Pars plana lensectomy combined with pars plana vitrectomy for dislocated cataract

Visual Outcomes of Traumatic Lens Dislocations and Subluxations Managed by Pars Plana Vitrectomy and Lensectomy

AIM

The aim of this study was to evaluate the visual outcome of lens dislocation and subluxation managed by pars plana vitrectomy (PPV) and lensectomy in patients with open (OGIs) or closed globe injuries (CGIs).

METHODS

Medical records of 70 consecutive patients treated by PPV and lensectomy over a period of 11 years (1 January 2010-31 December 2020) were retrospectively reviewed. We collected demographic data, best corrected visual acuity (BCVA) using a Snellen Chart pre- and postoperatively, associated ocular injuries and treatment strategy. Visual outcome was evaluated according to the final BCVA which was defined as poor <0.1 or good ≥0.1.

RESULTS

The mean age was 57.9 ± 17.6 years. CGIs were present in 49 (70.0%) cases and open OGIs in 21 (30.0%) cases. The dislocation mechanism was zonular lysis in 59 cases (84.3%) and capsular rupture in 11 cases (15.7%). The intraocular lens implant (IOL) was sutured to the sclera in 51 (72.9%) cases or positioned in the capsular bag or in the sulcus in 3 (4.3%) cases and 1 (1.4%) case, respectively, whereas 15 (21.4%) patients remained aphakic. A good BCVA ≥ 0.1 was achieved in 45.71% of the eyes. The presence of retinal detachment (RD) (p = 0.014), iridodonesis (p = 0.011) and initial BCVA (p = 0.000) achieved statistical significance in predicting visual outcome. After treatment, 45.71% of patients achieved a final BCVA ≥ 0.1.

CONCLUSION

RD, iridodonesis and initial BCVA were risk factors for poor visual outcome in our series.

Polychromatic Aqueous and Vitreous Crystals Due to Phacolytic Glaucoma in a Patient With Marfan Syndrome and Lens Dislocation

Purpose: To describe a patient with Marfan syndrome and crystalline lens luxation who developed phacolytic glaucoma with polychromatic crystals in the anterior chamber and vitreous. Methods: We present a retrospective case report. Results: A 58-year-old man with Marfan syndrome and crystalline lens luxation since childhood presented with 2 days of pain in the left eye. The visual acuity was 20/30 OS with an aphakic contact lens, and the intraocular pressure (IOP) was 31 mm Hg. Polychromatic crystals were evident in the anterior chamber and vitreous. The retina was attached. Despite medical treatment, the IOP remained elevated; therefore, a pars plana vitrectomy and lensectomy were performed. At the last follow-up, the IOP was normal and the retina remained attached. Conclusions: Phacolytic glaucoma can be seen in eyes with a subluxated or luxated mature or hypermature lens. In these rare cases, iridescent crystals can be observed in the aqueous and vitreous. Vitrectomy with lensectomy is the definitive treatment.

Phacoemulsification Combined With Supra-Capsular and Scleral-Fixated Intraocular Lens Implantation in Microspherophakia: A Retrospective Comparative Study

Background

Microspherophakia (MSP) is a rare ocular condition, the lens surgery of which is complicated by both insufficient zonules and undersized capsule.

Methods

This study included MSP eyes managed with phacoemulsification combined with supra-capsular and scleral-fixated intraocular lens implantation (SCSF-IOL) and made the comparison with those treated by transscleral-fixated modified capsular tension ring and in-the-bag intraocular lens implantation (MCTR-IOL).

Results

A total of 20 MSP patients underwent SCSF-IOL, and 17 patients received MCTR-IOL. The postoperative best corrected visual acuity was significantly improved in both groups (P &lt; 0.001), but no difference was found between the groups (P = 0.326). The IOL tilt was also comparable (P = 0.216). Prophylactic Nd:YAG laser posterior capsulotomy was performed 1 week to 1 month after the SCSF-IOL procedure. In the SCSF-IOL group, two eyes (10.00%) needed repeated laser treatment and one eye (5.00%) had a decentered capsule opening. Posterior capsule opacification was the most common complication (6, 35.29%) in the MCTR group. No IOL dislocation, secondary glaucoma, or retinal detachment was observed during follow-up.

Conclusions

SCSF-IOL is a viable option for managing MSP and is comparable with the MCTR-IOL. Nd:YAG laser posterior capsulotomy was necessary to prevent residual capsule complications after the SCSF-IOL procedure.

Management of the subluxated crystalline lens: A review

Cataract surgery for the subluxated crystalline lens is challenging. A thorough preoperative evaluation is important to determine the appropriate surgical approach for lens removal and the subsequent technique of intraocular lens placement. Important considerations include the extent and location of zonular weakness, and whether the zonular deficiency is caused by a static or progressive disease. The capsular bag should be preserved where possible. Creating a good-sized and centred continuous curvilinear capsulorhexis is crucial to facilitate the use of capsular retractors and capsular tension devices, which provide capsular stability. Nucleus sculpting and rotation should be minimised to reduce zonular stress. Being cognisant of the possible intraoperative complications that may occur at each stage of the surgery and knowing how to reduce the risk of these complications occurring will enable surgeons to perform safe cataract surgery in these complex cases.

Surgical outcomes of modified capsular tension ring and intraocular lens implantation in Marfan syndrome with ectopia lentis

OBJECTIVE

To evaluate surgical outcomes of modified capsular tension ring (MCTR) and intraocular lens (IOL) implantation in eyes of Marfan syndrome (MFS).

METHODS

This retrospective case series included MFS patients receiving MCTR transscleral fixation and IOL in-the-bag implantation. The MCTR was sutured to the sclera through a sulcus by 9-0 polypropylene with the modified knotless Z-suture technique. Main outcomes were visual acuity and postoperative complications.

RESULTS

A total of 109 MFS patients (187 eyes) had the surgery. Patients were 15.47 ± 14.36 years old and followed up for 10.07 ± 8.99 months. MCTR and IOL implantations were performed in 174 eyes (93.05%). The postoperative BCVA (LogMAR) was 0.24 ± 0.24 (1 month), 0.26 ± 0.20 (3 months), 0.22 ± 0.20 (6 months), 0.20 ± 0.19 (12 months) and 0.25 ± 0.32 (over 12 months), which was significantly better than preoperatively (0.63 ± 0.35) (p < 0.001). Major complications included posterior capsular opacification (PCO) in 41 eyes (23.56%) and decentered anterior capsular opacification (ACO) in 15 eyes (8.62%). The mean occurrence time was 9.44 ± 7.08 and 8.87 ± 15.08 months respectively. Other complications included transient intraocular pressure elevation in seven eyes (4.02%), retinal detachment in two eyes (1.15%), cystoid macula edema in one eye (0.57%), and endophthalmitis in one eye (0.57%). No eye had suture breakage or IOL dislocation.

CONCLUSIONS

The visual improvement is significant in eyes of MFS undergoing MCTR transscleral fixation and IOL in-the-bag implantation. The long-term monitoring of complications is warranted, especially in the first-two years.

PARS PLANA VITRECTOMY AND LENSECTOMY FOR ECTOPIA LENTIS WITH AND WITHOUT THE INDUCTION OF A POSTERIOR VITREOUS DETACHMENT

PURPOSE

Posterior hyaloid removal during pars plana vitrectomy and lensectomy for ectopia lentis is commonly performed, but may increase the risk of intraoperative retinal breaks and postoperative retinal detachment. This study evaluated outcomes after pars plana vitrectomy and lensectomy with or without posterior hyaloid removal.

METHODS

This retrospective observational cohort study included ectopia lentis cases that underwent pars plana vitrectomy and lensectomy (2005-2014), with or without intraoperative induction of a posterior vitreous detachment (PVD). The primary outcome was postoperative retinal detachment. The secondary outcomes were the incidence of iatrogenic retinal breaks, and change in visual acuity.

RESULTS

Twenty-six cases were included. The posterior hyaloid was preserved intraoperatively in 11 cases (non-PVD group). In the remainder (15 cases), the vitreous was removed completely (PVD group). Postoperative retinal detachment occurred in 2 cases in each group (18.2% non-PVD vs.13.3% PVD, P = 0.7). Intraoperative breaks occurred more frequently in the PVD group (2 vs. 9 cases; P = 0.03). There was no difference in mean improvement in visual acuity (7 [PVD] vs. 3 [non-PVD] ETDRS lines; P = 0.2).

CONCLUSION

The preservation of posterior hyaloid attachment during vitreolensectomy for ectopia lentis was associated with fewer iatrogenic retinal breaks. Postoperative retinal detachment did not seem to be influenced by the choice of surgical technique.

Dangling Lens Phacoemulsification: A Novel Technique for Near Complete Zonular Dehiscence

PURPOSE

To demonstrate a novel technique for the management of dangling lenses with near complete zonular dehiscence.

METHODS

A capsule-sparing combined anterior and posterior surgical approach for dangling lenses with severe zonular dehiscence is described. The surgical record of a patient who underwent phacoemulsification with "dangling lens technique" and in-the-bag intraocular lens (IOL) implantation was evaluated.

RESULTS

This technique was able to preserve the lens capsule, allowing freedom of IOL choice and an optimally reconstructed anterior segment. Placement of sutured capsular tension rings (CTRs) or segments provided long-term stabilization of the capsular bag and the bag-fixated posterior chamber IOL. No intraoperative or postoperative complications occurred during a follow-up of 3 years.

CONCLUSIONS

Combined microincisional pars plana vitrectomy, posterior levitation of the crystalline lens, phacoemulsification with sutured CTR, and in-the-bag IOL placement may be considered for surgical management of patients with nearly luxated, dangling, crystalline lenses.

25-gauge pars plana lensectomy with vitrectomy

BACKGROUND AND OBJECTIVE

To describe a technique of 25-gauge pars plana lensectomy with primary posterior capsulotomy and sparing of the anterior lens capsule that is suitable for all lens densities.

PATIENTS AND METHODS

The authors describe a technique they routinely employ for pars plana vitrectomy using primarily a 25-gauge, three-port approach with intraoperative lens density assessment and possible fragmatome use for dense lenses. An analysis of the ability to achieve surgical goals is provided.

RESULTS

Surgical goals were achieved in all 68 cases performed during an 18-month period. Anterior lens capsule was consistently spared, and 25-gauge fluidics functioned well even in the presence of a fragmatome and single 20-gauge sclerotomy.

CONCLUSION

25-gauge pars plana lensectomy with vitrectomy with and without fragmatome incision is an efficacious technique for lensectomy.

Management of traumatic cataract in adults at a reference center in Mexico City

The purpose of the study was to determine the clinical presentation, mode of injury, surgical, and postoperative outcomes in adult patients with traumatic cataract. This is a clinical, observational, and retrospective study with review of records of patients in the period 2010-2012. Eighty patients were included, of whom 67 (83.75 %) were male. The mean age at presentation was 46 years (range 18-82 years). Sixty-four patients (80 %) had a closed-globe blunt ocular trauma and 16 (20 %) had an open-globe penetrating trauma. Seventy-seven (96.25 %) patients underwent phacoemulsification; 13.7 % (n = 11) required placement of capsular tension rings and 22.5 % (n = 18) automated anterior vitrectomy. In 53 % of the cases the intraocular lens (IOL) was placed in the capsular bag. Forty-seven patients (58.75 %) achieved a best-corrected visual acuity of 20/40 or better. In 57 (71.25 %) the final refraction was obtained, with a mean spherical equivalent of -0.56D (range -3.50D to +2.00 D). The improvement in visual acuity was significantly higher when the IOL was placed in the capsular bag compared to when it was placed in the sulcus (average difference of 0.667, p = 0.001). The most common mechanism of trauma is closed globe. Phacoemulsification was the procedure most common performed, with the IOL placed most commonly in the capsular bag. The final best-corrected visual acuity in most patients was 20/40 or better. Placing the IOL in the capsular bag represented an improvement in visual acuity compared to placement in the sulcus.

Multiple methods of surgical treatment combined with primary IOL implantation on traumatic lens subluxation/dislocation in patients with secondary glaucoma

AIM

To describe clinical findings and complications from cases of traumatic lens subluxation/dislocation in patients with secondary glaucoma, and discuss the multiple treating methods of operation combined with primary intraocular lens (IOL) implantation.

METHODS

Non-comparative retrospective observational case series.

PARTICIPANTS

30 cases (30 eyes) of lens subluxation/dislocation in patients with secondary glaucoma were investigated which accepted the surgical treatment by author in the Ophthalmology of Xi'an No.4 Hospital from 2007 to 2011. According to the different situations of lens subluxation/dislocation, various surgical procedures were performed such as crystalline lens phacoemulsification, crystalline lens phacoemulsification combined anterior vitrectomy, intracapsular cataract extraction combined anterior vitrectomy, lensectomy combined anterior vitrectomy though peripheral transparent cornea incision, pars plana lensectomy combined pars plana vitrectomy, and intravitreal cavity crystalline lens phacofragmentation combined pars plana vitrectomy. And whether to implement trabeculectomy depended on the different situations of secondary glaucoma. The posterior chamber intraocular lenses (PC-IOLs) were implanted in the capsular-bag or trassclerally sutured in the sulus decided by whether the capsular were present.

MAIN OUTCOME MEASURES

visual acuity, intraocular pressure, the situation of intraocular lens and complications after the operations.

RESULTS

The follow-up time was 11-36mo (21.4±7.13). Postoperative visual acuity of all eyes were improved; 28 cases maintained IOP below 21 mm Hg; 2 cases had slightly IOL subluxation, 4 cases had slightly tilted lens optical area; 1 case had postoperative choroidal detachment; 4 cases had postoperative corneal edema more than 1wk, but eventually recovered transparent; 2 cases had mild postoperative vitreous hemorrhage, and absorbed 4wk later. There was no postoperative retinal detachment, IOL dislocation, and endophthalmitis.

CONCLUSION

To take early treatment of traumatic lens subluxation/dislocation in patients with secondary glaucoma by individual surgical plan based on the different eye conditions would be safe and effective, which can effectively control the intraocular pressure and restore some vision.

Surgical management of lens subluxation in Marfan syndrome

PURPOSE

To review the literature on the surgical management, describe a simplified surgical technique, and to report the postoperative clinical course of ectopia lentis removal in patients with Marfan syndrome.

METHODS

The medical records of patients with a clinical diagnosis of Marfan syndrome and clinically significant lens subluxation were retrospectively reviewed. Patients underwent lens extraction by a single surgeon via a simplified anterior segment approach. The pre- and postoperative best-corrected visual acuity, biometric measurements, intraocular pressure, and incidence of surgery-related complications were reviewed.

RESULTS

A total of 42 eyes of 22 patients were included. Mean postoperative follow-up was 4.9 ± 2.9 years (range, 1-10 years). Average age at surgery was 10.2 ± 9.2 years (range, 2-37 years), with 18 patients (36 eyes) ≤ 18 years of age. The average preoperative best-corrected visual acuity was 20/80, and the average postoperative best-corrected visual acuity at last follow-up was 20/25, with an average improvement of 6 lines on the Snellen chart. All eyes had a best-corrected visual acuity > 20/30 at last follow-up with aphakic correction. One eye of 1 patient developed a retinal detachment following blunt trauma. No other intra- or postoperative complications were reported.

CONCLUSIONS

Anterior lensectomy and limited vitrectomy with aphakic correction is safe and provides a consistent visual outcome in patients with lens subluxation secondary to Marfan syndrome. This is especially important in pediatric patients, in whom long-term follow-up for iris- and scleral-fixated intraocular lenses is limited.

Lens dislocation has a possible relationship with laser iridotomy

We report our recent experience of four eyes with spontaneous lens dislocation in four patients with no history of trauma or any systemic disease associated with zonular dialysis. Lens dislocation developed with 0.5 to 6 months following laser iridotomy. All patients were male and two eyes were complicated with acute primary angle closure glaucoma preoperatively. Case 1 showed bilateral lens dislocation, while cases 2 and 3 involved unilateral lens dislocation. Cases 2 and 3 showed lenses completely dislocated into the vitreous cavity. All cases needed lens removal and scleral fixation of intraocular lenses. Final visual acuity was 1.2 in all cases. We suspect that laser iridotomy may induce localized zonular dialysis that results in progressive zonular weakness, leading to lens dislocation.

Case of bilateral complete posterior dislocation of lens caused by elder abuse

We report a case of bilateral complete dislocation of lenses into the vitreous cavities due to elder abuse in a patient with senile dementia. According to the patient's son, bilateral complete lens dislocation occurred after he hit his father in the head with socks in order to control his violent behavior. Although the patient was taken to our ophthalmological ward for a planned vitrectomy, restlessness and inability to remain in his room during the night led to his leaving the hospital. The patient has not returned but did receive a vitrectomy at another clinic. While the number of patients with senile dementia has dramatically increased, no specific remedy is currently available. When treating medical concerns of seniors with unknown backgrounds, elder abuse needs to be considered as a potential cause of such injuries.

Use of pars plana vitrectomy with phacoemulsification in vitreous cavity to treat complete posterior dislocation of lens

Background

The purpose of this study was to evaluate pars plana vitrectomy (PPV) with phacoemulsification in the vitreous cavity for treatment of complete posterior dislocation of the lens without any damage to the lens capsule.

Methods

We evaluated factors such as cause of dislocation, scleral fixation of an intraocular lens (IOL), preoperative and postoperative visual acuity, corneal endothelial cell density, and intraoperative and postoperative complications.

Results

Displacement in the eleven eyes studied was mostly caused by ocular trauma and was idiopathic (four eyes each). Scleral fixation of the IOL was performed in seven of the eyes during first-time PPV. Visual acuity was improved in two eyes, unchanged in eight eyes, and worse in one eye. Mean corneal endothelial cell density was 2485 cells/mm² preoperatively and 2301 cells/mm² postoperatively. No significant differences were seen before and after the surgeries (P = 0.15, paired t-test). Intraoperative complications included retinal detachment and suprachoroidal hemorrhage in one eye each. The most common postoperative complication was transient ocular hypertension, which occurred in three eyes. IOL dislocation and vitreous incarceration of the anterior chamber in one eye required a second operation, while retinal detachment in one eye required a third operation.

Conclusion

When treating a completely dislocated lens, prevention of retinal detachment which subsequently can affect the visual prognosis is the most important factor to be addressed after PPV with intravitreal phacoemulsification.