His VA is 6/12, other media are clear and fundus is normal. He is emmetrope and complaining of daytime difficulty in vision. On colored glasses he is partially improving. His IOP is 14 mm Hg on applanation.
If the decreased vision impacts on his daily activities, I would go ahead and operate. But if he can cope with the symptoms and live normally I would observe him. I think the decision is the patient's to make at the end..
I agree with Mohammed. As it entirely depends upon the patient's need, risk and benefit analysis. I think, state of art technologies have made cataract surgery quite safe so I would recommend going ahead with the surgery especially if the patient's daily living activities are hampered.
Cheers.
I think, we can go ahead with the cataract surgery and multifocal IOL implant as day time activities are very important in a young person's life. So, there is a need of improving QOL for him. We should explain him the pros and cons.
He can maintain his reading with other eye.
So, go ahead and do the needful.
Dear Manpreet Singh, thanks for a good answer but the patient is having one functioning eye, the other eye is blind.
There is always risk of operating on one good eye. Make the patient understand if the surgery is absolutely necessary esp. with the higher risks involved in posterior polar cataract surgery. Thought should be put into how long of good vision would he have and how much higher the risk would be if he delays surgery as he is still very young, weighing the pros and cons, he may ultimately think of the right time to do the surgery.
I agree with Mohammad. But final decision is by patient based on visual requirement vs risk to only eye because of surgery. Risk varies from region to region. Should check with centre / surgeon operating.
His VA may be 6/12, when tested in an examination room, but the VA will drop significantly in day light testing. I will go ahead and operate. There are some risks associated with a posterior polar cataract in particular with phacoemulcification. One should be careful in hydodissection and spinning of nucleus, other wise one can end up with a posterior capsule rupture.
I am also thinking on the line of Aik Chun Heng, as I usually encounter difficulty in preserving posterior capsule in posterior polar cataracts during phacoemulsification.
The patient must be carried along in making the decision to operate or delay for a while considering the visual acuity, the fact of only eye and potential risk of surgery in posterior polar cataract.
As patient is practically only eyed , we must evaluate whether cataract is only cause of disturbed vision- there might be element of amblyopia ( depending on age when he developed cataract ). So old ophthalmic examination record matters a lot to care fully weigh out the risk benefit ratio regarding surgery.
I agree with respected researchrs Ian Christopher and Dana Robaei in not performing hydrodissection (only relying on hydrodlineation) to protect the central posterior capsule, although in eyes where I have already encountered higher incidence of posterior capsular opacification I do perform posterior capsulorrexis while operating the other eye of the same patient. But in this case I am afread might encounter lenticonus element, and in my experience nuclei with lenticonus are hard not soft.
Factors to be considered before deciding to perform the surgery:
1. BSCVA
2. Occupational needs
3. quality of vision ( glare , halo,...)
4. The reason of loosing the other eye ( be careful if it was related to cataract surgery complications! or RRD)
5. The refractive error of the patient ( extra risk of RRD after vitreous loss in high myopic or risk of glaucoma in sulcus IOLs in occludable angle of hyperopic patients should be considered)
6. Baseline IOP
7.Your expertise and previous experience with pos. polar cataracts
8. Your estimate of the degree of confidence that patient has to your competence and your system ( it is not necessarily related to your abilities and is more related to the popularity)
You can use pentacam and or ant. Segment OCT to evaluate the posterior capsule- though not very accurate). Explain your concerns to the patient.
If you decided to go for surgery , perform a relatively small (~5 mm) ant. Capsulorrhexis - in case you need to insert the lens in the sulcus- and have a 3 piece IOL available.
In my hands, pos polar cataract is not very challenging when I try to aspirate the lens first in the periphery then proceed to the center.ant. Vitrectomy can remove the residual nucluar and epinuluar material in case the pos. capsule is open.
But for this case, to be honest, I would prefer to ask a retinal surgeon to operate on this patient to be able to handle the case in the same session, in case more clinically significant nucleus drop occurs!
BTW, good luck :)
Thanks Fateme Alipour for an answer with logical justifications. I do agree with the content of your answer.
Concur with all comments and caveats of others with respect to small rhexis, no hydrodissection, viscodissection prn, cautious lens aspiration at relatively low infusion press (50-60 mm bottle height). If post polar plaque does not aspirate directly, then do not attempt PLC polish as capsule defect may result. Rather insert IOL and manage residual opacity after 4-6 wks with YAG laser.
Thanks Ken, I do agree with your point of view but sometimes I find wonderful outcome with broader rhexis and going behind the IOL after insertion, your comment ?
Yes Farah, I do agree with you, old ophthalmic record is of immense value but unfortunately not available.
Most of the cases which I operated had clear lenses with high lenticular myopia of around 25 diopters. The patients were happy after the lens removal.
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