Figure 2. Topography of the lefteye. Paracentral cornea thinned (up-per left: corneal thickness; lower left:anterior float. Insert: posterior float);irregular corneal surface with radii(right).

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the damaged structures between 8 o’clock and11 o’clock, prevent vitreous loss, and keep the pupildilated during continuous curvilinear capsulorhexis(CCC). If the pupil were not dilated enough, I woulduse 3 iris hooks inserted at 1 o’clock, 4 o’clock, and6 o’clock. I would prefer standard iris hooks to aMalyugin ring because of the damaged iris near9 o’clock.

After the pupil is well dilated, I would create a 4.0 to5.0mmdiameter CCCwith a forceps on the intact tem-poral side of the capsule. After gentle and slow hydro-dissection, I would gently rotate the nucleus in thecapsule and perform phacoemulsification using achop or crack technique. I would use a slow-motionmethod and keep the infusion bottle low to prevent ex-cessive tension on the capsule and zonules. After aspi-ration of the cortex using coaxial or biaxial irrigation/aspiration (I/A) instrumentation, a capsular tensionring (CTR) could be implanted, if necessary, followedby implantation of a hydrophobic acrylic foldable pos-terior chamber intraocular lens (IOL). I would use anIOL that can be easily implanted in the bag in a foldedposition and would open gently and slowly.

I would not deal with the limbal corneal scar or withthe adjacent sector coloboma. I would also leave thepearl-shaped epithelial implantation cyst untouched

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because it may have been there for more than 35 yearswithout causing problems.

Zsolt Biro, MD, PhDPecs, Hungary

- This challenging high-risk case has a potentiallygood outcome given the documented reading vision,albeit with a hard contact lens. Preoperative counsel-ing is essential and should offer fairly low expecta-tions, despite the encouraging potential. A majorfactor that may limit uncorrected postoperative acuityis difficulty obtaining accurate biometry because of thebadly misshapen cornea with irregular astigmatism.

Risk factors (poor visibility, corneo-lenticular inclu-sion cyst, traumatic iris coloboma, zonular dialysiswith vitreous herniation, prolonged surgery withincreased risk for endophthalmitis, corneal decompen-sation) must be addressed with a clear surgical strat-egy, including availability of a donor cornea shoulda penetrating graft be needed.

I would favor a superonasal limbal incision at ap-proximately 110 degrees because it would provide bet-ter visibility of the phaco tip than a temporal approach,in which case the tip would be under the scar. If pupil

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dilation were poor, 3 iris hooks (subincisional, inferior,temporal) would help; a fourth hook might be neededfor symmetrical capsulorhexis support if the lens wereunstable.

After the incisions, I would perform triamcinolone-guided anterior vitrectomy to ensure prolapsed gel iscleared. I would remove the inclusion cyst at this stage.I would use trypan blue for capsule visualization be-cause of the capsule breach sustained during the perfo-rating trauma.Althoughold anterior capsule tears tendto be fairly stable, the challenge herewould be to obtainadequate visibility to tear the capsulorhexis outsideand around the preexisting defect. Because capsulo-rhexis creation will take much longer than normal, Iwould use a coaxial forceps through a matched side-port incision to ensure fine control of the tear and avoidcreeping chamber collapse from loss of the OVD.

If visibility were impossible and unacceptably risky,I would proceed to penetrating keratoplasty.

If it were possible to proceed, through a superiorstab incision, I would start the capsulorhexis at about7 o’clock by the temporal edge of the scar and tear itcounterclockwise up to 12 o’clock. I would thenmove temporally to tilt the eye nasally and obtaina better view under the scar. I would make a temporalstab incision to regrasp the flap close to the root of thetear to allow controlled completion of the last 90 de-grees of the capsulorhexis under the corneal scar.This may involve an ‘‘extrapolated guesstimate’’ ofthe course of the tear.

Complete hydrodissection with free nucleus rota-tion must be confirmed before the subcapsular spaceis expanded with OVD and a CTR injected (with lead-ing end toward defect) to buttress the weakened zon-ules. I would use the iris hooks as capsule anchors tosquare-off the capsulorhexis and stabilize the lens byanchoring it to the sclera. Phacoemulsification wouldbe by an extra-deep groove, stop-and-chop technique.

I would remove the hooks before IOL implantationto prevent them from tearing through the anterior cap-sule from downward pressure of the IOL on the sup-ported edge of the capsulorhexis.

Although a pupilloplasty would probably not behelpful other than for cosmesis because of the densecorneal scar covering the sectorial iris defect, if needed,a Siepser suture technique with a single stitch shouldsuffice.

Brian Little, FRCOphthLondon, United Kingdom

- This case presents many difficult problems. Firstare technical surgical issues related to the clinical prob-lem (brown cataract, zonular weakness, punctured

J CATARACT REFRACT SURG

capsule). Second is the treatment of the corneal scar ex-tending into the center with significant irregular astig-matism that had been effectively treated with a rigidgas-permeable contact lens.

Apparently, the patient has been satisfied with thevision in the left eye for 37 years. Unfortunately, wedo not know what level of vision the patient found ac-ceptable during this period; knowing this could helpset the goal for the proposed strategy.

Initially, I would propose restricting the treatmentstrategy to the least amount of surgical repair. I wouldperform phacoemulsificationwith 1 of the current newtechnologies to diminish endothelial damage as muchas possible. Based on the slitlamp photograph, it is dif-ficult to judge whether visualization will be sufficient.After a successful phaco procedure, scar formationand flattening of the corneawould require fitting a con-tact lens to restore vision to the level the patient wasused to. I would suggest a scleral contact lens fittingto increase comfort because this lens does not bearon the irregular corneal surface.

If phacoemulsification were not possible based onpreoperative judgment of corneal clarity or becauseof complications during surgery, a conversion tomore extensive surgery is needed. This would includecorneal transplantation, probably placement ofa scleral-fixated IOL, partial removal of the epithelialinclusion cyst, and iris and pupil reconstruction. Thismay result in a high level of postkeratoplasty astigma-tism due to the old corneoscleral perforation wound(see topography), in which case there would be aneed for contact lens fitting and a high risk for cornealdonor rejection/graft failure.

Finally, the quality of vision in this category of cor-neal graft patients depends on the vision in the nonop-erated eye, which in this case is excellent.

The key to treatment is to communicate the differentoptions and perspectives to the patient so she canmake a decision that fulfills her expectations and re-quires the least amount of surgery.

Rudy Nuijts, MD, PhDMaastricht, The Netherlands

- Because the length of surgery would be difficult topredict in this case, I would use general anesthesia andbegin as follows: approach from the 1 o’clock position;displace the conjunctiva; create a 11.0mm limbus-paral-lel scleral incision, a 2.0 mm scleral tunnel to the innerlimbus (without perforation), and 1.1 mm paracentesesat 10 o’clock and 3 o’clock; fill the anterior chamberwith air; instill methylene blue to stain the lens capsuleand rapidly aspirate it; instill medium-viscosity sodiumhyaluronate through the 3 o’clock paracentesis. (The

- VOL 36, APRIL 2010