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    Complicated case underscores need for care, preparation

    Take-home: Routine cataract surgery easily can become complex. Therefore, surgeons must pay meticulous attention to technique to minimize the risk of complications, but at the same time, be prepared to handle adverse events and to revise their surgical plan.

    A case of cataract surgery with planned presbyopia-correcting IOL implantation– complicated by posterior capsule rupture and a postoperative refractive surprise– reinforced important lessons and provided a new revelation to one experienced surgeon.

    Related: AD-IOLs mimic movement of natural lens

    Thomas Kohnen, MD, the operating surgeon, outlined a case that reminded him to always be careful and to have a back-up plan because there is a risk for complications during routine procedures. In addition, Dr. Kohnen found after this case that a patient can achieve a satisfactory visual outcome when implanted with a bifocal IOL in one eye and a trifocal IOL contralaterally.

    Dr. Kohnen is professor and chairman, department of ophthalmology, Goethe University, Frankfurt, Germany.

    The patient was a 90-year-old woman who was slightly hyperopic (+1.75 -0.50 @140° OD; +0.75 -2.5 @154° OS) and she wanted to be spectacle independent after cataract surgery. She had an incipient cortical cataract in her right eye and mature cortical cataract in her left eye.

    The initial plan

    Dr. Kohnen decided to perform femtosecond laser-assisted cataract surgery (FLACS) and implanted a single-piece, trifocal IOL (AT Lisa tri839MP, Carl Zeiss Meditec) bilaterally, operating first on the eye with the cataract and soon after on the fellow eye.

    “A study we conducted that was recently published in the American Journal of Ophthalmology showed that patients who underwent bilateral implantation with this trifocal IOL achieved good visual acuity (VA) at far, intermediate, and near distances, as well as high rates of spectacle independence and satisfaction,” Dr. Kohnen said.

    Related: Unique approach to managing a posteriorly dislocated IOL

    The first eye surgery was performed uneventfully, and two days later, the patient returned for her second procedure. The femtosecond laser steps were completed successfully, but during lens removal, the posterior capsule ruptured, followed by loss of cortex and nucleus into the vitreous. The femtosecond laser-created anterior capsulotomy remained intact.

    “Removal of the lens is facilitated after pretreatment with the femtosecond laser, but the surgeon still needs to be careful,” Dr. Kohnen said. “When the plan is to implant an advanced technology presbyopia-correcting IOL, it is important to have a back-up solution in the event of an intraoperative complication that precludes adhering to the original IOL plan,”

    Recent: Toric trifocal IOL widens patient pool

    Since the posterior capsule rupture was too large, Dr. Kohnen expected he could not implant the single-piece trifocal IOL in the capsular bag. The alternatives were to leave the patient aphakic and subsequently implant a three-piece multifocal IOL in the bag or sulcus, a three-piece monofocal IOL, or an anterior chamber or iris claw IOL.

    The back-up plan

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