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End-of-the-year wrap-up
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It's hard to believe that 2009 is coming to an end. Of the thousands of patients that we see and help each year, there are always a few who are particularly memorable. Since this blog focuses on ocular surgery, I have presented patients with surgical challenges over the course of the last year. I'd like to give you a wrap-up of the surgical decisions, the patient outcomes and the lessons learned.
 Neovascular glaucoma, hyphema and dense cataract. |
This patient with severe neovascular glaucoma and a dense cataract underwent a repeat injection of Avastin (bevacizumab, Genentech), with little effect. The suggestions to do transscleral cryoablation of the retina (since there was no view for panretinal photocoagulation) were excellent. We proceeded to take the patient to the operating room for a combined procedure. The cataract was removed, and while the patient was aphakic, intraoperative indirect panretinal photocoagulation was performed by a retina colleague. The lens implant was inserted in the capsular bag and then an Ahmed glaucoma valve was placed. The patient had a great anatomic result, but with the extensive diabetic retinopathy, her visual prognosis is still guarded.
 A traumatic cataract and iris defect caused by a penetrating corneal injury. |
This patient with a ruptured globe and traumatic cataract did well. The white cataract was removed using 25-gauge instrumentation, trypan blue dye and irrigation/aspiration. A three-piece monofocal IOL was implanted securely, and the patient had improved vision. The visual acuity was limited by the irregular cornea.
 Extensive zonular loss after trauma. |
The patient with zonular loss and a traumatic cataract appeared to have 4 clock hours of absent zonules when examined preoperatively at the slit lamp. Intraoperatively, it turned out to be 6 clock hours.
The prolapsed vitreous was removed using a 25-gauge vit cutter. A capsular tension ring with an eyelet was implanted, along with a three-piece IOL. The ring was then sutured in place to ensure stability of the IOL. The patient had an excellent postoperative outcome.
 Iris capture with the haptic of a single-piece acrylic IOL. |
The patient with a displaced IOL and iris capture of the haptic was a relatively easy surgery. Using Dr. Garry Condon's technique of placing a 27-gauge needle on a syringe of viscoelastic, the anterior capsular rim was dissected away from the optic, and then, switching to a blunt 27-gauge canula, the capsular bag was opened and the IOL was repositioned within the bag. The IOL was rotated 90° so that it was in the meridian of the most support and capsulorrhexis coverage. The patient had an excellent postoperative outcome.
 Iris defect and aphakia. |
For this aphakic lady with no capsule and sectoral iris loss, I used Dr. Amar Agarwal's glued IOL technique with a three-piece lens. Scleral flaps were made and the haptics were inserted into intrascleral tunnels. I went for the belt-and-suspenders approach, and I sutured the haptics in place in addition to the tissue glue. The iris defect was partially closed using sutures, taking advantage of the ptosis to cover the superior defect. The patient is very happy with her resultant vision.
 Retroillumination reveals the iris defects. |
I agree with the reader comments regarding this malpositioned IOL: Single-piece acrylic IOLs do not belong in the sulcus. I removed this old lens and implanted a three-piece IOL in its place. The haptics were placed in the sulcus and the optic was captured behind the capsulorrhexis. I also cleaned up the prolapsed vitreous. The patient did great.
I'm sure that 2010 will bring even more interesting and challenging surgical cases. I look forward to presenting them to you here and I encourage your comments. Happy New Year.
Get more expert perspective from Dr. Devgan live at Hawaiian Eye 2010, to be held January 17-22, 2010 at the Grand Hyatt Kauai. Learn more at OSNHawaiianEye.com.