Fun with trauma repair

Fun with traumatic repair

Ok, so it's been a while since I (John) posted some cool ophthalmology cases. For those that don't like eye ball pictures, I promise these aren't too bad....

1. A 24-year-old male reported decreased vision in the right eye for 2 years. After some questioning he admited that the eye had been struck by a soccer ball, and that is when the decrease in vision began. His vision was found to be hand motions olny. The pupil was irregular, and appeared to have a traumatic iris coloboma. There was no afferent pupillary defect and a sonagraphy (B-Scan) was done showing a normal appearing retina and optic nerve. IOP was normal. *Disclaimer, this photo is not my actual patient but, you get the idea

 

I was very concerned about potential zonular pathology in the area of iris defect, but agreed to attempt a surgical correction. I spent more time than usual pre-operatively explaining that the vision result of surgery may not be good.

At the start of surgery I was pleasantly surprised to find the lens stable and no obvious zonular loss. I was able to complete a linear capsulotomy ( was worried about CCC causing troubles here and still worried about long term zonular stability for in the bag placement of IOL).

For the lens implant I placed a 1 piece PMMA lens with haptics in sulcus and optic beneath linear flaps of capsule.

I then turned attention to the iris coloboma. It had been a few years since I performed iris suturing, but figured this was a great case to get some practice. I only had one error, the first pass I attempted with the long CIF-4 needle was completely wrong, and had to redo it. However, the second pass was much better, and I tied it with a McCannell knot. Couldn't quite remember the siepser slip knot. The result is shown below at 1 week. The vision result was a pleasant surprise, 20/40 un-corrected, resulting in happy patient and even happier doctor. 

 

2. A 32-year-old man had been involved in a motorcycle accident one day before coming to the clinic. The only injury he suffered was to the left eye. Vision was perception of light, no APD. He had a corneal laceration and traumatic cataract, (This picture is actually from a different patient, but very similar presentation)

I performed urgent surgical repair. During surgery it became apparent that the posterior capsule had been violated from the perforation. I performed a lensectomy, vitrectomy and sutured the corneal wound. I left him aphakic. Fortunately, the eye did well post repair, as shown. 

 

With a +10.00 lens he was seeing 6/36 in our clinic. The problem was his other eye is a perfect 6/5 and the imbalance prevented glasses correction. You eye people out there may be wondering about contact lens correction, but frankly it doesn't exist in Angola. So my options were leave him afakic (he declined this), anterior chamber lens (surgeon was hesitant for this because ascan showed a 22D lens would be best and I only have 19D ACIOL) or iris sutured lens. All of these options have pluses and minuses. I elected to place an iris sutured IOL. I think it was a good enough option for him and plus I was really wanting a case to practice this technique on. Surgery went well, only had a little trouble positioning the lens with haptics behind iris with optic capture anteriorly. I used a monarch injector to place a 3 piece MA60-AC acrylic lens (which I now have with our phaco supplies).

Here is his appearance at one week. Vision has improved to 20/60, which I am pleasantly surprised with, given the cornea scar and astigmatism. 

 

Please, for any anterior segment surgeons who may be reading, send me your comments, tips or other feedback.

Acknowledgments: Thank you for showing me the technique Dr Pineda and a big thanks to Dr Croasdale for supplies.

John