Phacoemulsification in eyes with long anterior zonules

Long anterior zonule trait, lessons learned about an uncommon form of secondary angle closure: a case report

A 62-year-old black woman with uncontrolled chronic narrow-angle glaucoma on 3-drug therapy underwent phaco-non-perforating deep sclerectomy of her left eye. During surgery it was revealed that she had long zonule trait. She later required goniopuncture and conjuntival needling, presenting an iris herniation in the goniopuncture that could be reduced conservatively. Long anterior zonule trait should be suspected in those patients presenting with a combination of narrow angle and pigment dispersion syndrome. The management of ocular hypertension and glaucoma associated to this trait is not protocolized. This communication discusses on the best action in this rare form of glaucoma.

Long anterior lens zonules with retinal stripes: a case report

Background

Long anterior lens zonules   (LAZs) is a rare disease that was mostly conducted among African Americans. Through the observation of a Chinese patient, we discoverd that the disease may show different characteristics in Asians.

Case presentation

A patient with vision loss due to a macular hole was found to have several special clinical signs during vitrectomy combined with phacoemulsification and intraocular lens implantation surgery in our hospital, including radially oriented lines on the anterior capsule with pigment, a shallow anterior chamber, slightly high intraocular pressure, and radial retinal stripes in the peripheral retina. Finally, he was diagnosed with long anterior lens zonule syndrome.

Conclusion

Clinicians need to pay more attention to the rare disease LAZs. It is important to tear the appropriate size of the anterior capsule so as to avoid radial capsular tearing and intraocular lens dislocation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02496-7.

Ultrasound Biomicroscopy Observation of Suspicious Primary Angle Closure Combined with the Relaxation of Zonule

Purpose

To investigate the difference in anterior segment parameters between suspicious primary angle closure (PACS) patients and normal patients as assessed by ultrasound biomicroscopy (UBM).

Methods

From June 2019 to November 2020, 39 patients (50 eyes) with PACS in the Ophthalmology Department of Qingdao University Affiliated Hospital who underwent phacoemulsification and intraocular lens implantation were selected as the PACS group. 32 patients (50 eyes) who underwent phacoemulsification and intraocular lens implantation were selected as the normal group. In addition to routine preoperative examinations such as visual acuity, noncontact intraocular pressure, axis length (AL), and ocular B-ultrasound examination, UBM examinations were also performed, including measuring the central anterior chamber depth (ACD), the maximum transverse diameter of the ciliary process at both ends (STS), the vertical distance between the anterior apex of the lens and the maximum transverse diameter at both ends of the ciliary processes (h), and angle opening distance (AOD500), iris-zonule distance (IZD), trabecular-ciliary process distance (TCPD), trabecular-iris angle (TIA), iris thickness (IT), trabecular-ciliary process angle (TCPA), and anterior placement of the ciliary body (APCB) at four quadrants (superior, nasal, inferior, and temporal quadrants).

Results

Compared with the normal group, the PACS group showed statistically differences in AL, ACD, h, ACD/AL, h/STS, IZD, AOD500, TCPD, TIA, TCPA, and APCB (P < 0.05), and there were no significant differences in STS and IT between the two groups (P > 0.05). In the PACS group, there were significant differences in AL, ACD, h, ACD/AL, h/STS, IZD, TCPD, TCPA, and APCB between PACS patients with zonular relaxation and without zonular relaxation (P < 0.05), while there were no significant differences in STS, AOD500, TIA, and IT (P > 0.05).

Conclusion

UBM quantitatively enables to identify the anterior segment morphology, especially the zonules in patients of suspicious primary angle closure combined with the relaxation of zonule. Accurate measurement of UBM can be used to predict whether patients with PACS are combined with zonular relaxation, so as to provide a clinical imaging evidence for the diagnosis.

Long Anterior Zonules and Angle Closure Disease

PRCIS

Angle closure disease was present in 59.3% of eyes with long anterior zonules (LAZ). The cause is multifactorial including a thick anteriorly positioned crystalline lens, shorter axial length, and increased lens thickness to axial length factor.

PURPOSE

To study the profile of eyes with LAZ presenting in a glaucoma clinic in a tertiary eye care centre and understand the pathogenesis of angle closure disease in these eyes.

METHODS

This was a retrospective cross-sectional study.All patients with LAZ seen from January 2014 to December 2018 were included. Demographic and clinical characteristics were noted. LAZ eyes (177 eyes of 177 patients) were compared with an equal number of age and sex-matched controls. LAZ was defined as radially oriented zonular fibers (both pigmented and nonpigmented), extending central to the normal zonular termination zone on the anterior lens surface >1 mm beyond their usual insertion of 1.42±0.24 mm from the lens equator onto the mid peripheral zone or central to it, as seen on slit-lamp examination, following pupillary dilation by a single examiner. Glaucoma was defined according to the International Society for Geographical and Epidemiological Ophthalmology classification. The following biometric parameters were compared: anterior chamber depth (ACD), axial length (AXL), lens thickness (LT), lens position (LP=ACD+0.5×LT), relative lens position (RLP=LP/AXL); lens thickness to axial length factor (LAF=(LT/AXL)×10). LAZ eyes without angle closure disease were also compared with controls.

RESULTS

Mean age of patients with LAZ was 64.8±8.1 years. Of these, 63.3% were females. Angle closure disease was present in 59.3% (105/177) patients. Majority of these eyes were primary angle closure suspects (PACS) (53.3%, n=56). Significant differences were found between LAZ eyes and controls for LT (4.8±0.38 mm vs. 4.49±0.40 mm, P<0.0001), ACD (2.68±0.39 mm vs. 3.0±0.32 mm, P<0.0001), AXL (22.37±0.79 mm vs. 22.94±1.1, P<0.0001), LAF (2.14±0.19 vs. 1.96±0.21, P<0.0001), and LP (5.07±0.37 vs. 5.3±0.25, P<0.0001).

CONCLUSIONS

Angle closure was present in more than half the eyes with LAZ. Majority of these eyes were PACS or had primary angle closure. LAZ eyes had a thicker lens, shallow AC, a shorter axial length and an increased LAF as compared with age and sex matched normal controls. The presence of LAZ may be an indicator of increased risk for angle closure.