Surgical Correction for Late Postoperative Subluxation of a Diffractive Optic Multifocal IOL, Capsule Bag and Capsule Tension Ring Complex: Case Report

Bilaterally subluxed diffractive intraocular lenses: big expectations and even bigger comorbidities

A 78-year-old woman with an ocular history of cataract surgery with a diffractive intraocular lens (IOL) in each eye has developed fluctuating vision, greater in the right eye than the left eye, after 4 years. She has a history of inactive central serous retinopathy and a vision potential of 20/25 + 2 in the right eye and 20/25 in the left eye. She has well-controlled diabetes, hypertension, and hypercholesterolemia. She has enjoyed her spectacle independence for some time and wishes to have her vision restored. On examination, her uncorrected distance visual acuity (UDVA) was 20/50 in the right eye and 20/25 in the left eye and her uncorrected near visual acuity (UNVA) was J3 in the right eye and J1 in the left eye. Intraocular pressures (IOPs) measured 22 mm Hg in the right eye and 18 mm Hg in the left eye. Pupils had limited reactivity with irregularity in the right eye but no obvious relative afferent pupillary defect. Motility and confrontation visual fields were unremarkable in both eyes. Retinal acuity meter was 20/20 in both eyes, and manifest refraction was plano -1.25 × 105 20/40, J3 in the right eye and +0.50 × 20/25, J1 in the left eye. Pertinent findings on slitlamp examination included temporal iris atrophy and transillumination defects greater in the right eye than the left eye, peripupillary pseudoexfoliative changes in both eyes, significant inferior subluxation of a diffractive 3-piece posterior chamber IOL in the capsular bag with lens-pitting peripherally and few central, moderate pseudophacodonesis, and an open posterior capsule in the right eye. In the left eye, she had mild inferior subluxation of a single-piece acrylic diffractive IOL in the capsular bag with moderate pseudophacodonesis and an open posterior capsule (Figure 1JOURNAL/jcrs/04.03/02158034-202403000-00019/figure1/v/2024-02-20T193212Z/r/image-tiff). All other anterior segment findings were unremarkable. On dilated posterior examination, she had a cup-to-disc ratio of 0.50 in the right eye and 0.65 in the left eye without edema hemorrhage or pallor. There were attenuated vessels in both eyes, posterior vitreous detachment in both eyes, and a few small drusen peripherally in both eyes. There was retinal pigment epithelium irregularity and dropout parafoveal in the right eye and subfoveal in the left eye (Figure 2). There was no evidence of macular edema, subretinal fluid, choroidal thickening, or neovascular membranes. The periphery was unremarkable in both eyes.JOURNAL/jcrs/04.03/02158034-202403000-00019/figure2/v/2024-02-20T193212Z/r/image-tiff What testing would you obtain preoperatively to help guide your decision-making? How would you counsel the patient regarding comorbid conditions and expectations?

Cataract surgery in patients with retinitis pigmentosa: systematic review

Retinitis pigmentosa (RP) is an inherited bilateral retinal degenerative disease with an incidence of 1 in 4000 people. RP affects more than 1 million individuals worldwide. Although night blindness and restricted visual field are the most typical symptoms of these individuals, generalized vision loss due to cataracts can be expected in the latter stages of the disease. It has been demonstrated that posterior subcapsular cataract is the most prevalent cataract in younger individuals with RP, as opposed to age-related cataracts. Although most ophthalmologists may have a negative view of cataract surgery in patients with RP, it appears that it can play an important role in the visual restoration of patients with RP. However, there are concerns about performing cataract surgery for patients with RP. Herein, a systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses on databases of MEDLINE and Scopus.

Cable tie technique for securing scleral fixation suture to intraocular lens

Purpose

To report a new flanged intrascleral fixation technique for subluxated or dislocated intraocular lens (IOL) with c-loop or double c-loop haptics (cable tie fixation method).

Observations

We introduced a cable tie fixation method using 6–0 polypropylene for subluxated multifocal IOL with C-loop or double C-loop haptics. After passing the 6–0 polypropylene monofilament under the optic-haptic junction, the other end of the strand was taken out of the eye after passing it above the optic-haptic junction. A knot was made at one end, and the opposite strand was passed through the knot to form a loop. Both ends of the monofilament were tugged to make the loop fixed to the optic-haptic junction smaller. Both ends of the monofilament were externalized 2.5 mm posterior to the limbus using a 30 G needle. Another 6–0 polypropylene monofilament was tied to the opposite optic-haptic junction and scleral fixation was performed. While checking the IOL centration, the four ends of the 6–0 polypropylene monofilaments were heated with a cautery to form flanges.

Conclusions and Importance

A four-flanged intrascleral fixation technique involving a cable tie-shaped loop using 6–0 polypropylene could provide stable IOL fixation without damage for subluxated or dislocated IOLs with C-loop or double C-loop haptics.