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

Vitreous management in Yamane's technique for crystalline lens dislocation: anterior vitrectomy or PPV?

OBJECTIVE

To study the postoperative visual outcomes and surgical complications of anterior/pars plana vitrectomy and concurrent Yamane's IOL fixation for crystalline lens dislocation.

METHODS

Fifty-three patients (56 eyes) with crystalline lens subluxation/dislocation were enrolled in this retrospective interventional study. Patients received anterior/pars plana vitrectomy and concurrent Yamane's IOL fixation. Main outcome measures were postoperative BCVA and surgical complications. Proportion of spontaneous PVD and preoperative undetected retinal holes/degeneration (PURH/D) were recorded.

RESULTS

Twenty-four eyes were treated with anterior vitrectomy (Group AnV) and 32 eyes with pars plana vitrectomy (Group PPV). Overall incidence of PURH/D was 10.7% (6/56). Spontaneous PVD occurred in 68.8% (24/32) in Group PPV. During six months follow-up, one case of postoperative RRD and one case of choroidal detachment occurred in Group AnV. There was no significant difference between anterior vitrectomy and PPV in the final BCVA and postoperative complications.

CONCLUSION

Anterior or pars plana vitrectomy, which are both applicable in YAMANE technique for crystalline lens dislocation, exhibit similar surgical outcomes. Patient's age, PVD status and PURH helps to determine the route of vitrectomy. Pediatric patients might be potential candidates for transcorneal vitreolensectomy. For adult, PURH managed with total vitrectomy and intraoperative lase retinopexy might be beneficial to decrease the incidence of postoperative RRD.

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.

Incidence and management of rhegmatogenous retinal detachment after pars plana vitrectomy and sutureless scleral-fixated intraocular lens

Purpose

To evaluate the incidence, risk factor(s), and surgical outcomes of rhegmatogenous retinal detachment (RRD) in patients undergoing pars plana vitrectomy (PPV) with sutureless scleral-fixated intraocular lens implantation (SFIOL).

Methods

Records of patients (1311 eyes, 1234 patients) who underwent PPV and sutureless SFIOL from 2017 to 2018 were retrospectively analyzed.

Results

The indications SFIOL were subluxated lens (33.7%), dislocated IOL (21.7%), surgical aphakia (20.1%), congenital lens subluxation (11.1%), nucleus drop (6.9%), and post-open globe injury (OGI) repair (6.5%). History of closed-globe injury (CGI) was present in 27.2% eyes.Twenty-two eyes (1.7%) developed RRD. The incidence of RRD in eyes, which underwent SFIOL surgery for subluxated lens, dislocated IOL, surgical aphakia, congenital lens subluxation, nucleus drop, and post-OGI repair was 1.4% (n = 6), 2.5% (n = 7), 1.1% (n = 3), 3.4% (n = 5), 0 and 1.2% (n = 1), respectively (P = 0.382). The incidence of RRD in eyes with and without CGI was 1.7% each (P = 0.996).Twenty-one eyes underwent RD surgery. Retinal reattachment was achieved in 76.2% eyes, while 66.7% eyes required only one surgery. The eyes in which retina failed to reattach had a high grade of proliferative vitreoretinopathy present at the time of presentation. Final best-corrected visual acuity of ≥20/60 and <20/60 to ≥20/200 and <20/200 was seen in 38.1%, 19.0%, and 42.9% eyes.

Conclusion

Eyes with the congenital subluxated lens are at a marginally higher risk of developing post-SFIOL RRD. The surgical outcome of RD surgery in these eyes is good.

Outcomes of lensectomy and risk factors for failure in spherophakic eyes with secondary glaucoma

PURPOSE

To report the outcomes of lensectomy in spherophakic eyes with subluxated or dislocated crystalline lenses and secondary glaucoma.

METHODS

Lensectomy was performed in 52 eyes, 36 eyes with lens subluxation and 16 eyes with lens dislocation with secondary glaucoma from 1991 to 2016. Glaucoma was diagnosed based on intraocular pressure (IOP) ≥22 mm Hg and/or glaucomatous optic disc damage. Complete success was defined as IOP ≥5 and ≤21 mm Hg without antiglaucoma medications (AGMs) or surgery, and eyes needing oral AGM or surgical intervention for IOP control or those with complication causing loss of light perception were considered failure.

RESULTS

Median (IQR) age at lensectomy was 12 (6-18) years, and median spherical equivalent was -14.5D (-23.7to -13). Median follow-up was 30.6 (5.4-103.4) months. Median logMAR (logarithm of minimal angle of resolution) visual acuity improved from 0.95 (0.6-1.8) to 0.4 (0.2-1.3) after lensectomy (p=0.01). Median IOP decreased from 22 mm Hg (17-31) to 14 mm Hg (11-19) at final follow-up (p=0.01). Median number of AGM decreased from 2 (2-3) to 1 (0-2) at final follow-up (p<0.0001), and glaucoma surgery was needed in four eyes (7.7% eyes). Complete success probability was 69% at 1 year and 51% at 5 years. Younger age (<6 years), higher presenting IOP (>32 mm Hg) and larger cup to disc ratio at presentation were found to be significant risk factors for failure.

CONCLUSION

Lensectomy was effective in controlling IOP in close to half of all eyes with spherophakia and secondary glaucoma, 40% eyes needed AGM and only 7.7% eyes needed glaucoma surgery for IOP control. In this cohort, younger age, higher IOP and larger cup to disc ratio at presentation were risk factors for poor glaucoma control after lensectomy.

Modified technique of endocapsular lens aspiration for severely subluxated lenses

PurposeSeverely subluxated crystalline lenses pose a difficult situation to anterior segment surgeons and can only be managed surgically by removal of the lens as well as the capsular bag. Several techniques have been described in literature for the management of such cases. We describe a modified technique of endocapsular lens aspiration by the limbal route for lens extraction through small incisions on the cornea.Patients and methodsThirty-two eyes of 16 consecutive patients with severely subluxated crystalline lenses were recruited in the study. All eyes underwent a modified technique of lens aspiration within the capsular bag using a single instrument, vitrectomy cutter, and irrigation cannula, followed by sacrificing of the capsular bag. The patients were either left aphakic or implanted with an open loop anterior chamber intraocular lens (ACIOL Kelman Multiflex) and prospectively followed up for a period of 3 months.ResultsThe mean age of the patients was 9 years 3 months±3 years (range 5-15 yrs). All eyes underwent complete lens aspiration within the capsular bag with no dislocation of the lens matter. ACIOL was inserted in 22 eyes (68.7%) and 10 eyes (31.2%) were left aphakic. All the surgeries were uneventful. The mean best corrected visual acuity (BCVA) at 3 months post surgery was 0.47±0.11 logMAR which was significantly better than pre-operative BCVA (P=0.001). The percentage endothelial cell loss at 3 months was 7.1%. There was no evidence of glaucoma, corneal decompensation, or retinal detachment. The astigmatism which increased from 1.45D±086 preoperatively to 3.76D±2.02 1 week post-operatively due to sutures reduced to 1.97D±0.81 post suture removal at 3 months.ConclusionThe modified technique of endocapsular lens aspiration proves to be a simple and effective method of removal of the lens-capsular bag complex in severely subluxated lenses.