January consultation # 8

Article Outline

• Copyright

This patient had several problems preoperatively. These include a history of strabismus, minor anisoiconia, and large scotopic pupils. The postoperative problems include glare and halos, unsatisfactory UCVA due to remaining refractive cylinder, and transient difficulties with intermediate vision.

The images of the wavefront and topography do not provide any unusual information. Indeed, a higher-order aberration value of 0.46 μm in the right eye and 0.29 μm in the left eye correspond to this degree of anisometropia. The Orbscan shows a reduction in with-the-rule astigmatism from 2.00 D cylinder to 1.60 D cylinder in the right eye and 1.40 D cylinder to 0.80 D cylinder in the left eye. Particularly in the right eye, the bow-tie astigmatism became partially irregular. These changes are in accordance with the with-the-wound shift produced by a superior sclerocorneal incision. Some minor change in the axis can be explained when the surgical incision has been made slightly off axis at the steep meridian.

Based on the information given, my first step would be a full neuroophthalmological workup to exclude a decompensated squint. Next would be a thorough evaluation of the IOL position, particularly in the right eye, as the IOL is probably off the target axis. I would then suggest a trial of brimonidine eyedrops to reduce pupil diameter to alleviate the glare and halos.

If there are no strabismus-related problems and the patient is happy on brimonidine (or even pilocarpine 0.1%), I would consider reenclavation of the pIOL in the right eye. However, if this were not the case, explantation of the pIOL is a viable option. Approximately 5 years ago, I had a similar case. A 19-year old patient with a 7.5 mm scotopic pupil had total disability at night despite a 6.0 mm Artisan/Verisyse spherical pIOL and a UCVA of 1.4 under photopic conditions. The symptoms resolved immediately after the pIOL was removed, and the patient went back to wearing spectacles.