Managing A Small Pupil In A Post-Keratoplasty Cataract Case With Toric Iol Implantation

To present a challenging case of post-keratoplasty cataract surgery with toric IOL implantation in a patient with anterior synechiae and poor pupillary dilation.

Ophthalmology Department - Prof. Doutor Fernando Fonseca Hospital, Lisbon, Portugal

We present a 74-year-old caucasian male with history of penetrating keratoplasty 4 years ago due to a central corneal leukoma from recurrent herpetic keratitis and tamsulosin use. Preoperative DCVA was 0.3 and biomicroscopy showed a transparent corneal graft, dense cataract, anterior synechiae and poor pupillary dilation. Preoperative astigmatism was 6.13 D@160º, therefore phacoemulsification with toric IOL implantation was programmed. Intracameral injection of tropicamide 0.02% and phenylephrine 0.31% (Mydrane®) was performed, followed by viscodissection of the anterior synechiae, excision of a superior pupillary membrane in a circular fashion with a capsulorhexis forceps and mild iris stretching with a spatula. A 5 mm pupil was obtained avoiding additional manipulation implanting an iris expansion device. Loss of mydriasis during phacoemulsification created further difficulties in epinucleus and cortex removal, that we managed with bimanual irrigation aspiration, as well as proper alignment of the single piece +9.0 cylinder toric IOL implanted in the capsular bag.  No intraoperative complications were found.  The patient’s refraction was -1.00:-1.50(160º) and was very satisfied with the final surgical result.

Proper toric IOL alignment in high astigmatism and avoiding excessive surgical manipulation are paramount in post-keratoplasty cataract cases. Decreased visibility from a small pupil creates difficulties for both these aspects and the surgeon must adapt his surgical technique so that pupillary expansion, either with viscodissection, mechanical membrane removal, iris streching or iris expansion devices, allows sufficient visibility with minimal surgical trauma. We highlight that despite Mydrane® injection, further intraoperative loss of mydriasis can still occur, and bimanual irrigation-aspiration proves to be very useful in these cases allowing complete and safe removal of cortex even in the most challenging settings.