strong preference for local anesthesia, and given the complexity of the case, this seemed prudent; I administered a 2% lidocaine and .75% bupivicaine retrobulbar block.
To address the glaucoma, I performed a routine trabeculectomy superiorly, with mitomycin C, using a fornix-based conjunctival incision and a 4- X 3-mm scleral flap. I did not open the internal ostomy with the trabecular punch until I completed the cataract portion of the case. After I closed the bleb with 10–0 Vicryl (Ethicon, Piscataway, NY) in horizontal mattress fashion, a well-formed bleb was elevated at the conclusion of the case.
Extracting the subluxed lens was more challenging. I made a routine stab incision and a 3.2-mm clear corneal incision. As I entered the anterior segment, generous use of space-maintaining viscoelastic and delicate movements were required to avoid disturbing the tenuous zonules and visible vitreous strands. In order to apply minimal downward pressure on the subluxed lens, I used a classic cystitome to pierce the anterior capsule. I then performed the capsulorhexis in a halting fashion, opening each quadrant of rhexis with the Utrata forceps (Duckworth & Kent, St. Louis, MO). I introduced a Greishaber pupil hook (Alcon Laboratories, Fort Worth, TX) (Figure 1) through a peripheral clear corneal stab incision, hooking the lip of the capsulorhexis until four hooks stabilized the four quadrants of the capsule. I tightened the inferior and temporal hooks by sliding their discs along the hook shaft and moving the capsular bag into centration.
With the capsular bag suspended by the four iris hooks and the remaining 7 clock hours of zonules, I gently performed hydrodissection. Unequivocal hydrodissection, in which the nucleus is freely separated from the epinucleus, is imperative in cases of zonular insufficiency. Low power and low-flow phacoemulsification with the Neosonix hand piece (Alcon Laboratories) allowed removal of the lens without disrupting the capsular bag. Due to the known presence of vitreous, I carried out irrigation and aspiration steps with the anterior vitrector on rapid cutting speed.
Introducing a posterior chamber lens into an unstable capsule can result in decentration, lens dislocation, and haptic malpositioning. Use of a capsular tension ring can eliminate these complications, and for this patient, I selected a Morcher brand ring (Morcher GmbH [not currently approved by the US Food and Drug Administration]) with suture eyelet. I carefully dialed the ring into the bag, securing the eyelet by 10–0 Prolene (Alcon Laboratories) sutures that passed through the capsular bag and ciliary sulcus, exiting the sclera and tying securely 1 mm posterior to the limbus. I intentionally positioned the eyelet in order to secure the region of greatest capsular dehiscence.
Once I stabilized the capsular bag, introducing the gently unfolding Acrysof SA60 lens (Alcon Laboratories) was relatively easy, and I completed the cleanup with the anterior vitrector. No vitreous was present in the anterior chamber and no suture was required to close the clear corneal wounds. I used a 10–0 Vicryl suture to close the conjunctiva overlying the Prolene suture.
OUTCOME
On postoperative day 1, the patient's vision was 20/40 uncorrected, and the IOP was 42 mm Hg, releasing at the slit lamp to 30 mm Hg (Figure 2). On postoperative day 3, his vision remained 20/40 uncorrected and the pressure had normalized to 16 mm Hg. At 1-month follow-up, the patient's vision was in the 20/30 range, the pressure was 18 mm Hg, the lens was centered, and there was a large superior bleb.
