March 2018

CATARACT

Presentation spotlight
MFIOL implantation in a traumatic eye


by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer


Anterior capsular tear, cataract

Well-centered multifocal IOL 1 day postop
Source: Anca Tomi, MD

 

Taking the right steps in managing a traumatic eye injury can make all the difference in restoring good vision

Eye trauma can be hard to handle, with many moving parts that require the ophthalmologist’s close attention. In a case presentation shown as an e-poster at the XXXV Congress of the ESCRS, visual acuity was restored through careful handling of the damaged tissues and implantation of a multifocal IOL following a perforating eye injury involving an intraocular foreign body with resultant traumatic cataract. The author of the poster, Anca Tomi, MD, Emergency Eye Hospital, Bucharest, Romania, discussed her thought process in treating the traumatic, perforated eye and what helped her decide on a multifocal IOL implant.

Case description

The case study described a young male patient, 20 years old, who injured his left eye while hammering, 2 days prior to presentation at the Emergency Eye Hospital. Dr. Tomi suspected an intraocular foreign body (IOFB), which she confirmed in the course of a thorough ocular examination.
Fortunately, the IOFB was smooth, passing through the cornea and into the eye without causing extensive corneal damage. Dr. Tomi explained, “The IOFB was a metallic, small, and sharp splinter. It probably entered the eye with high velocity and caused small and clear-cut perforations in the cornea, iris, anterior capsule, and posterior crystalline capsule. You can hardly notice the small, self-sealed corneal wound, paracentrally at 4 o’clock on the cornea. Because of the paracentral location, the wound itself did not affect vision, and the patient delayed presentation at the clinic until the cataract developed, 2 days after the injury.” 
Upon presentation, the patient’s left eye had a visual acuity of 0.2, and his IOP was 14 mm Hg. There was a small, self-sealed corneal wound, just off center at 4 o’clock. The anterior chamber was present, and there was evidence of a ruptured pupillary sphincter, ruptured anterior capsule, as well as cataract. IOFB extraction was performed through a pars plana sclerotomy using a magnet.
Dr. Tomi performed cataract surgery on the patient 2 weeks after presentation. “A delay of 2–4 weeks may allow central corneal healing and reduce the inflammatory response. It may sometimes even be preferable to do a multi-step procedure, after control of inflammation, with adequate corneal clarity and an appropriate IOL power calculation,” she said.
The patient’s visual acuity was counting fingers, and there was an absence of inflammatory signs. Dr. Tomi carried out B and A scan ultrasonography and keratometry readings. The patient’s preoperative left eye biometry was as follows: axial length (AL) 23.45 mm, R1 7.98 mm/42.29 D @ 151 degrees, R2 7.64 mm/44.18 D @ 61 degrees, spherical equivalent (SE) 43.23 D, cylinder –1.89 D @ 151 degrees, R 7.81 mm.
She opted for the implantation of a multifocal IOL (ReSTOR, Alcon, Fort Worth, Texas). In-the-bag implantation was possible with good centration, despite the anterior capsule not being intact and a hole that she discovered intraoperatively in the posterior capsule.
“I decided to implant the MF-IOL intraoperatively, after assessing the ‘damages’ to the capsular bag and only when I anticipated a good centration and stability of the MFIOL in the bag. The integrity and stability of the capsular bag can only be evaluated intraoperatively. The option to implant a multifocal IOL in this patient was considered because of his age, 20 years, his strong desire for a multifocal implant, and the possibility to obtain accurate biometry measurements. We should take other options into consideration when performing cataract surgery in cases like these, such as a three-piece IOL implanted in the sulcus or sutured at the sclera. Sometimes a two-step approach is necessary, with delayed IOL implantation,” Dr. Tomi explained.
The surgery achieved good visual outcomes. Dr. Tomi followed the patient regularly for 9 months postoperatively. “The postop VA OS was 1, for far and near. Postop refraction in the right, uninjured eye was +0.25, and it was 0.50 in the left, injured eye. The SE was 0.00. At the 3-month follow-up visit, the VA OS was 0.8 and there was mild posterior capsule opacification (PCO). By 9 months after surgery, the VA OS was 0.3, and there was considerable PCO requiring YAG laser capsulotomy,” she said.

Management of injury and surgical approach

Physicians confronted with perforating eye injuries need to respond to the problem at hand. There is no blueprint for managing trauma, however, certain guidelines can help to plan the course. For the management of perforating eye injuries, Dr. Tomi performs a complete evaluation of the damage to the intraocular structures. She recommends first dealing with the repair of the cornea, iris, or scleral wound. Next, careful extraction of the foreign body allows the physician a better overview of the damage, including damage to/rupture of the posterior capsule, the presence of vitreous hemorrhage, and retinal detachment. Once damage is assessed, the physician can do primary or secondary cataract extraction and primary or secondary IOL implantation.

The choice of surgery

Restoring vision to an injured eye is all about the right choices, which are dictated by the degree and location of the trauma. Overall, cases in which there is a significantly disrupted anterior capsule with free floating lens matter in the anterior chamber call for primary cataract extraction, with or without IOL implantation. IOL implantation
will rely on another set of criteria that surround the state of the capsule and zonules. If the injured eye presents a lens vitreous admixture, Dr. Tomi performs combined cataract extraction with limited anterior vitrectomy. When there is injury
to the posterior segment, she may do an early pars plana lensectomy and a vitrectomy. Cases involving an intact anterior capsule with a total traumatic cataract require secondary cataract extraction with IOL implantation.
The first thing to assess when considering the implantation of an artificial lens is the patency of the posterior capsule. According to Dr. Tomi, an intact lens capsule with zonular support allows for capsular IOL fixation, the least complicated scenario. In eyes with zonular dialysis of less than 180 degrees, she employs capsular tension rings to afford the capsule added support. Further options include sulcus fixation, sulcus suture IOLs, or if conditions allow, anterior chamber IOL placement. If all else fails, aphakia may not be avoidable.
Choosing a lens depends on a number of factors. According to Dr. Tomi, the lens type the physician chooses is largely dependent on the patient’s age, the optical and physical status of the contralateral eye, and the extent and nature of trauma to the involved eye. “Determining the optical power of the lens to be implanted in cases with distorted anterior segment anatomy that resulted from the trauma can be difficult. You may have to use the biometry of the fellow eye. Also, the implantation of a premium IOL should not be excluded in traumatic eyes in cases when an accurate biometry is possible and a good centration in the bag is anticipated,” she said.

Editors’ note: Dr. Tomi has no financial interests related to her comments.

Contact information

Tomi: ancatomi@yahoo.com

MFIOL implantation in a traumatic eye MFIOL implantation in a traumatic eye
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