Question of the Week

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. His BCVA OD is 20/25.

Your slit lamp examination findings are shown below. Based on these findings, you recommend cataract surgery to the patient. However, you explain that his surgery will be complex. How might his surgery be different than a more “routine” case?

A. Cumulative dissipated energy (CDE) will be high

B. Hydrodissection should be skipped

C. Post-surgery visual acuity is limited by amblyopia

D. There is an increased risk of zonular weakness

E. Polishing the posterior lens capsule is a critical step

Answer

Correct answer: B

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. A: 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 phaco energy. B: This 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. C: 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. D: PPCs are not 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 the phrase: “perfect is the enemy of good.”