Aqueous misdirection syndrome post silicone oil removal in a vitrectomized eye - a case report

PUROPSE

Aqueous misdirection syndrome (AMS) is an aggressive post-operative glaucoma unresponsive to conventional measures with grave outcomes. In this report, we describe a rare case of AMS following silicon oil removal in a vitrectomized eye.

METHODS

A diabetic patient with tractional retinal detachment underwent pars plana vitrectomy with silicon oil injection. Following retinal reattachment, silicon oil removal was performed at three months. Post oil removal she developed increased intraocular pressure with shallowing of both the peripheral and central anterior chamber suggestive of AMS.

RESULTS

Initial medical management with anti-glaucoma medications and cycloplegics was not beneficial. A pars plana lensectomy with complete anterior hyaloidectomy along with a surgical peripheral iridectomy helped relieve the aqueous misdirection.

CONCLUSION

AMS can rarely occur following vitrectomy and is likely secondary to intact anterior hyaloid. Lensectomy along with zonulo-hyaloido-iridectomy is essential. This report highlights the occurrence of this rare complication and its effective management.

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.

Endoscopy-assisted pars plana lensectomy for brunescent cataracts in eyes with microcornea with microphthalmos

Purpose: Conventional cataract surgeries can be a challenge in eyes with microcorneas due to difficult manipulation in a crowded anterior chamber (AC) and can lead to a high occurrence of corneal edema and an increased rate of complications. Similarly, in cases of dense brunescent cataracts even a lensectomy through posterior approach may prove to be difficult because of inadequate visualization. An endoscopyassisted pars plana lensectomy can help in obviating these difficulties. This study aims to describe the surgical technique of endoscopy-assisted pars plana lensectomy in eyes with brunescent cataract, microcornea, and microphthalmos.Methods: Retrospective review of two cases where endoscopy-assisted pars plana vitrectomy and lensectomy was performed for patients with dense cataract and microcornea and microphthalmos.Result: Complete clearance of the cataract was achieved without having to resort to a sclerocorneal incision. Postoperatively the cornea was clear and there was no postoperative corneal edema.Conclusion: Endoscopy-assisted pars plana lensectomy can help in overcoming the challenges of conventional anterior and posterior approaches of cataract extraction in cases of microcornea with reduced intraoperative and postoperative complications.

Outcomes of three surgical approaches for managing ectopia lentis in Marfan syndrome

OBJECTIVE

To investigate the clinical outcomes of three surgical approaches for ectopia lentis in Marfan syndrome (MS) patients who had undergone crystalline lens removal with posterior chamber intraocular lens (IOL) implantation techniques comprising the intrascleral fixation of IOL, sutured scleral fixation of IOL, and IOL implantation with the use of a Cionni capsular tension ring (CTR).

METHODS

This is a retrospective comparative study, including 35 eyes of 21 patients who underwent the intrascleral fixation of IOL (group 1), scleral IOL fixation with the Z-suture (group 2), and IOL implantation with the use of a Cionni CTR (group 3) following crystalline lens removal. The surgical indications were as follows: no improvement in visual function after eyeglasses or contact lens application due to excessive irregular astigmatism and advanced crystalline lens decentration in which the edge of the crystalline lens came up to the optical axis, or dislocation of the crystalline lens resulting in aphakia and secondary glaucoma due to lens dislocation. The surgical outcomes and complications due to surgery were compared between the groups.

RESULTS

The mean age of the patients in the study was 12.3 ± 8.7 years (5-32 years). There were 10 eyes in group 1, 13 eyes in group 2, and 12 eyes in group 3. Visual acuity improved significantly in each group after surgery. Ocular residual astigmatism did not differ significantly between the groups (p = 0.51).

CONCLUSION

There were no significant differences between the three surgical approaches in the current study in terms of the postoperative results and complications.

Outcomes of Cataract Surgery Complicated by Retained Lens Fragments Requiring Pars Plana Vitrectomy

Objective

To analyze outcomes and complications related to cataract surgery complicated by retained lens fragment (RLF) requiring pars plana vitrectomy (PPV) in a county hospital where procedures are performed by trainees.

Methods

Retrospective study of consecutive patients who met inclusion criteria and underwent PPV for RLF in the vitreous cavity at an urban teaching hospital between January 2010 and January 2016 (N=20).

Main Outcomes/Measures

Visual acuity was recorded pre- and post-operatively over a follow-up period of 3 to 12 months. Complications and patient factors contributing to outcomes were assessed using paired and unpaired t-tests and multiple linear regression.

Results

The average rate of cataract surgery with RLF requiring PPV was 0.75%. Twenty patients met inclusion criteria. Mean pre-operative visual acuity (VA) was logMAR 1.7 (Snellen 20/1000). Nearly half (8/20) had nuclear cataracts grade 3+ or higher. The majority (14/20) had factors predisposing them to cataract surgery complications. Most patients underwent PPV within 1 week (median 6.5 days). At 12-month follow-up, significant (p=0.001) visual acuity (VA) improvement from initial VA was observed, with final mean logMAR 0.6 (± 0.75; Snellen 20/80) and median logMAR 0.35 (Snellen 20/45). Nearly half of the patients had a final Snellen VA ≥20/40. Factors associated with less VA improvement were older age and greater proportion of lens dropped (p<0.01). Complications following PPV included hypotony (5 patients), corneal edema (4), elevated intraocular pressure (IOP) (3), and cystoid macular edema (3).

Conclusions/Relevance

Despite patients with advanced pathology and trainee surgeons, rates of cataract surgery-associated RLF requiring PPV at a large tertiary care teaching hospital are similar to reported rates in the literature.

Optic capture pars plana lensectomy

Objective

To describe an optic capture pars plana lensectomy technique.

Methods

After core vitrectomy, pars plana lensectomy is performed with preservation of the anterior capsule. Capsulorhexis is performed on the preserved anterior capsule through a 2.8 mm clear corneal incision. An intraocular lens (IOL) is placed in the ciliary sulcus, and then the optic of the IOL is pushed back to the vitreous cavity so that the optic is captured by the surrounding capsulorhexis margin.

Results

The captured IOL-capsule diaphragm remained stable during air–fluid exchange and prevented air prolapse to the anterior chamber. IOL stability and a clear visual axis were preserved during the follow-up period.

Conclusion

With this modified pars plana lensectomy technique, stable IOL position and clear visual axis can be maintained when a pars plana approach is needed during combined cataract and vitreoretinal surgery.

Surgical results of pars plana vitrectomy combined with pars plana lensectomy with anterior capsule preservation, endophotocoagulation, and silicon oil tamponade for neovascular glaucoma

Purpose

To report on pars plana vitrectomy (PPV) combined with pars plana lensectomy (PPL) with a preserved anterior capsule, panretinal endophotocoagulation (EPC) throughout the pars plana, and silicon oil (SO) tamponade (PPV + PPL + EPC + SO tamponade) for neovascular glaucoma (NVG).

Methods

Thirteen eyes with NVG were treated. Ten eyes also underwent SO removal and intraocular lens (IOL) implantation (SO removal + IOL). Intraocular pressure (IOP), number of medications, and visual acuity were evaluated at the first visit, immediately before and 3 months after the procedure, 3 months after SO removal + IOL, and 1 year after the procedure.

Results

At the first visit, immediately before and 3 months after the procedure, 3 months after SO removal + IOL, and 1 year after the procedure, the IOPs were 29 ± 19, 23 ± 12, 13 ± 5, 17 ± 10, and 17 ± 6 mmHg; numbers of medications, 0.7 ± 1.4, 2.1 ± 2.0, 0.6 ± 0.7, 1.2 ± 1.2, and 1.6 ± 1.6; and best-corrected visual acuities converted to logarithm of the minimum angle of resolution (BCVA logMAR), 0.96 ± 0.96, 1.27 ± 0.80, 1.67 ± 0.91, 1.37 ± 0.89, and 1.90 ± 1.44, respectively. No severe hypotony or phthisis bulbi developed within 1 year after the procedure. The success rates (IOP ≤ 21 mmHg and sustained light perception) were 92.3% after 3 months and 69.2% after 1 year.

Conclusion

PPV + PPL + EPC + SO tamponade might have prevented acute increases of vascular endothelial growth factor and inflammatory cytokine production postoperatively and resulted in good vision in patients with NVG.