Cataract surgical problem

Abstract

A 28-year-old man had cataract surgery with intraocular lens (IOL) implantation in both eyes 10 years earlier after prolonged systemic cortisone therapy. Surgery in the left eye was uneventful but was complicated in the right eye. The patient reports that uncorrected vision in the left eye is good but that it is significantly reduced in the right eye. He suffers from dysphotopsia and monocular diplopia (right eye) at night. The best corrected visual acuity (BCVA) is 20/20 -2 2 (Jaeger [J] 1) in the right eye and 20/20 (J1) in the left eye. Refraction is -5.25+3.25 x 175 and -0.25 +0.75 x 180, respectively, and the keratometric cylinder, +0.75@45 and +0.50@165, respectively. A slitlamp examination shows a capsular bag-fixated posterior chamber IOL and a posterior neodymium:YAG laser capsulotomy in the left eye. In the right eye, the pupil is slightly ovalized and the superior edge of the IOL optic is parallel to its superior margin (Figure 1). The optic appears to be significantly tilted. Mydriasis shows severe IOL decentration and tilt in the right eye. The anterior capsulorhexis, which is approximately 4.0 mm in diameter, is intact and fibrosed. The decentered optic exposes the superior portion of the capsulorhexis opening, with the superior edge of the optic, optic-haptic junction, and proximal part of 1 loop visible within the pupillary and capsulorhexis openings (Figure 2). The superior optic is significantly tilted anteriorly. The IOL is 1-piece poly(methyl methacrylate) (PMMA) with an optic that appears to be 7.0 mm and has a wide haptic spread. The horizontal corneal diameter is approximately 12.0 mm and the axial length, 23.5 mm. A corneal lip extending along the superior limbus between 10 o'clock and 2 o'clock suggests extracapsular extraction of the nucleus has been performed. The anterior vitreous body has been thoroughly removed by vitrectomy, with no vitreous strands left behind. The peripheral retina is normal. Intraocular pressure (IOP) without medication is 12 mm Hg in both eyes. Given the patient's young age; large anterior segment; uncertain status of the zonules, especially along the inferior circumference; and that the large 7.0 mm PMMA IOL optic cannot be removed through a small incision by folding and would be difficult to cut, what would be your surgical approach?