ANAT GALOR, MD, MSPH

The first issue to consider is the patient's visual prognosis. Although the timing of the accident (age 8) is generally considered to be outside the window of amblyopia development, the possibility of visual limitations due to amblyopia should be considered. Furthermore, given the nature of the trauma, there is a possibility of visual limitation due to unidentified ocular damage (eg, macular scar or optic nerve atrophy).

If the patient remains interested in pursuing visual rehabilitation despite the guarded visual prognosis, the next issue becomes the surgical approach. Options for management include removal of the cataract followed by rehabilitation with a contact lens or combined cataract and corneal surgery. Because the central visual axis is clear, my preference would be to remove the cataract with the assistance of iris hooks, capsular staining, and a capsular support device (if needed due to zonular dialysis), followed by the placement of a single-piece acrylic lens in the bag or a three-piece lens in the sulcus, depending on the ocular anatomy. Given the potential compromise of the zonules and other ocular structures, I would discuss this case with a retinal surgeon and have backup available in case anatomical abnormalities precluded safe anterior segment removal of the cataract. Considering the steep keratometry measurements, the patient might benefit from a scleral lens or keratoconic design (eg, Rose K [Menicon Company Ltd.]) if a traditional hard contact lens does not fit well. If he is unable to tolerate a contact lens, however, a full-thickness penetrating keratoplasty could be performed at a later date.

ARUORIWO M. OBOH-WEILKE, MD

When approaching this patient, it would be important to counsel him preoperatively about the uncertainty of his final visual outcome and to explain that more than one surgery might be required. An ocular injury occurring at age 8 may cause some degree of amblyopia. The dense corneal scar has resulted in significant irregular astigmatism, rendering standard keratometry unreliable. In my experience, it is helpful to look at the results of different videokeratography systems like the Pentacam Comprehensive Eye Scanner (Oculus Optikgeräte GmbH) and the Orbscan (Bausch + Lomb). Also, in challenging cases like this one, I run the power calculations through different IOL formulas until I arrive at a consistent result.

The next challenge is to obtain a reliable axial length. Going back to a manual A-scan might be necessary. If a consistent IOL estimation could be achieved with the methods mentioned earlier, an IOL could be placed at the time of the initial cataract surgery, and the astigmatism could be addressed by a trial of an RGP lens. I would use the lowest keratometry readings and aim for mild myopia. If there were an undesirable refractive outcome, the patient's refractive needs could be evaluated with the use of contact lens overrefraction. An IOL exchange, potentially with the off-label use of a toric IOL, could be considered.

In terms of planning, I would not consider a penetrating keratoplasty as a first-line option. Of course, these cases present intraoperative challenges as well, and surgeons have to use all the tools in the bag, including pupil expanders, trypan blue, and lysis of synechiae. The surgeon must be prepared to perform suture fixation of the IOL if he or she encounters loose zonules. For this type of patient, there may be a role for intraoperative wavefront aberrometry to aid in IOL selection, but I have no data on how tolerant the method is of irregular corneal scars.

MARIA A. WOODWARD, MD

Given the history and clinical picture, some additional information would be helpful prior to surgical intervention. An evaluation for sensory strabismus should be noted; if present, possible postoperative diplopia should be discussed. Potential acuity meter testing and an RGP contact lens overrefraction should be considered, but they likely will not be helpful because of the cataract opacity. Red cap color testing would determine how well the cone photoreceptors are functioning. Dynamic anterior segment ultrasound might help determine the stability of the lens-capsular bag complex.

After these tests, I would have a conversation with the patient regarding his options and prognosis. The alternatives are cataract surgery alone or combined with corneal transplantation. In the former scenario, an RGP contact lens fitting for corneal astigmatism will be necessary postoperatively. If the potential for good visual outcomes is guarded, avoiding corneal transplantation may be preferable. Combined surgery, however, would address all of the anterior segment problems in one surgical intervention.

In terms of surgical technique, the extent of the iridocorneal adhesions should be determined. With focal adhesions at the pupillary margin, cataract surgery alone is possible with synechiolysis at the time of surgery. With extensive iridocorneal adhesions, corneal transplantation is preferable. For cataract removal, iris hooks and staining of the anterior capsular bag will be necessary. A can-opener capsulotomy (vs continuous capsulorhexis) is likely preferable if there is anterior capsular fibrosis or if the lens is dense. Overall, the patient has a good prognosis for visual recovery.

Section Editor Bonnie A. Henderson, MD, is a partner in Ophthalmic Consultants of Boston and an assistant clinical professor at Harvard Medical School. Dr. Henderson may be reached at (781) 487-2200, ext. 3321; bahenderson@eyeboston.com.

Section Editor Thomas A. Oetting, MS, MD, is a clinical professor at the University of Iowa in Iowa City.

Section Editor Tal Raviv, MD, is an attending cornea and refractive surgeon at the New York Eye and Ear Infirmary and an assistant professor of ophthalmology at New York Medical College in Valhalla.

Anat Galor, MD, MSPH, is a staff physician at Miami VAMC and an assistant professor of clinical ophthalmology at Bascom Palmer Eye Institute, University of Miami. She acknowledged no financial interest in the product or company she mentioned. Dr. Galor may be reached at (305) 575-7000, ext. 4178; agalor@med.miami.edu.

Aruoriwo M. Oboh-Weilke, MD, is an assistant professor of ophthalmology at Georgetown University in Washington, DC. She acknowledged no financial interest in the products or companies she mentioned. Dr. Oboh-Weilke may be reached at (202) 444-2745; dr-oboh@dr-oboh.com.

Maria A. Woodward, MD, is a lecturer, ophthalmology and visual science, at the Kellogg Eye Center of the University of Michigan in Ann Arbor. Dr. Woodward may be reached at (734) 763-5506; mariawoo@med.umich.edu.