A 35-year-old man presents to your clinic with a chief complaint of blurry vision in his right eye. He tells you that for as long as he can remember, his vision has been worse in the right eye, and he is especially bothered by the glare of lights when driving at night. He super-pinholes to 20/25 in the right eye. Your slit lamp examination findings are shown below.
Based on this finding, you recommend cataract surgery to the patient. However, you explain that his surgery will be complex. How might his surgery be different from a more “routine” case?
A. Cumulative dissipated energy (CDE) will be high
B. Post-operative visual acuity will be significantly limited by amblyopia
C. There is an increased risk of zonular weakness
D. Hydrodissection should be skipped
E. Polishing the posterior lens capsule is a critical step
Correct Answer: D
Explanation: The slit lamp finding shown in this question is a classic posterior polar cataract. Posterior polar cataracts (PPCs) are a congenital condition, which matches the history of our patient. The symptoms of blurred vision with glare around lights, even with a BCVA of 20/25, are typical. PPCs can be a remnant of the hyaloid artery that supplied the developing lens and are related to the more benign Mittendorf dot. D is the correct answer, because PPC developmentally are often associated with a capsular defect. Hydrodissection and rotation of the lens could cause a posterior capsule break, and therefore, should be avoided.
A: Since PPCs are congenital, the patients undergoing cataract extraction are often on the young side compared to typical cataract surgery patients (This patient is 35). Therefore, nuclear density is usually low, and the lens material may be removed by aspiration alone or with minimal phaco energy (low CDE). B: If the PPC is severe enough, it may lead to amblyopia if it is not addressed as a child. However, in this patient, with a BCVA of 20/25 prior to surgery, this does not appear to be the case. C: PPCs are not usually associated with zonular weakness. E: Polishing the lens capsule may not be advised in this case because of the presumed weakness of the posterior lens capsule. Remember that sometimes perfect is the enemy of good.
Source: Eyerounds, Eyewiki (image)
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