CASE PRESENTATION
An 88-year-old white male farmer suffered a concussive injury to his right eye when an air hose blew off its machinery attachment. The injury occurred 4 months prior to presentation, during which time the patient experienced progressively decreasing vision. His best-corrected visual acuity (BCVA) in the damaged eye was 20/200. The cornea was clear, however there was a fixed 5.5-mm iridoplegia. There was 4+ brunescent nuclear sclerosis and a 4+ posterior subcapsular cataract present (Figure 1). Pressures were normal in both eyes, and they did not show any reverse relative afferent pupillary defect. The BCVA of the fellow eye measured 20/50, with 3+ brunescent nuclear sclerosis and an otherwise normal examination.
1. What are the patient's options for visual rehabilitation?
2. Would you plan phacoemulsification, and if so, how?
3. Where would you place the incision?
4. What IOL would you choose, and why?
SURGICAL COURSE
I scheduled the surgery after an extended wait for FDA permission on a compassionate basis to utilize the Morcher Cionni endocapsular tension ring. I achieved anesthesia and akinesia via a peribulbar injection with Marcaine®, lidocaine, and Wydase® (Wyeth-Ayerst Laboratories', Radnor, PA), and I made a clear corneal self-sealing incision at 11 o'clock to avoid working over broken zonules. To push back vitreous and to help compartmentalize the open zonular area, I injected Viscoat® (Alcon Surgical, Fort Worth, TX) under the endothelium using Healon®5 as the inferior component of the soft-shell technique. I superiorly decentered a continuous curvilinear capsulorhexis to approximate a central opening when the bag would be repositioned later in the case. I created a potential space under the inferior and temporal capsule with Viscoat®, and made two stab incisions in the clear cornea that transected the perimeter of zonulysis, permitting the placement of the Mackool lens suspension hooks. I then carefully freed the nucleus within the bag using three-point hydrodissection. I used my usual vertical chop technique (Figure 2) with high flow and vacuum parameters, and burst mode to remove the brunescent nucleus. I took care to leave the epinucleus in place until the last nuclear fragment was removed. I instilled more Viscoat® through the paracentesis prior to removing the phaco handpiece to prevent the anterior chamber from collapsing and any egress of vitreous. Nevertheless, when I checked the incision with a cellulose sponge, there was a small strand of vitreous present coming around the zonules at 9 o'clock. I cut this at the scleral surface, swept it to the interior with a cyclodialysis spatula through the paracentesis, and pushed it back to the level of the zonules with Viscoat®. Rather than using automated irrigation and aspiration, I decided to remove the remaining cortex with a “dry technique” (aspiration only under viscoelastic), so as not to further hydrate the vitreous or encourage prolapse. There was minimal unpolishable fibrosis of the posterior capsule, and pigment on the anterior hyaloid face.
I selected a site for the sutured eyelet of the Cionni endocapsular ring that was inferotemporal to approximately bisect the area of zonulolysis. I raised a fornix-based conjunctival flap, and applied light cautery with the eraser tip that helped to mark the two points 1 mm posterior to the limbus of the intended entrance and exit of the suture. I inspected the Cionni ring and passed a 10-0 prolene double-armed suture through the eyelet. The eyelet is designed to come off the tension ring in a plane anterior and central to the ring, allowing it to be placed above the anterior capsule while the ring is inside the bag. I placed it with a two- handed technique into the bag to leave the eyelet in the ideal position. An Osher “Y” hook fits through the paracentesis to aid the placement of the ring. I removed the Mackool hooks by slipping the stopper off the shaft and guiding the hooks out the main incision. Next, I bent a 25-gauge injection needle with bevel up to fit the orbit, and introduced it through the sclera at the marked point 1 mm posterior to the limbus between the anterior capsule and the iris, while introducing Viscoat® into the posterior chamber. Using my nondominant hand, I introduced the prolene needle through the clear corneal incision (without catching any fibers on the way through), threaded it into the syringe guide needle, and back out through the sclera. I then repeated this with the second needle. It should have been easy to pull up the two suture ends, taking care to guide the eyelet over the capsule and under the iris, and bring the capsular bag into a central and stable position. Unfortunately, as I drew the suture up, I found it had been inadvertently cut and thereby no longer continuously double-armed. It took a few uncomfortable minutes to recognize that it was possible to tie the cut ends to each other and then to externalize the superfluous knot. The goal is not to snug the eyelet to the wall of the eye, but rather to leave it in an ideal position with respect to centration of the bag and capsulorhexis. I rotated the knot under the sclera (which eliminated the need for a scleral flap), and closed the conjunctival flap.
I chose a one-piece acrylic, 6-mm optic implant (the SA60AT by Alcon Surgical) for its excellent centration qualities and the unique memory of the haptics. Despite the iridoplegia, it was easy to center the lens in the pupil and bag, and to cover the edges with the iris by instilling Miochol E® (CIBA Vision, Duluth, GA) and using mechanical massage. I removed the remaining viscoelastic with a vitrector using an irrigation/aspiration/cut mode.
Because this was a prolonged case with an open vitreous face, I prescribed a one-time oral prophylactic dose of Levoquin 500 mg, as well as topical prophylaxis. I also administered a carbonic anhydrase inhibitor along with timolol and Alphagan® in the immediate postoperative period.OUTCOME
On the first postoperative day, the patient reported having had a comfortable night. His BCVA was 20/60. There was a trace of Descemet's folds, and the chamber was deep with 1-2+ cells. The IOL was centered and the edges were just covered by the 5-mm pupil. All incisions were Seidel negative, and the IOP was 16 mm Hg. The conjunctival flap covered the suture site. The posterior capsule had 20/40 fibrosis and pigment. The ring and eyelet were not visible, and there was no pseudophacodonesis noted. The posterior segment exam was entirely normal. At the first postoperative week, the patient's UCVA measured 20/40 and refracted to 20/30 with a pressure of 15 mm Hg on Alphagan® alone. The pupil covered all edges of the IOL and the eye was quiet and comfortable. I will use scleral depression at the 1-month postoperative visit to evaluate the periphery, and expect an uneventful, long-term course, with a likely YAG capsulotomy for optimal vision.
