Cataract Surgical Problem: May consultation #1

Abstract

Figure 1. Mydriasis shows a sulcus-fixated IOL with 2-hole PMMA optic and polypropylene loops fixated in the sulcus. The iris exhibits a basal coloboma at 12 o'clock, giving visual access to the anterior capsule rim sealed to the posterior capsule. The IOL optic is decentered inferiorly and slightly tilted but definitely shows a positive distance to the pupillary margin with the pupil undilated. A 79-year-old woman had cataract surgery with intraocular lens (IOL) implantation in the left eye in 1990. A 3-piece IOL with a poly(methyl methacrylate) (PMMA) optic with positioning holes and polypropylene loops was fixated in the ciliary sulcus. In 1993, the right eye also had cataract surgery with implantation of a PMMA diffractive multifocal IOL. In 2013, 23 years after the first surgery, the patient started having repeated attacks of blurred vision and pain in the left eye, mostly after bowing her head. These symptoms subsided within several hours. When immediately consulting with the local ophthalmologist on 2 such occasions, a 3+ erythrocyte Tyndall phenomenon was found in the anterior chamber aqueous and trickle marks (traces) were found in the inferior sector of the cornea; the intraocular pressure (IOP) approached 60 mm Hg. The patient was treated with pressure-lowering eyedrops and acetazolamide tablets; by the following day, the condition of the eye had returned to normal. The attacks, however, recurred with increasing frequency. On 1 such occasion, 1 IOL loop was reported to be visible in the peripheral coloboma at 12 o’clock; however, this was not the case when the patient returned later. When these attacks persisted, the patient was finally referred to an anterior segment specialist. When the patient first presented, the pupil in the left eye was small, the IOL optic was at a distinct distance to the pupillary margin, and no IOL loop was visible in the slit-shaped peripheral coloboma. The refraction was 1.50 +1.25 175 in the right eye and 1.50 +0.50 5 in the left eye. The decimal corrected distance visual acuity (CDVA) was 0.8 and 0.9, respectively. Both central capsules where clear, the retina and macula were normal, and the optic nerve head was vital and centrally excavated with a cup-to-disc ratio of 0.4 in the right eye and 0.3 in the left eye. On full pupil dilation, a 3-piece IOL with a PMMA optic with positioning holes and polypropylene loops was exposed in the left eye (Figure 1). The loops were fixated in the ciliary sulcus, and the slightly tilted optic was decentered inferiorly. The aqueous was clear, and the IOPwas 17mmHg. No change in haptic position or IOL rotation could be induced by gently massaging the limbus with a cotton swab under topical anesthesia. The patient was asked to immediately return if the symptoms recurred. Ten days later, she presented 2 hours after another attack. The biomicroscopic findings in the left eye were as described above, and the