Small Corneas, Big Decisions : Cataract Surgery In Uveal Coloboma With Microcornea - A Case Series

To describe a case series of surgical management of cataract in 5 patients of uveal coloboma with microcornea

L V Prasad Eye Institute, Hyderabad (India)

We report a case series of 5 patients who underwent cataract extraction for advanced brunescent cataracts, in a setting of microcornea and uveal coloboma. The patients presented to us with an average visual acuity (VA) of being able to appreciate hand movements, along with brunescent advanced cataract with poor zonular support, shallow anterior chamber depth and uveal coloboma. The intraocular pressure (IOP) was within normal limits for all, and an ultrasound B scan of all patients showed an anechoic vitreous cavity with attached retina. The average white to white measurement in the patients was found to be above 8.5 mm. A dilemma was faced while deciding the best course of treatment for these patients : Performing phacoemulsification can result in large incisions, limited space for manipulations and increased chances of complications. An extracapsular cataract extraction (ECCE) or Small incision cataract surgery (SICS) seemed like the logical way to go, however the question of intraocular lens (IOL) placement proved to be challenging due to sizing.  A decision was made to perform an intracapsular cataract extraction (ICCE) and implant a retropupillary iris fixated IOL (IFIOL) of around 8.5-9 mm. All surgeries went as planned without any additional inadvertent complications, with stable IOLs at the end of surgery and at 1 month follow up. The average Best Corrected Visual Acuity (BCVA) of the patients was 20/60, with a satisfactory subjective visual outcome.

The presence of microcornea, small, poorly dilating pupils, absence of zonules or lens coloboma, make surgery challenging with increased complications in eyes with uveal colobomas. Options for softer cataracts include phacoemulsification and SICS, however these cannot be employed in brunescent cataracts with poor zonular support. Another challenge arises while implanting IOL due to issues with sizing and lack of support for standard lens placement. Well oriented IFIOL sized between 8.5-9mm proved to be useful. Our case series aims to guide the anterior segment surgeon in decision making in the management of these challenging cataracts in eyes with abnormal anatomy, to provide the best possible visual outcome, with minimal complications.