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Inside Eyetube.net | Jun 2012

The Prodigal Haptic

Successful patient outcomes may require more than routine surgery.

Certain complications of cataract surgery may only manifest at a later stage, requiring detailed exploration of the patient’s symptoms and clinical signs. This article presents the case of a woman who underwent apparently uneventful cataract surgery, but, despite achieving a good visual outcome, experienced repeated bouts of anterior uveitis in the months following her operation.

EXPLORATION

The patient had a history of retinitis pigmentosa but retained good central visual acuity of 6/9 (20/30) in both eyes. Careful slit-lamp examination revealed iris thinning in the inferotemporal region, suggesting a possible mechanical etiology for the uveitis due to iris chafing. After discussing treatment options with the patient, exploration was pursued.

We prefer a bimanual approach using coaxial 23-gauge forceps to facilitate both access and manipulation. Initial exploration revealed an IOL within the capsular bag, although one haptic appeared to lie within the ciliary sulcus (Figure 1). The option to excise this haptic and leave the IOL and the remaining haptic within the bag, as was performed in a previous case (Figure 2), was considered. We decided to attempt to reposition this prodigal haptic.

As with any surgical procedure, the primary aim is to achieve exposure to allow adequate access to the surgical site. In this case, we used a Malyugin Ring (MicroSurgical Technology), which functions as a good tool in providing both iris support and pupil enlargement to gain access to the retroirideal plane (Figure 3A). The lens-bag complex was then carefully examined to highlight the perceived problems (Figure 3B).

TECHNIQUE

Our first step was to free the anterior capsule, again using a bimanual approach and two coaxial 23-gauge forceps. While attempting to remove the prodigal haptic from the ciliary sulcus, we noted that it was entangled with some of the remaining zonular support and weakening of the bag was observed. To reduce IOL movement, and thereby minimize further zonular damage, one set of forceps was used to stabilize the capsular bag while the other was used to bring the haptic back into the bag. With careful manipulation, the haptic was successfully released from the zonules (Figure 4), allowing it to be correctly positioned within the bag. The IOL position was deemed satisfactory (Figure 5), and the Malyugin Ring was then removed using its insertion-removal device. For a video demonstration of the procedure, visit eyetube.net/?v=gubuw.

With more than 6 months’ follow-up, the patient remains asymptomatic with no further episodes of uveitis or other complications.

CONCLUSION

This case highlights a number of factors in the management of postoperative cataract surgery complications. First, what is perceived as a completely routine case may present with unexpected problems for the patient, requiring review of the history followed by careful examination. If a reversible cause requiring a surgical approach is found, a thorough discussion must take place with the patient regarding the proposed plan and possible outcomes of the operation. During surgery, good exposure and visualization are key factors, and a variety of tools such as the Malyugin Ring can help in this regard. After careful evaluation of the problem, a bimanual approach using 23-gauge forceps can be helpful to provide stability and dexterity within the anterior segment. Finally, during any manipulation of the IOL-bag complex, careful attention must be paid to minimize any trauma to the zonular support.

In summary, a careful plan, incorporating different approaches to the problem combined with optimum use of current advanced surgical tools, affords the surgeon the best chance of giving the patient an excellent outcome.

Ahsen Hussain, MBChB, FRCOphth, is a Senior Registrar in Ophthalmology within the Mersey Deanery, currently at the Wirral University Teaching Hospital NHS Foundation Trust. Dr. Hussain states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: ahsen@doctors.org.uk.

Som Prasad, FRCS, FRCOphth, is a Consultant Ophthalmologist at the Wirral University Teaching Hospital NHS Foundation Trust & Spire Murrayfield Hospital. He states that he is a consultant to Bausch + Lomb (UK) but has no financial interest relevant to the products or companies discussed in this article. He may be reached at tel: +44 151 6047193; fax: +44 151 9098091; e-mail: sprasad@rcsed.ac.uk.

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