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The interesting case challenge: What would you do?
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A 71-year-old man is seeing you for a second opinion after cataract surgery on his right eye 6 months ago. The case was complicated, and he had an anterior vitrectomy with placement of the IOL in the sulcus. He has recovered a best corrected visual acuity of 20/25 and is generally happy with his vision. What is bothering him is the constant inflammation of the eye, for which he has been using topical steroids for months.
 Retroillumination reveals the iris defects. |
Examination reveals a pressure of 24 mm Hg in the right eye and 19 mm Hg in the left eye. Slit-lamp exam of the right eye shows a temporal clear corneal incision, a sub-incisional iris defect and loss of iris pigment nasally. There is a single-piece monofocal acrylic IOL in the ciliary sulcus, oriented at the 3-to-9 o'clock meridian. There are 2+ cells/flare and pigment dusting across the anterior segment. The exam of the left eye shows a 2+ nuclear cataract, giving a BCVA of 20/50 in that eye. The optic nerve and retina of both eyes appear normal.
What is your next move?
A. Continue medical treatment with topical steroids in the right eye and add an IOP-lowering medicine for the right eye.
B. Do cataract surgery of the left eye, being careful not to break the posterior capsule.
C. Do an IOL exchange of the right eye and put a three-piece IOL in the sulcus with optic capture behind the capsulorrhexis.
D. Switch to a different medicine to control the inflammation, such as an NSAID, which may help to alleviate the IOP rise in the right eye.