I recently examined a patient who had an interesting type of cataract in each eye. The patient was young, in his early 20’s. He was a refugee from Ukraine. During his exam, he told me that all of his siblings and his father had cataracts at a very young age. Not only did they have cataracts, he went on to tell me, but they also had a problem with the iris. The iris is the colored part of the front of the eye. It sits just behind the cornea. A round iris has a circular opening in the middle, like a donut. The opening is the pupil.
According to the patient, he and his siblings and father did not have round pupils. When I examined him, he appeared to have a pupil that looked more like a cat’s pupil. He had something called an iris coloboma. Essentially, a coloboma is a developmental problem that arises when a certain part of the body is developing. The tissues that are supposed to come together to form the part of the body get close but don’t actually come together. An example outside of the eye realm would be a cleft lip and palate.
Essentially the patient and his family had a cleft in the iris. This developmental abnormality also resulted in the development of the cataracts. Cataracts are clouding of the eyes natural lens. Whatever went wrong to cause the malformation of the iris also resulted in a malformation of the lens. A cataract resulting from an iris coloboma can be very tricky to remove. Sometimes, the cleft may include not just the iris, but parts of the support structures of the lens. These support structures are called the zonules. A weakness or absence of some or all of the zonules can lead to a major complication in cataract surgery. The cataractous lens can fall into the back of the eye during surgery. Because of this risk, during my discussion with the patient, I recommended laser cataract surgery.
In cases of weakness or missing zonules, I always prefer and recommend laser cataract surgery. This patient’s iris coloboma is a rare finding. However, there are many common findings that increase the risk of cataract surgery due to zonular issues. The findings included past trauma or injury or a condition called pseudoexfoliation. Pseudoexfoliation is a condition where the layers of the lens flake off inside of the eye. The flakes can clog the inside of the eye leading to a form of glaucoma. But, the flakes can also weaken or sever the zonules. In cases of past injury and pseudoexfoliation, I always recommend a prefer laser cataract surgery.
Other conditions that benefit from the use of laser cataract surgery are diseases of the cornea. The most common condition I see includes hereditary corneal endothelial dystrophy, or Fuch’s dystrophy. The cornea is the clear, front “window” part of the eye. We have tiny little pumps on the back side of the cornea to keep the cornea clear. Without a clear cornea, we would lose our vision. Fuch’s dystrophy is a condition where these pumps fail prematurely. Essentially, the cornea can age 10, 20 or even 30 years faster than the patient age. Studies have shown a benefit with laser cataract surgery in limiting the damage to the back side of the cornea. I have observed the same finding with laser cataract surgery. When I use laser cataract surgery, I spend just a fraction of the time in the eye using ultrasound and fluid washing of the cataract. The ultrasound and fluid washing of the cataract are what can cause damage to the cornea. In my opinion, laser cataract surgery is superior to manual cataract surgery in patients with certain corneal diseases.
My patient with the coloboma and cataract is set to have cataract surgery soon. You can read about him here. The take home is this: there are two options for cataract surgery…Laser cataract surgery and manual cataract surgery. In patients with certain developmental abnormalities, diseases, or injury or trauma, I prefer laser cataract surgery to cataract surgery by hand. If you need cataract surgery and have an usual type of cataract, come see me for an appointment. I would be happy to determine if you would benefit from laser cataract surgery.