This week I am pulling out a case from about 7 years back.
An 18 year old man presented with traumatic iridodialysis and underlying zonular dialysis with cataract (Fig. 1).
The patient was planned for iridodialysis repair along with phacoemulsification and IOL implantation. The cataract was removed without much difficulty. Subsequently, iris was repaired using prolene suture as shown in the video. A 3-piece foldable IOL was placed in the sulcus, without any bag fixation (remember, this is circa 2006). The IOL appeared quite stable on the table, and even sustained the pressure of viscoelastic removal without getting decentered.
Post operatively, the iris repair showed good outcome with only a mild distortion of the pupil. However, the IOL subluxated soon after.This was then treated with IOL explanation and scleral fixation of a PMMA IOL. Finally, the patient had a good overall outcome with a well centered IOL, adequately covered iris defect and BCVA improving to 6/6 (-0.5 DS) (Fig. 2) .
An 18 year old man presented with traumatic iridodialysis and underlying zonular dialysis with cataract (Fig. 1).
The patient was planned for iridodialysis repair along with phacoemulsification and IOL implantation. The cataract was removed without much difficulty. Subsequently, iris was repaired using prolene suture as shown in the video. A 3-piece foldable IOL was placed in the sulcus, without any bag fixation (remember, this is circa 2006). The IOL appeared quite stable on the table, and even sustained the pressure of viscoelastic removal without getting decentered.
Post operatively, the iris repair showed good outcome with only a mild distortion of the pupil. However, the IOL subluxated soon after.This was then treated with IOL explanation and scleral fixation of a PMMA IOL. Finally, the patient had a good overall outcome with a well centered IOL, adequately covered iris defect and BCVA improving to 6/6 (-0.5 DS) (Fig. 2) .
What I learnt from this Case
In cases with zonular dialysis >90 degrees, sulcus placement of IOL might appear stable on the table, but may not hold during the post operative period. These cases require some type of capsular bag/IOL fixation.
Thanx Dr Tushar sharing complicated case and its management along with a very nice conclusion !
ReplyDeleteif u dont mind pls take trouble to adrees and clrify the following points.
1.Was it not possible to manage zonular dialysis by implanting CTR before putting PCIOL during the initial procedure?
2. Is it not safe to repair the Iris dialysis either before doing catarct surgery or after implanting the iol just to be safe side for unintentional damage to Post.Capsule during passage of needle?
3. Was it not possible to use the SAME 3 piece IOL for Scleral fixation as it would only need to externalise the haptics ......and perhaps wont need to have any larger fresh incision for explantation and Re implantation......and probably will save time as well.
4.Do u have any experience with Hoffman technique for scleral fixation pciol.
Dr Saif
Jeddah
KSA
Saif Khan Thanks for the comments. 1.Initial plan for this case was to remove the cataract and repair the iridodialysis as a first stage procedure and then go for IOL implantation as a secondary procedure as this was my first case of iris repair. The decision to implant the IOL was taken after the iris repair. 2. Having a done many iris repairs since, in my opinion, it is best undertaken after removal of cataract as it allows for the capsule to be pushed back with healon. 3. You are right, the same IOL can be refixed with a lasso suture but I did not know about this technique back then (around 2006) 4. I have used the Hoffman technique for both SFIOL and iris repair. It saves you from making a conjunctival peritomy. However, I find that creation of a reverse scleral pocket is quite tricky. Hope this answers the questions and thanks again for the comments. I hope you view this in light of the fact that this was my first case of this kind. I will share a more recent case this week of a similar nature. It addresses most of the shortcomings.