Iris fixation of foldable intraocular lenses for ectopia lentis in children

Congenital anomalies of lens shape

The crystalline lens is an important structure in the eye that starts to develop as early as the 22nd day of gestation, with further differentiation that continues after the induction. Congenital anomalies of the lens may involve the size, shape, and position of the lens. They may sometimes be associated with anterior segment dysgenesis or persistence of the tunica vasculosa lentis and hyperplastic vitreous and hyaloid system. Manifestations of anomalies of the lens shape are usually seen in early or late childhood however may sometimes be delayed into adulthood based on the level of visual impairment or the presence or absence of any syndromic associations. While lens coloboma has more often been reported in isolation, the more commonly implicated genes include the PAX6 gene, lenticonus in particular anterior is often part of Alport syndrome with extra-ocular manifestations in the kidneys and hearing abnormalities due to mutations in the alpha 5 chain of the Type IV collagen gene. Recognition of these manifestations and obtaining a genetic diagnosis is an important step in the management. The level of visual impairment and amblyopia dictates the outcomes in patients managed either conservatively with optical correction as well as surgically where deemed necessary. This review discusses the various anomalies of the lens shape with its related genetics and the management involved in these conditions.

Long-term Outcomes of Fibrin Glue-Assisted Intrascleral Haptic Fixation of Posterior Chamber Intraocular Lenses in Children

OBJECTIVES

To evaluate the long-term outcomes of intrascleral haptic fixation of posterior chamber intraocular lens (PCIOL) with fibrin glue in children.

METHODS

This is a retrospective case study conducted in a tertiary eye institute in North India. A total of 118 eyes of 82 children who underwent glued intrascleral haptic fixation of PCIOLs were retrospectively analyzed. Detailed analysis of the indication for surgery and ocular and systemic associations was performed. The outcome measures included intraoperative complications, final visual and refractive outcomes, and postoperative complications.

RESULTS

The mean age of the patients was 10.16±3.94 years. Fifty-one patients (62.2%) were male and 31 (37.8%) were female. The mean follow-up period was 31.28±13.22 months. The mean preoperative corrected distance visual acuity was 1.18±0.63 Logarithm of Mean angle of resolution (logMAR) which improved to 0.60±0.58 logMAR postoperatively at 6 weeks (P<0.001). The mean preoperative and 6 weeks postoperative endothelial cell density were 3,176.08±318.6 and 2,936±289.9 cells/mm2, respectively (P=0.23). In the immediate postoperative period, corneal edema (19 eyes; 16.1%), decentered IOL/tilt (3 eyes; 2.54%), vitreous hemorrhage (3 eyes; 2.54%), optic capture (4 eyes; 3.38%), and hypotony (2 eyes; 1.69%) were seen. In the late postoperative period (>6 weeks), retinal detachment was observed in two eyes that had associated Marfan syndrome. Cystoid macular edema was seen in four eyes (3.38%), and glaucoma was seen in five eyes (4.23%).

CONCLUSIONS

Fibrin glue-assisted intrascleral haptic fixation of a PCIOL is a safe and effective method to manage aphakia with inadequate capsular support in children.

Surgical Management of Paediatric Aphakia in the Absence of Sufficient Capsular Support

There are several available options for the demanding surgical correction of paediatric aphakia without sufficient capsular support. The literature suggests the implantation of a transscleral fixated posterior chamber-intraocular lens (PCIOL), an intrascleral fixated PCIOL, an iris-sutured intraocular lens (IOL), or an anterior chamber iris-claw IOL. We searched for reports on the management of paediatric aphakia in case of inadequate capsular support that delineated the diverse surgical approaches and their postoperative results. Analysis demonstrated that different complications can be encountered depending on IOL placement technique, such as suture rupture, IOL dislocation, secondary glaucoma, endophthalmitis, vitreous hemorrhage, and endothelial cell loss. However, it was shown that various IOL designs have similar visual outcomes. Taking into consideration the advantages and disadvantages of each surgical technique, ophthalmic surgeons can determine the safest and most efficient approach for paediatric aphakic patients.

Unilateral and Spontaneous Complete Anterior Dislocation of the Crystalline Lens in a Patient With Homocystinuria

Homocystinuria is a metabolic disorder caused by a deficiency of cystathionine beta-synthase with autosomal recessive inheritance. Clinically it is characterized by lens subluxation, skeletal abnormalities, and thromboembolic accidents. We present a 6-year-old boy who was a known case of homocystinuria. The patient had a previous history of thrombotic cerebrovascular infarction at the age of 3. He had mild and vague pain in the left eye two weeks before presentation without being exposed to trauma. Ophthalmic examination revealed the dislocation of the crystalline lens into the anterior chamber with diffuse corneal stromal edema in the affected eye. The patient was treated with topical atropine and betamethasone eye drops, but due to the corneo-lenticular contact and corneal edema, he underwent lens extraction and placement of iris-fixated intraocular lens after 48 hours. Corneal edema exhibited improvement at follow-up visits. Early age onset and unilateral complete lens dislocation to the anterior chamber in the absence of a history of trauma is a less common presentation of homocystinuria. In patients with systemic diseases including homocystinuria that cause zonulysis, lens dislocation is usually symmetric and bilateral. Nevertheless, in unilateral cases especially in those who did not have any history of trauma, evaluation for systemic diseases like homocystinuria is necessary for early diagnosis and prevention from other systemic involvements.

Three-Year Outcomes of Cionni-Modified Capsular Tension Ring Implantation in Children Under 8 Years Old With Ectopia Lentis

PURPOSE

This study evaluated visual outcomes and complications at 3 years post-implantation of a Cionni-modified capsular tension ring (MCTR) with an intraocular lens (IOL) in ectopia lentis patients ≤8 years old.

DESIGN

Prospective clinical cohort study.

METHODS

Included were 101 eyes from 57 patients <8 years of age, who underwent surgery for nontraumatic ectopia lentis between November 2015 and December 2016. Exclusion criteria were planned IOL fixation in the ciliary sulcus, severe intraoperative complications, and incomplete follow-up. All eyes received in-the-bag implantation of a posterior IOL and Cionni-MCTR. Posterior capsulectomy and anterior vitrectomy were performed through the pars plana in 23 eyes of children <5 years of age. Patients were examined at 1 day, and 1, 6, and 12 months, and at 2 and 3 years postoperatively. Outcome; measurements included best-corrected visual acuity (BCVA), intraocular pressure (IOP), IOL centration, and posterior capsule opacification (PCO).

RESULTS

In all eyes, BCVA improved significantly after surgery, especially during the first 12 months (P < .05). Three years post-operatively, 44 eyes had BCVA 0.9 or better. Prophylactic Nd:YAG laser capsulotomy was performed 3 months post-surgery in 24 eyes; 34 eyes underwent this; procedure 6 months post-surgery because of PCO. A second surgery was; warranted in 4 eyes because of severe IOL decentration and combined anterior capsule contraction. No severe postoperative complications, such as retinal detachment or endophthalmitis, occurred.

CONCLUSIONS

Implantation of in-the-bag IOL with Cionni MCTR is effective for visual rehabilitation in young children with ectopia lentis. A close follow-up of these patients is necessary to monitor IOL centration and stability.

Scleral Fixation of Carlevale Intraocular Lens in Children: A Novel Tool in Correcting Aphakia With No Capsular Support

BACKGROUND AND OBJECTIVE

To report the clinical outcomes of the use of a novel, specially designed, scleral-fixated intraocular lens (IOL) for the correction of aphakia in the absence of capsular support of variable etiology in children.

PATIENTS AND METHODS

This is a retrospective, noncomparative, interventional case series of five eyes of five consecutive patients who underwent three-port pars plana vitrectomy and scleral fixation of the IOL. Inclusion criteria were at least 6 months of follow-up in children who underwent vitrectomy and IOL placement for aphakia and inadequate capsular support. Patients were excluded from the analysis if there was a previous open globe injury or any other ocular comorbidity such as macular pathology or previous surgery for retinal detachment, glaucoma, corneal transplantation, or strabismus.

RESULTS

The median follow-up period was 9 months (range: 7-13 months). The median age was 8 years (range: 2-10 years), and the male-to-female ratio was 5 to 0. Mean postoperative best-corrected visual acuity (VA) at the last follow-up visit was 20/32 (0.26 ± 0.32 logMAR [mean ± standard deviation]), improving from a mean baseline uncorrected VA of 20/800 (1.6 ± 0.7 logMAR), a statistically significant change (P = .003). The uncorrected postoperative VA was 20/63 (0.54 ± 0.37 logMAR). No significant postoperative complications were noted and all patients had good IOL position at the end of the follow-up without IOL capture. The mean tilt in four eyes (the 2-year-old was excluded from the analysis) was 2.1 ± 1.9 degrees. None of the patients required reoperation.

CONLCUSIONS

The present study represents the first to date in evaluating the use of a scleral-fixated IOL in patients with aphakia and in pediatric patients with inadequate capsular support. The technique is safe and provides excellent postoperative IOL fixation without IOL capture in any of the patients studied. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:94-101.].

Sutureless Scleral-Fixated Intraocular Lens Implantation for Refractive Rehabilitation in Eyes With Spherophakia

PURPOSE

Spherophakia is a rare, debilitating congenital ocular disorder.

METHODS

This institution-based, retrospective, interventional study evaluated medical records of 16 patients with spherophakia with a median age of 19.5 years. Twenty-six eyes underwent scleral-fixated intraocular lens implantation. The technique involved 2 parallel-to-limbus scleral tunnels fashioned using a microincision vitrectomy blade, followed by lensectomy, core vitrectomy, externalization of haptics through 2 separate diametrically opposite sclerotomies, and tucking in of the haptics into the tunnels. Anterior and posterior segment examination, visual acuity, and intraocular pressure (IOP) were noted at baseline and final follow-up.

RESULTS

Baseline best-corrected visual acuity (BCVA) of all eyes was 0.49 ± 0.51 logarithm of the minimum angle of resolution (logMAR) (Snellen equivalent, 6/18). BCVA of more than 6/60 was present in 28 of 32 (87.5%) eyes, and 13 of 26 (50%) eyes that were operated on had a baseline BCVA of more than 6/18. Postoperative BCVA in 26 eyes improved from 0.43 ± 0.32 logMAR to 0.19 ± 0.21 logMAR (Snellen equivalent, 6/9) (P = .002). Postoperative BCVA was more than 6/18 in 20 of 26 (76.9%) operated-on eyes (P = .046), and all eyes had a final BCVA of more than 6/60. In 20 of 26 (76.9%) eyes, BCVA improved from preoperative status. Postoperatively, spherical equivalent improved from -9.55 ± 5.17 diopters to -0.29 ± 1.45 diopters (P < .001). Apart from 2 patients with Marfan syndrome, 1 with Weill-Marchesani syndrome, and 1 with homocystinuria, the remaining patients had isolated spherophakia. Six eyes presented with an IOP greater than 21 mm Hg, and 50% of these eyes had a final IOP that decreased to less than 15 mm Hg after lensectomy.

CONCLUSIONS

Lensectomy with pars plana vitrectomy and scleral-fixated intraocular lens is an effective method of refractive rehabilitation for patients with spherophakia presenting with visual disability.

Evaluation of Sutureless, Glueless, Flapless, Intrascleral Fixated Posterior Chamber Intraocular Lens in Children with Ectopia Lentis

Aim

This paper aims at evaluating refractive outcome and complication profile of sutureless, glueless, flapless, intrascleral fixation of intraocular lens (SFIOL) in pediatric population.

Methods

This retrospective study included patients ≤18 years of age who underwent SFIOL for ectopia lentis. Details obtained included preoperative uncorrected visual acuity (UCVA), cycloplegic refraction, and best-corrected visual acuity (BCVA); intraoperative complications; and postoperative UCVA, cycloplegic refraction, and BCVA and complications.

Results

Median pre- and postoperative UCVA was logMAR 1.78 (Snellen 20/1200) and logMAR 0.30 (Snellen 20/40), respectively, (p < 0.001). Median pre- and postoperative BCVA was logMAR 0.24 (Snellen 20/34) and logMAR 0.18 (Snellen 20/30), respectively. UCVA ≥20/60 was attained in 90% of eyes. BCVA ≥20/30 was attained in 85.0% of eyes. Most common early postoperative complications were hyphaema (10%), transient vitreous hemorrhage (2.5%), and ocular hypotony (2.5%). None of these developed any long-term sequelae. Only one case of subluxation of IOL was seen. No case of late endophthalmitis or retinal detachment was seen.

Conclusion

Since refractive error induced is minimal, the procedure is suitable for IOL implantation in children, who are noncompliant with spectacles. The complication profile is similar to that reported in adults.

Clinical spectrum and surgical outcomes in spherophakia: a prospective interventional study

PurposeTo study the varied clinical presentations of patients with spherophakia, their management using surgical methods, and the clinical outcomes.Patients and methodsA prospective interventional study of 13 patients of spherophakia who presented to us from January 2014 and were followed up over the course of their treatment, and the data were documented for analysis.ResultsIn all, 26 eyes of 13 patients were reviewed and the median age of presentation was 12±12.05 years. All patients had a bilateral presentation with 22 eyes having lenticular myopia with a mean refractive error of -11.5±12.945 DS. Ten eyes presented with glaucoma of which six had raised intraocular pressure (IOP) >21 mm Hg. A total of 23 eyes underwent lens extraction for dislocation/subluxation. Lens extraction helped lower overall IOP. Refractive rehabilitation was done with ACIOL, posterior chamber intraocular lens (PCIOL) with capsular tension ring, and scleral-fixated intraocular lens (SFIOL) in respective cases with ACIOLs being the most commonly used option.ConclusionsSpherophakia is a rare condition, which exhibits a varying degree of lenticular myopia, glaucoma, and subluxation of the crystalline lens. Lensectomy with proper rehabilitation using ACIOL, PCIOL, or SFIOL is a method of managing subluxation and unacceptable myopia. Lensectomy may also be a viable option of controlling glaucoma alongside medications and glaucoma surgery for the management of glaucoma in such cases.

Bilateral posterior crystalline lens dislocations in an otherwise healthy child

Introduction: Ectopia lentis is defined as a crystalline lens displacement, either partially or completely, due to zonular abnormalities. It can be a result of trauma, hereditary ocular disease, or part of systemic diseases, like Marfan syndrome and homocystinuria. Case description: We report a case of a medically free 16-year-old girl, who was referred to our hospital complaining of poor vision and a squint in both eyes since childhood. Her history included a traffic accident when she was one-year-old. She was previously diagnosed with alternating esotropia, which was treated with glasses, alternating patching, and bilateral Botox injections. On examination, she had a visual acuity of 6/7.5 with correction in the right eye and 6/6 with correction in the left eye. She had an esotropia of 60 prism diopters, which was partially corrected to 40 prism diopters for near and distance vision. Fundus examination showed myopic changes in each eye and dislocated lenses in the posterior pole at 6 o'clock. Our case was stable, so we used conservative management with contact lenses. Conclusion: Bilateral posterior lens dislocation is very rare. A proper examination is important and early diagnosis can prevent serious complications, such as retinal detachment or pupillary block glaucoma.

Long-Term Outcomes of Iris-sutured Posterior Chamber Intraocular Lenses in Children

PURPOSE

To report the long-term outcomes and complications of iris-sutured posterior chamber intraocular lenses (PCIOLs) in the pediatric population.

DESIGN

Retrospective interventional case study.

METHODS

This study involved 12 consecutive pediatric patients (17 eyes) who underwent placement of foldable iris-sutured PCIOLs between September 2004 and September 2007. Outcome measures included change in visual acuity and complications.

RESULTS

Of the 17 eyes were reviewed, 6 (35%) had hereditary or idiopathic ectopia lentis, 5 (29%) had Marfan syndrome, 2 (12%) were aphakic after pars plana vitrectomy and 4 (24%) were aphakic after surgical intervention for trauma. Average follow-up was 4.69 ± 3.21 years and mean age of surgery was 7.21 ± 3.78 years. Seven eyes suffered dislocation of the PCIOL an average of 12.11 ± 11.97 months after surgery, with 2 patients undergoing dislocation a second time. There was a higher rate of dislocation in patients with a history of ectopia lentis due to Marfan syndrome, idiopathic causes, or hereditary causes than in patients being treated for aphakia resulting from other causes (71% vs 29%). Mean visual acuity improved in 12 of 17 patients (71%), from 0.80 ± 0.6 logMAR preoperatively to 0.35 ± 0.5 logMAR at most recent visit, P = .009. One eye of a Marfan patient sustained a retinal detachment 8 months after dislocation of the PCIOL, and 1 patient experienced iris capture of the PCIOL after surgery.

CONCLUSIONS

Iris-sutured intraocular lenses have been used as an alternative to transsclerally sutured intraocular lenses to correct aphakia in pediatric patients. Dislocation of the intraocular lenses can occur frequently, however. The procedure should be considered with caution in pediatric patients.

New Management Strategies for Ectopia Lentis

Ectopia lentis refers to displacement of the crystalline lens in the setting of various systemic and metabolic disorders. A literature review was conducted to investigate the management of non-traumatic ectopia lentis in the pediatric population, particularly focusing on surgical intervention. Both limbal and pars plana approaches for lensectomy are well established in the literature. Surgical options for intraocular lens implantation in pediatric eyes with ectopia lentis include anterior chamber intraocular lenses and iris-fixated or scleral-fixated posterior chamber intraocular lenses. Recently, the use of capsular tension rings has also been described with promising results. Visual rehabilitation and treatment of amblyopia are essential for patients within the amblyogenic age group following surgical intervention.

Scleral-fixated capsular tension rings and segments for ectopia lentis in children

PURPOSE

To report the short-term outcomes and complications of implantation of scleral-fixated capsular tension rings and/or capsular tension segments with intraocular lenses (IOL) in pediatric patients with ectopia lentis.

DESIGN

Retrospective, observational case series.

METHODS

Thirteen consecutive pediatric patients (19 eyes) underwent placement of in-the-bag IOL with either a Cionni modified capsular tension ring or a capsular tension segment in conjunction with a conventional capsular tension ring between January 1, 2009 and March 30, 2013 by 3 anterior segment surgeons at a single academic center. The scleral fixation suture was 9-0 polypropylene in 16 eyes and CV-8 Gore-Tex (expanded polytetrafluoroethylene) in 3 eyes. Outcome measures included change in corrected distance visual acuity (CDVA) and complications.

RESULTS

The mean age was 10.2 years ± 4.8 (SD) and the median follow-up, 23.4 months. A Cionni modified capsular tension ring was implanted in 5 eyes and a capsular tension segment with an unsutured capsular tension ring was implanted in 12 eyes. In 2 eyes, capsular tension segment alone was placed. The mean CDVA at the final follow-up (0.10 ± 0.11 logMAR, 18 eyes) was significantly better than preoperatively (0.58 ± 0.26 logMAR, 15 eyes) (P < .001). The CDVA at the final follow-up was 20/40 or better in 18 eyes (94.7%). All IOLs were well centered. Posterior capsule opacification developed in 11 eyes (57.9%), 9 eyes (47.4%) required neodymium-yttrium-aluminum-garnet capsulotomy, and 3 eyes (15.8%) required pars plana vitrectomy and posterior capsulotomy. Other complications included broken suture (5.3%) (9-0 polypropylene at CTR eyelet, repaired with CV-8 Gore-Tex), conjunctival dehiscence (5.3%), suture exposure (5.3%) (trans-scleral 9-0 polypropylene), and vitreous strand at inferior paracentesis (5.3%).

CONCLUSIONS

Implantation of in-the-bag IOL with either a Cionni modified capsular tension ring or a capsular tension segment in conjunction with a conventional capsular tension ring appears to be a safe and effective technique for visual rehabilitation in pediatric ectopia lentis.

Posterior iris-claw aphakic intraocular lens implantation in children

PURPOSE

To evaluate the indications, visual outcomes, and complication rate after posterior implantation of an iris-claw aphakic intraocular lens (IOL) in children.

DESIGN

Noncomparative retrospective cohort study.

METHODS

setting: Institutional practice. patients/intervention procedures: Seven eyes of 4 children without adequate capsular support had posterior chamber iris-claw aphakic IOL implantation between 2007 and 2012. main outcome measures: Visual acuity, endothelial cell changes, intraoperative and postoperative complications.

RESULTS

The mean age of the 3 boys and 1 girl was 12.0 ± 3.4 (SD) years (range 8-16 years). In all eyes, the mean postoperative best spectacle-corrected visual acuity (0.13 ± 0.17 logMAR) was statistically significantly better at the last follow-up than at 1 day preoperatively (0.60 ± 0.39 logMAR) (P < .05). The mean follow-up was 31 months (range 10-64 months). The mean endothelial cell density decreased from 3013 ± 155 cells/mm(2) preoperatively to 2831 ± 236 cells/mm(2) at last follow-up, representing a mean endothelial cell loss of 6.4%. No corneal decompensation, iritis, secondary glaucoma, or pupillary block occurred after surgery in any eye. Postoperative complications included transient postoperative hypotony in 1 eye and a traumatic dislocation of a posterior aphakic iris-claw IOL in 1 eye.

CONCLUSION

The posterior implantation technique of aphakic iris-claw IOL provided good visual outcomes with a favorable complication rate and can be used as a reasonable alternative for a wide range of indications in pediatric eyes without adequate capsular support.

Fulminant Panuveitis following Iris Suture Fixation of Posterior Chamber Intraocular Lens

We present a case of fulminant panuveitis following iris suture fixation of a posterior chamber intraocular lens. We hypothesize that the zonular dehiscence allowed the inflammatory cells in the anterior compartment to gain access to the posterior segment mimicking endophthalmitis or toxic anterior segment syndrome. Also certain bulky lens designs, like the current Rayner hydrophilic acrylic lens, are difficult to manipulate and hold in the optic capture position, and hence the iris fixation of these lenses can be traumatic and lengthy. It is advised to exchange such lenses with 3-piece intraocular lenses that are easy to fixate.

Management of lens dislocation and iris cyst after iris sutured intraocular lens implantation in children with Marfan syndrome

The authors describe two brothers with Marfan syndrome who developed severe complications after iris-suture fixation of an intraocular lens (IOL). A secondary iris cyst developed in one and the IOL dislocated into the vitreous in the other, requiring pars plana vitrectomy and IOL removal. Although the visual outcome was good in both cases, severe complications of iris-suture fixated IOLs must be considered when surgical correction of aphakia is attempted in children with Marfan syndrome.

Cionni ring and in-the-bag intraocular lens implantation for subluxated lenses: a prospective case series

PURPOSE

To report the intraoperative performance and postoperative outcomes of the Cionni-modified capsule tension ring (CTR) implantation in eyes with subluxated lenses.

DESIGN

Prospective, observational case series.

METHODS

This study was carried out at Iladevi Cataract & IOL Research Centre, Ahmedabad, India. The study population comprised 41 eyes with subluxated lenses that underwent lens extraction, capsular bag fixation with modified CTR, and in-the-bag single-piece AcrySof intraocular lens (IOL) implantation. Main outcome measures were intraoperative performance and postoperative best-corrected visual acuity (BCVA), IOL centration, and complications.

RESULTS

The mean age was 29.46 ± 16.16 years (3-68 years). Mean extent of subluxation was 6.1 ± 1.0 clock hours. Preoperatively, vitreous was detected in the anterior chambers of 5 eyes (12.2%). Two-port anterior chamber vitrectomy was performed in 2 eyes. Mean follow-up was 45.8 ± 2.9 months. Mean preoperative BCVA was 0.66 ± 0.22 logMAR (35 eyes). Mean postoperative BCVA at final follow-up was 0.33 ± 0.21 logMAR (41 eyes) (P < .001). BCVA improved in 35 eyes (85.4%) at the last follow-up. In 3 eyes (7.3%) IOL decentration was noted and repositioning was required in 2 eyes. Posterior capsule opacification developed in 14 eyes (34.2%); 12 eyes (29.3%) required Nd:YAG capsulotomy. Other complications included cystoid macular edema in 1 eye (2.4%), posterior synechiae in 1 eye (2.4%), and retinal detachment in 1 eye (2.4%).

CONCLUSION

In-the-bag implantation of a Cionni-modified CTR with IOL appears to be a safe option in eyes with subluxated cataract, ensuring a stable IOL with few complications.

Bilateral transient pupil closure after iris supported intraocular lens implantation in a case with Marfan syndrome

A 16-year-old woman presented with Marfan syndrome and bilateral ectopia lentis. The surgical treatment including removal of the crystalline lens and implantation of an iris-supported intraocular lens in both eyes at a week interval. Postoperatively, the biomicroscopic examination showed total pupil closure bilaterally. After the topical tropicamide treatment, the pupil returned to normal shape.

Surgical management of non-traumatic pediatric ectopia lentis: A case series and review of the literature

PURPOSE

To report a small series of pediatric patients with ectopia lentis that underwent limbal-approach lensectomy and vitrectomy and scleral-fixated intraocular lens implantation and to review the literature on the topic of surgical management of ectopia lentis.

METHOD

A retrospective review of 13 eyes of seven patients that underwent lensectomy, vitrectomy, and scleral-fixated intraocular lens implantation and a review of the ophthalmic literature.

RESULTS

In our series, the average age at surgery was 70.3 ± 13.8 months and the average length of follow-up was 23.8 ± 5.9 months. The mean pre-operative visual acuity was 0.86 ± 0.17 which improved to 0.23 ± 0.09 post-operatively (p < 0.001). No complications were encountered in our series. A review of the literature found that amblyopia was the biggest vision-limiting factor. In general, the literature suggested that a higher percentage of eyes that were left aphakic achieved better vision than those implanted with a scleral-fixated intraocular lens. However, there may be selection bias in that more eyes receiving an intraocular lens may have pre-existing amblyopia. The complication rates for lensectomy or scleral-fixated intraocular lens implantation were low in the literature. In the latter group, suture breakage and resultant intraocular lens dislocation is a worrisome late complication.

CONCLUSION

Surgical intervention for ectopia lentis via vitrectomy techniques yields good result. In cases of unilateral aphakia or in settings where compliance with aphakic refractive correction is questionable and amblyopia is a constant threat, scleral-fixated intraocular lens implantation is highly encouraged. However, long-term follow-up is required due to the risk of suture breakage and resultant intraocular lens dislocation over time.

Glued intrascleral fixation of posterior chamber intraocular lens in children

PURPOSE

To evaluate the short-term results of glued intrascleral fixation of posterior chamber intraocular lens (glued IOL) in children without adequate capsular support.

DESIGN

Noncomparative retrospective observational case series.

PATIENTS

SETTING

Institutional practice.

METHODS

Forty-one eyes of 33 children who underwent glued IOL implantation were retrospectively evaluated. The indications were postsurgical aphakia, subluxated cataract, ectopia lentis, traumatic subluxation, and decentered IOL.

MAIN OUTCOME MEASURES

Visual acuity (VA), endothelial cell changes, intraoperative and postoperative complications.

RESULTS

The mean age at the time of glued IOL was 10.7±3.6 years (range 5-15). The mean duration of follow-up after surgery was 17.5±8.5 months (range 12-36). The mean postoperative best spectacle-corrected visual acuity (BCVA in decimal equivalent) was 0.43±0.33 and there was significant change noted (P<0.001). Postoperatively, 20/20 and >20/60 BCVA was obtained in 17.1% and 46.3% of eyes respectively. BCVA improvement more than 1 line was seen in 22 eyes (53.6%). The mean postoperative refraction was myopic (-1.19±0.7 diopters [D]) in 19 eyes and hyperopic (+1.02±0.7 D) in 22 eyes. The mean endothelial loss was 4.13% (range 1.3%-5.94%). The 3 causes of reduced BCVA were the preexisting corneal, retinal pathology, and amblyopia. Postoperative complications included optic capture in 1 eye (2.4%), macular edema in 2 eyes (4.8%), and clinical decentration in 2 eyes (4.8%). There was no postoperative retinal detachment, IOL dislocation, endophthalmitis, or glaucoma.

CONCLUSION

Short-term results in children after glued IOL were favorable, with a low rate of complications. However, regular follow-ups are required since long-term risks are unknown.

Outcomes of iris-claw anterior chamber versus iris-fixated foldable intraocular lens in subluxated lens secondary to Marfan syndrome

PURPOSE

To compare the outcome of phacoemulsification using 2 different iris-fixation techniques for intraocular lens (IOL) replacement, a foldable posterior chamber IOL (PCIOL; AcrySof MA60AC, Alcon Laboratories Inc, Fort Worth, TX) and an iris-claw anterior chamber IOL (ACIOL; Artisan, Ophtec BV), for treatment of subluxated lenses in patients with Marfan syndrome (MFS).

DESIGN

Randomized, controlled trial.

PARTICIPANTS

A total of 31 eyes of 16 patients with subluxated lenses associated with MFS and a preoperative corrected visual acuity (CVA) < or =20/40 based on the Early Treatment Diabetic Retinopathy Study chart.

METHODS

Patients were enrolled and the eye with worse visual acuity was randomly assigned to 1 of 2 study arms: phacoemulsification and iris-fixated PCIOL or phacoemulsification and iris-claw ACIOL; the second eye of the same patient received the other IOL type. Preoperative and postoperative ophthalmologic examination, optical coherence tomography, and endothelial cell counts were performed.

MAIN OUTCOME MEASURES

We recorded CVA results at 3, 6, and 12 months, complications, endothelial cell loss, and central retinal thickness.

RESULTS

In the iris-fixated PCIOL group, CVA was significantly improved at 3 (P = 0.011; n = 16), 6 (P = 0.006; n = 16), and 12 months (P = 0.002; n = 16). In the iris-claw ACIOL group, CVA was significantly improved at 3 (P = 0.001; n=15), 6 (P = 0.001; n = 15), and 12 months (P = 0.009; n = 12). The CVA results did not differ significantly between groups. Dislocation of the IOL occurred in 3 of 16 (18.75%) eyes in the PCIOL group. Retinal detachment occurred in 3 eyes (2 in the PCIOL group and 1 in the ACIOL group) and was successfully repaired. Postoperative foveal tomograms in both groups revealed a decrease in the mean foveal thickness (MFT; < or =172 microm) in 54.16% of the patients.

CONCLUSIONS

The iris-sutured PCIOL and iris-claw ACIOL produced comparable improvements in CVA at 3, 6, and 12 months postoperatively. Although IOL dislocation tended to occur more frequently in the iris-fixated PCIOL group, the difference was not significant. At 6 months postoperatively, all study patients tended to have a thinner MFT. None of the patients in either group developed cystoid macular edema.

Iris-fixated posterior chamber intraocular lenses in children

PURPOSE

To report the short-term outcomes and complications of iris-fixated posterior chamber intraocular lenses (PCIOL) in the pediatric population.

DESIGN

Retrospective, observational case study.

METHODS

Twelve consecutive pediatric patients (17 eyes) underwent placement of foldable iris-sutured PCIOLs between September 1, 2004 and September 30, 2007 by two anterior segment surgeons at a single academic center. Outcome measures included change in visual acuity (VA) and complications.

RESULTS

In our series, there was a higher rate of dislocation of iris-sutured IOLs in patients with a history of ectopia lentis resulting from Marfan syndrome or hereditary or idiopathic causes than in patients being treated for aphakia resulting from other causes (45% vs 0%). Mean final VA improved by 0.23 logarithm of the minimum angle of resolution units from preoperative baseline. One eye of a Marfan patient sustained a retinal detachment eight months after dislocation of the PCIOL, and one patient experienced iris capture of the IOL after surgery.

CONCLUSIONS

Iris-fixated IOLs are reasonable alternative to transsclerally sutured IOLs to correct aphakia in pediatric patient. Dislocation of the IOLs can occur, however, and there is concern for suture degradation over time. The procedure should be considered with caution in pediatric patients.

Pathophysiology of zonular diseases

PURPOSE OF REVIEW

The mechanisms implicated in the clinical manifestations of zonular diseases, especially ectopia lentis, are reviewed.

RECENT FINDINGS

The molecular mechanisms involve fibrillin in a large spectrum of heritable diseases characterized by zonular stretching. The usual complications are refractive errors, especially myopia, glaucoma (either primary open angle, secondary angle closure and pupil block by anterior displacement of the lens) and retinal detachment.

SUMMARY

The genetics and molecular understanding provide information for genetic counseling. Treatment of myopia and glaucoma depend on the underlying mechanism, and lens surgery techniques are continuously improved.

Cionni endocapsular ring implantation in Marfan's Syndrome

OBJECTIVES

To evaluate the visual outcomes, intraoperative and postoperative complications of Cionni ring implantation in eyes with a subluxated lens associated with Marfan Syndrome.

METHODS

This case series included 15 eyes of 12 patients aged 19-56 years with a subluxated lens secondary to Marfan's syndrome operataed at the Departament of Ophtalmology, Toronto Western Hospital between 2003 and 2007. A 2-eyelet Cionni ring and an AcrySof (Alcon) foldable intraocular lens (IOL) were implanted in 13 eyes. Two eyes had trans-scleral IOL fixation in the ciliary sulcus. Best-corrected visual acuity, wavefront evaluation of eye aberration and complication rates were analysed.

RESULTS

In all eyes, capsular bag centration was excellent. Preoperative visual acuity ranged from 20/50 to counting fingers, and improved to better than 20/40 in all eyes. The mean follow-up duration was 14+/-9.49 months. The most frequent postoperative complication was posterior capsule opacification, which occurred in 3 eyes (18.7%), 2 of which required a neodymium:YAG posterior capsulotomy. No eye developed retinal detachment. Total eye aberration, tilt and high-order aberrations with a 6-mm pupil diameter decreased significantly after surgery (n = 5): Total eye aberration decreased from a mean of 14.8+/-5.5 preoperatively to 2.1+/-4.3 microns after the operation. Tilt was decreased from 4.1+/-2.5 to 0.12+/-2.1 microns, and high-order aberrations decreased from 4.37+/-3.8 microns, before the operation, to 1.47+/-3.5 after the operation.

CONCLUSION

Cionni ring implantation is an effective procedure to correct partial lens subluxation and has few complications (during 14 months of follow-up) in patients with Marfan's Syndrome.