Consultation section. Cataract surgical problem.

A 68-year-old diabetic Pakistani presented with a 3 year history of progressive bilateral painless loss of vision. Although he was previously untreated for glaucoma, his examination revealed the following: visual acuity, finger counting in the right eye and 20/60 in the left; intraocular pressure (IOP), 41 and 31 mm Hg, respectively. Physical findings included bilateral shallow anterior chambers, minimal nuclear and cortical cataract formation, and extensive glaucomatous optic nerve cupping and atrophy worse in the right eye than in the left. Gonioscopy revealed angles narrowed to grade 1 for 360 degrees in both eyes. Visual field analysis was commensurate with the marked degree of optic nerve damage and reduced visual acuity. Bilateral laser iridotomies and a combination of topical antiglaucoma agents reduced IOP to the mid-20s in both eyes. Subsequently, the right eye had an uneventful trabeculectomy with application of intraoperative mitomycin. Postoperatively, the patient developed posterior aqueous entrapment and was managed with topical cycloplegics, aqueous suppressants, and corticosteroids. After a few weeks, a shallow anterior chamber was present centrally, a filtration bleb was noted, and IOP was 9 mm Hg. Unexpectedly, the patient returned to his native country, discontinued medications, and was lost to follow-up for 1 year. Upon his return, he presented with these findings: visual acuity, hand motion in the right eye and 20/60 in the left eye; IOP, 10 and 30 mm Hg, respectively. Physical findings in the right eye (Figure 1) included a superiorly oriented, thin-walled filtration bleb, a formed anterior chamber with multiple broad peripheral and midperipheral synechias, and a bound pupil covering a dense nuclear sclerotic cataract. The left eye had progressive glaucomatous optic nerve changes. Given the patient's history, now would you manage the glaucoma in the left eye, and what surgical methods would you plan for the right eye, assuming cataract surgery is indicated?