Question of the Week

A 33-year-old man presents to your clinic with blurry vision in his right eye. He tells you that for quite some time, his vision has been worse in the right eye, and he is especially bothered by the glare of lights when driving at night. His BCVA OD is 20/30. Your slit lamp examination findings are shown below. Based on this finding, you recommend cataract surgery to the patient. However, as you plan his surgery, you note that your approach will be different than a “routine” case.

What about this patient’s surgery will not be routine?

A. Cumulative dissipated energy (CDE) will be high

B. Hydrodissection should be skipped

C. There is an increased risk of zonular weakness

D. Extra polishing of the posterior capsule

Answer

Correct answer: B

Explanation: The slit lamp finding shown in this question is a classic posterior polar cataract. Posterior polar cataracts (PPCs) can be a congenital condition, which matches the history of our patient. PPCs can be a remnant of the hyaloid artery that supplied the developing lens and are related to the more benign Mittendorf dot. Since PPCs are congenital, the patients undergoing cataract extraction are often on the young side compared to typical cataract surgery patients. Therefore, nuclear density is usually low, and the lens material may be removed by aspiration alone or with minimal phacoemulsification energy (option A). Option B is the correct answer because given the developmental nature of a PPC, it is often associated with a capsular defect. Hydrodissection and rotation of the lens could cause a posterior capsule break and should not be performed. Hydrodelineation (separation of the epinucleus from the endonucleus is acceptable). Option C is incorrect because PPCs are not associated with zonular weakness. Polishing the lens capsule (option D) may not be advised in this case because of the presumed weakness of the posterior lens capsule. Remember the phrase: “perfect is the enemy of good.” Any remaining polar opacity can be removed with YAG laser capsulotomy in the post-op period.