Arun C. Gulani, MD, MS, focuses his blog on custom designed approaches to complex cases using practical surgical techniques.

BLOG: Complex case with corneal scar and cataract

This is a case of a dense corneal herpetic scar with corneal tissue compromise and an indented “divot.” It could be seen not only in the preop topography and corneal densitometry analysis, but also on OCT during femtosecond laser capsulorrhexis. The patient had poor central visibility with cataract and best corrected vision of 20/150.

The patient had an active lifestyle and after seeing numerous corneal specialists in the country was referred to me for options.

I applied my “5S system” to break down his complex case presentation and determined my plan of action using all of my “corneoplastique” principles: brief/topical, aesthetically pleasing, least interventional surgery with a goal of maximal uncorrected vision.

After a detailed informed consent in which I explained that none of his corneal specialists were wrong in suggesting a corneal transplant and the risks of herpetic reactivation, I planned to first perform an “in-corneal” laser PRK as a corneoplastique approach over this scar area module as stage 1.

The patient was so pleased with his vision that he postponed his cataract surgery.

When he did come in for his cataract surgery, I explained my concerns and suggested femtosecond laser-assisted capsulorrhexis to have a predictable capsular bag because I was planning for aphakia with refraction to be followed by IOL implantation as a next stage over a week.

Having refracted this aphakic patient, I was pleased to see him improve to 20/40- and so I was determined to attack all of his refractive errors using a toric lens implant.

He resulted in 20/25+ uncorrected vision in this eye.

Thus, taking this patient from 20/150 vision to 20/25+ uncorrected keeping all of my corneoplastique principles underscores a dedicated attempt by every eye surgeon to think visually for each and every patient in designing their surgery irrespective of how complex they may seem to begin with and also all the time resisting to take the easier road home.