Phacoemulsification and intraocular lens placement in eyes with cataract and congenital coloboma: visual acuity and complications

Unilateral Lens Coloboma With Congenital Cataract: A Case Report From Central India

A ten-year-old male child was referred with complaints of blurring of vision and deviation of the eye. On examination, the right eye has an esodeviation squint with a best corrected visual acuity of 6/60 Snellen's acuity and 6/6 Snellen's acuity in the left eye. Slit-lamp biomicroscope of the right eye showed coloboma at the 9 o'clock position with cataract. The rest of the anterior and posterior segments was normal in both eyes. Thus, a diagnosis of unilateral lens coloboma with amblyopia was made.

Optical changes and apparent emmetropization in a patient with a peripheral unilateral lens coloboma

Lens coloboma is a developmental defect resulting from abnormalities of the zonules and ciliary body. It may present as an isolated pathology or be accompanied by anomalies in different ocular structures. We report the case of a 20-year-old man referred for evaluation of anisometropic amblyopia in the right eye. Manifest refraction was -2.25 +3.00 ×35 in the right eye; corrected distance visual acuity, 20/50. Corneal topography revealed regular astigmatism of +2.46 D at 124°, and wavefront aberrometry revealed an irregular internal astigmatism of +6.27 D at 35°. Only after full pupillary dilation was a peripheral lens coloboma observed. This case demonstrates that even minor distortions of clear and normally positioned lenses may lead to amblyopia and raises the possibility that corneal changes may occur developmentally through the process of emmetropization partly to compensate for lenticular astigmatism arising from the coloboma.

Cataract surgery in eyes with associated coloboma: Predictors of outcome and safety of different surgical techniques

Purpose:

The aim of this study was to report the outcome of cataract surgery with different surgical techniques in eyes with coexisting coloboma and to define factors of prognostic importance.

Methods:

Retrospective case sheet review of patients presenting between January 2016 and December 2018, who underwent cataract surgery in eyes with coexisting coloboma.

Results:

Of the 3,30,231 cases operated during the study period, 280 eyes of 276 patients had associated colobomatous malformation. The prevalence of coloboma in eyes undergoing cataract surgery was 0.085%. The mean age of the patients was 46.4 years (range 19 - 88 years). Phacoemulsification (PE) was performed in 130 eyes (46.4%), manual small incision cataract surgery (M-SICS) was done in 115 eyes (41.1%), and 35 eyes (12.5%) underwent intra capsular cataract extraction. Intra-operative complications were noted in 26 (9%) eyes. Incidence of intra-operative and post-operative complications was comparable between PE and M-SICS groups (p = 0.94). The mean corrected distance visual acuity (CDVA) improved from logMAR 1.71 ± 0.62 to 0.87 ± 0.61 (p = 0.00009). On multivariate analysis, microcornea (p = 0.002), type 1 and 2 coloboma (p < 0.001), and intraoperative complications (p = 0.001) were associated with poor visual outcome.

Conclusion:

Favorable functional outcomes can be achieved with phacoemulsification in eyes with softer cataract and corneal diameter >8 mm and with M-SICS in eyes with hard cataracts and corneal diameter of 6–8 mm. PE should be considered as the primary choice whenever permissible by the corneal diameter and severity of nuclear sclerosis. Poor functional outcomes were seen in eyes with smaller corneal diameter, extensive chorioretinal coloboma, and intraoperative complications.

Cataract surgery in eyes with congenital ocular coloboma

PURPOSE

To assess the safety, efficacy, and complication rate of phacoemulsification and intraocular lens (IOL) implantation in patients with congenital uveal coloboma and to evaluate the role of pupilloplasty.

METHODS

A retrospective review of 41 eyes (31 patients) with congenital coloboma that underwent phacoemulsification and IOL implantation between September 2012 and September 2018. Preoperative, intraoperative, and postoperative data were collected for analysis.

RESULTS

The mean patient age at surgery was 53.9 years (range 15-82). The primary indication for surgery was cataract removal for visual improvement, and lens subluxation was additionally present in two eyes (5%) preoperatively. The mean preoperative corrected distance visual acuity (CDVA) was 0.90 LogMAR. Phacoemulsification surgery was performed in all cases and nine eyes (22%) had pupilloplasty for pupil reconstitution at the time of the procedure. Surgeon grade varied from trainee surgeon under supervision to consultant. Eight patients (19.5%) had posterior capsular rupture (PCR) with or without vitreous loss requiring anterior vitrectomy. Of these, 2 cases (5%) had dropped nuclear fragments requiring subsequent pars plana vitrectomy and lens fragment removal. The mean postoperative CDVA was 0.62 LogMAR (p = 0.0003).

CONCLUSION

Patients with iridolenticular choroidal coloboma appear to be more at risk of complications, as were cases performed by non-consultant surgeons. Contrary, patients with phakodonesis, preoperative anterior chamber vitreous, dense cataracts, and cases were iris hooks used had no significant difference at PCR rate. The risk of postoperative glare and pupilloplasty needs to be considered in cases with good visual potential to avoid a possible second procedure.

Scleral tunnel phacoemulsification: Approach for eyes with severe microcornea

Cataract surgery in eyes with microcornea is associated with frequent complications such as corneal edema, posterior capsular rent, and risk of unplanned aphakia. We describe an improved surgical technique for the creation of surgical incisions during phacoemulsification in eyes with cataract associated with microcornea. A retrospective analysis of eight patients (8 eyes) operated at our center was undertaken. The mean age of the patients was 29.5 ± 10.9 years. All eyes were operated using the scleral pocket incision for phacoemulsification. This scleral pocket incision was tangential to the limbus and created approximately 2.5 mm behind limbus through which phacoemulsification probe was inserted. Because of the posterior placement of incision, the anterior chamber crowding was minimized. There was no incidence of port-site peripheral corneal edema. Fifty percent eyes developed transient central corneal edema, the intraocular lens in bag was implanted in 5/8 eyes, and none developed Descemet's membrane detachment. Mean best-corrected visual acuity improved from 1.85 ± 0.38 logarithm of minimum angle of resolution (LogMAR) to 1.26 ± 0.70 LogMAR postoperatively (P = 0.01; paired t-test). Posterior incision placement during phacoemulsification in microcornea helps achieve favorable postoperative outcomes in contrast to outcomes using clear corneal approach described in literature.

Vitrectomy-assisted phacoemulsification for lenticular coloboma

We describe a technique to prevent continuous vitreous hydration during phacoemulsification in eyes with lenticular coloboma. The hydration results from communication between the anterior and posterior chambers from the edges of the colobomatous defect. To avoid this, a valved trocar is placed at the pars plana site around the area of the lenticular defect, which allows a limited dry vitrectomy during phacoemulsification. Intermittent vitrectomy with a moderate cutting rate and low vacuum parameters accompanied by temporary halting of the phacoemulsification procedure prevents vitreous herniation into the anterior chamber and limits the extension of zonular compromise, facilitating safe phacoemulsification with appropriate capsule expansion and fixation devices and implantation of an intraocular lens.

Lens coloboma treated with lens surgery

A 5-year-old boy was referred to our clinic due to an abnormal visual acuity test at school. His corrected visual acuity was counting fingers in the left eye. A nasal side deficiency of the lens substituted by a membrane was found. Lens coloboma was diagnosed. After making a 3 mm limbal incision, the colobomatous lens was removed by anterior continuous curvilinear capsulorhexis and lens aspiration. Posterior capsulorhexis and anterior vitrectomy on the side of the lens was performed to prevent posterior capsular or anterior hyaloid opacity. As the defect in the lens was very large, intracapsular placement of an intraocular lens was not feasible. A three-piece acrylic soft intraocular lens was placed in the ciliary sulcus. Since amblyopia was diagnosed by poor corrected visual acuity as 20/800 1 month after the operation, occlusion therapy with correcting eyeglasses was started at 6 h a day on the contralateral eye. The patient's corrected visual acuity improved to 20/125 7 months after the operation.

Lenticular changes in congenital iridolenticular choroidal coloboma

PURPOSE

To evaluate the lenticular changes associated with congenital iridolenticular choroidal coloboma.

DESIGN

Retrospective, observational case series.

METHODS

setting: Tertiary eye care center in south India. study population: Total of 145 eyes of 98 patients. observation procedure: Medical records of all patients with the diagnosis of congenital iridolenticular choroidal coloboma between January 2011 and December 2012 were reviewed retrospectively for demographic profile, extent of coloboma, and associated lenticular changes.

RESULTS

Median age of patients at the time of initial visit was 23 years (interquartile range, 13-38 years). The male-to-female ratio was ∼ 1:1. Forty-eight percent had bilateral involvement. Lens showed cataract changes in 68 eyes (48.9%). The most common type of cataract was nuclear sclerosis, which was noted in 51% of cases. A distinct type of cataract, called "coloboma cataract" (characterized by linear opacity in the region of the coloboma), was observed in 29% of cases. Other associated findings were phacodonesis in 3 eyes, dislocation in 3 eyes, and subluxation in 5 eyes. Disc and/or macular involvement in 57 eyes (39.3%) did not influence the type or density of cataract (P > .05).

CONCLUSIONS

Congenital iridolenticular choroidal coloboma is associated with early cataractous changes. The most common type of cataract is nuclear sclerosis. The type and density of cataract do not seem to be related to the extent of the choroidal coloboma. We suggest a distinct description with the nomenclature "coloboma cataract" to be considered in the clinical grading of cataracts in patients with this condition.

Iatrogenic diplopia [corrected]

Diplopia is a very disturbing condition that has been reported as a complication of several surgical procedures. The following review aims to identify the ocular and nonocular surgical techniques more often associated with this undesirable result. Diplopia is reported as an adverse outcome of some neurosurgical procedures, dental procedures, endoscopic paranasal sinus surgery, and several ophthalmic procedures. The most common patterns and some recommendations in order to prevent and treat this frustrating outcome are also given.

A case of spina bifida with ocular manifestations

Neural tube defects are common congenital abnormalities associated with a variety of complications. Spina bifida, among the most common, results from failure of the neural tube and the vertebral bones to close during embryogenesis. Myelomeningocele is the most common severe form of spina bifida. It may be associated with various anomalies in different tissues. Here we report a case of spina bifida with associated ocular anomalies and review the literature of previous spina bifida cases with ocular manifestations.

A modified iris repair technique and capsular tension ring insertion in a patient with coloboma with cataracts

Purpose

We describe our successful experience using a capsular tension ring (CTR) and iris repair during cataract surgery in a patient with bilateral coloboma.

Methods

A 67-year-old woman had no history of trauma, but had zonular deficiency and inferonasal iris defects in both eyes. An extracapsular cataract extraction and intraocular lens (IOL) scleral fixation was performed in the left eye. A CTR was implanted in the right eye through a sclerocorneal incision. After the IOL was placed centrally in the capsular bag, two paracenteses were made at the limbus (5 o'clock and 7 o'clock). A long, straight needle was passed through the 7 o'clock paracentesis site into a angled, blunt tipped 27 gauge needle inserted from the 5 o'clock paracentesis. The two needles were pulled out at 5 o'clock. After inserting the long needle into the blunt tipped needle at 7 o'clock, both were passed back through the 7 o'clock paracentesis site. The needles were pulled out again at the 5 o'clock paracentesis site tied. Equal tension was used to tie both sides.

Results

Visual acuity improved to 20/20 in the right eye.

Conclusions

Both capsular tension ring implantation and iris repair was successfully performed at the time of cataract surgery in a coloboma patient, which resulted in improvements in visual function and cosmesis.

Surgical technique for congenital iris coloboma repair

We describe a surgical technique for managing congenital iris coloboma. After phacoemulsification with placement of an intraocular lens in the capsular bag, coloboma repair is begun by bisecting the iris sphincter on both sides of its attachment near the chamber angle. The iris leaflets central to the sphincterectomies are approximated using a 10-0 polypropylene suture (Prolene, Ethicon, Inc.) and a modified Siepser pupilloplasty technique. The remaining peripheral iris defect is closed in a similar fashion. In patients with congenital iris coloboma, phacoemulsification with in-the-bag IOL implantation followed by this pupilloplasty technique was effective in providing functional and cosmetic repair of a congenital iris coloboma.

Uveal coloboma: clinical and basic science update

PURPOSE OF REVIEW

To integrate knowledge on the embryologic and molecular basis of optic fissure closure with clinical observations in patients with uveal coloboma.

RECENT FINDINGS

Closure of the optic fissure has been well characterized and many genetic alterations have been associated with coloboma; however, molecular mechanisms leading to coloboma remain largely unknown. In the past decade, we have gained better understanding of genes critical to eye development; however, mutations in these genes have been found in few individuals with coloboma. CHD7 mutations have been identified in patients with CHARGE syndrome (coloboma, heart defects, choanal atresia, retarded growth, genital anomalies, and ear anomalies or deafness). Animal models are bringing us closer to a molecular understanding of optic fissure closure.

SUMMARY

Optic fissure closure requires precise orchestration in timing and apposition of two poles of the optic cup. The relative roles of genetics and environment on this process remain elusive. While most cases of coloboma are sporadic, autosomal dominant, autosomal recessive, and X-linked inheritance patterns have been described. Genetically, colobomata demonstrate pleiotropy, heterogeneity, variable expressivity, and reduced penetrance. Coloboma is a complex disorder with a variable prognosis and requires regular examination to optimize visual acuity and to monitor for potential complications.

Modified flexible iris retractor to retract superior iris and support inferior capsule in eyes with iris coloboma and inferior zonular deficiency

Flexible nylon iris retractors are a useful adjunct to cataract surgery in cases of small pupil and subluxated lenses. A modification is presented of the standard application of iris hooks to retract the superior iris and support the inferior capsule during phacoemulsification in cases of iris coloboma with inferior zonular deficiency. Three iris hooks are applied to retract the iris, and 2 iris hooks are applied to the inferior capsule margin to support the crystalline lens in that quadrant. Clear corneal temporal phacoemulsification is then performed with adequate pupillary diameter and capsular support.