Cloudy complication: management of an opacified intraocular lens and diffuse iris transillumination defects: August consultation #1.

A 76-year-old man with a medical history of type 2 diabetes, hypercholesterolemia, and coronary artery disease presented with blurred vision in the right eye. His ocular history was significant for cataract surgery with posterior chamber intraocular lens (PC IOL) implantation in both eyes 3 years prior to presentation. His specific ocular complaints included blurred vision, whiteout visual episodes lasting 20 minutes, and intractable glare in the right eye. Of note, the patient was on anticoagulation therapy due to a history of stroke.On examination, the corrected distance visual acuity (CDVA) was 20/50 in the right eye and 20/25 in the left eye with a manifest refraction of plano -0.50 × 70 degrees in the right eye and plano -050 × 170 degrees in the left eye. Pupils were round and reactive in both eyes. However, there was a 3+ relative afferent pupillary defect with a corresponding constricted confrontational visual field test in the right eye. The left eye was unremarkable. Intraocular pressure (IOP) measured 14 mm Hg in the right eye and 12 mm Hg in the left eye by applanation tonometry, and the IOP was under excellent control on Timolol 0.5% 1 eyedrop twice a day and latanoprost every night at bedtime in the right eye.Pertinent findings on slitlamp examination of the right eye included a mild protective ptosis of the right upper eyelid, diffuse iris transillumination defects resembling the outline of the PC IOL (), and 2+ pigmented cell in the anterior chamber in the right eye. Gonioscopy revealed 3+ pigmented cell for 360 degrees without peripheral anterior synechiae in the right eye. A 1-piece acrylic toric PC IOL (SN6ATX, Alcon Laboratories, Inc.) was present in the ciliary sulcus with mild pseudophacodonesis and an open posterior capsule. In addition, there was a large discontinuous anterior capsule opening. Optic nerve examination revealed 0.9 cup-to-disc ratio (CDR) with diffuse 2+ pallor in the right eye and 0.4 CDR and a healthy neuroretinal rim in the left eye. The remainder of the dilated fundus examination was unremarkable without diabetic retinopathy or macular edema in either eye.(Figure is included in full-text article.)An opaque contact lens trial was performed for the right eye and the patient noted significant improvement in glare symptoms. Therefore, the surgical plan was to perform IOL exchange with a secondary IOL placement and artificial iris (HumanOptics AG) (AI) implantation using scleral fixation. However, the AI was cost-prohibitive at the time, and the patient decided to proceed with the IOL exchange alone.The patient had uneventful IOL exchange of the malpositioned PC IOL in the sulcus for an AO60 IOL (Bausch & Lomb, Inc.) with a pars plana-assisted anterior vitrectomy. Two months postoperatively, CDVA was 20/30 + 2 in the right eye with a manifest refraction of -0.50-2.00 × 30.At the 2-month postoperative visit, the patient reported increased flashes and cobweb-type floaters. He was diagnosed with a superior retinal horseshoe tear and an early macula-on retinal detachment. He underwent an uneventful pars plana vitrectomy (PPV), endolaser, and SF6 gas. Unfortunately, the patient experienced redetachment 2 weeks later requiring C3F8 gas. At the 6-week IOP check, the patient was noted to have early central opacification of the IOL (). IOL opacification continued to progress and the vision declined to CDVA of 20/200 by 3 months postoperatively ().(Figure is included in full-text article.)(Figure is included in full-text article.)What is the next step in management for this patient given the comorbidities of an opacified IOL, advanced glaucoma, anticoagulation status, and diffuse 360 degrees transillumination iris defects?