Eyeworld Daily News

EW SHOW DAILY 26 ASCRS Symposia Tuesday, April 21, 2015 surgery, decided to sclerally fixate a 3-piece silicone IOL (glued). However, on slit lamp exam postop, he found that part of the iris was behind the nasal edge of the optic. Massaging the eye and manip- ulating the haptic insertion point under the sclera did not correct the IOL's position. Unable to think of a solution and unwilling to put the patient back under the knife, Dr. Safran decided to think it through over a game of golf. He had bought a new golf bag and it was giving him problems; the bottom of the bag kept bumping against his leg. Adjusting the strap did not help—it repositioned the bag on his shoulder, but not in a way that kept the bottom from com- ing up and bumping against his leg. A possible solution to his case dawned on him. He called his pa- tient back to the clinic. At the slit lamp—after sterilizing the conjunctival surface with povi- done iodine and inserting a specu- lum—Dr. Safran lifted the scleral flap over the superior haptic insertion point. Instead of being parallel to the limbus, the superior haptic was angulated. Dr. Safran made another scleral tunnel, pulled the haptic out of the old tunnel and inserted it into the new one. The iris was free; the IOL was properly positioned. Dr. Safran derived a number of teaching points from this case: (1) 1-piece acrylic IOLs can still cause uveitis-glaucoma-hyphema (UGH) syndrome even when completely within the confines of the capsular bag; (2) zonular deficiency with phacodonesis/iridodonesis and a thin, diaphanous capsular bag may be associated with these cases; (3) the capsular bag may be eroded over the haptic; (4) IOL exchange can be curative; and (5) a glued, scleral-fix- ated IOL's optic may be repositioned at the slit lamp by manipulation of the haptics if needed. At the end of the symposium, this case earned Dr. Safran the audi- ence's vote for "Best Teaching Case," and he was awarded the coveted Golden Apple Award. EW Editors' note: The physicians have no financial interests related to their case presentations. by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer performed by Dr. Mackool—3 years prior to consultation with Dr. Safran —the patient started experiencing recurrent microhyphema. A slit lamp exam revealed a thin, diaphanous, shimmering cap- sular bag and iridodonesis. Intraoperatively, Dr. Safran found a thin capsule with some weakened zonules, the capsular bag probably having been eroded by the original 1-piece acrylic IOL's haptics. Dr. Safran explanted the IOL and, losing the capsular bag during T he "Complicated and Chal- lenging Cases in Cataract Surgery" video symposium on Monday made it clear that despite being one of the most advanced, well-defined, refined surgical procedures available today, challenging cases can still push our most cunning surgeons into coming up with surprising, innovative solutions. At the symposium, ASCRS mem- bers presented their challenging cases for discussion with a panel of experts. A 42-year-old patient was referred to Richard Mackool, MD, Astoria, N.Y. The patient had un- dergone cataract surgery 9 months prior and had a refractive surprise (+3.00–4.00 x 115). Dr. Mackool performed a refrac- tive lens exchange, trading the old IOL for a toric. Explanting the old IOL, Dr. Mackool could not free one of the haptics. He decided to amputate the haptic and leave it behind—not something that generally causes any problems, he said. However, during implantation of the new toric IOL, the IOL would not center due to the old haptic. Dr. Mackool's solution? A wedge resection at the base of the haptic to alter its angle. At the 9-month follow up, Dr. Mackool said the IOL remained perfectly positioned. The patient has had no visual complaints. Meanwhile, Steven G. Safran, MD, Lawrenceville, N.J., found himself dealing with one of Dr. Mackool's old cataract patients. It wasn't anything Dr. Mackool had done, Dr. Safran clarified, but about 7 years after the cataract surgery Innovative thinking solves challenging cases Richard S. Hoffman, MD, one of the moderators of the symposium, presents Dr. Safran with the Golden Apple Award.

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