Scleral fixation of a capsular tension ring for severe ectopia lentis

Trends and characteristics of congenital ectopia lentis in China

AIM

To elucidate the trends and characteristics of congenital ectopia lentis (CEL) in southern China.

METHODS

CEL patients from China admitted to Zhongshan Ophthalmic Center (ZOC) from January 2006 to December 2015 were recruited in our study. Residence, gender, hospitalization time, age at surgery, and the presence of other ocular abnormalities and system disease were statistically analyzed in different subgroups.

RESULTS

Four hundred and thirty-seven hospitalizations (306 in-patients) diagnosed with CEL from a total of 283 308 hospitalizations were identified, which accounted for 0.15% of the total in-patients. Of the identified CEL in-patients, the total ratio of boys to girls was 2.22:1. Based on a subgroup analysis according to age, patients aged 12-18 years old constituted the highest proportion (31.70%) of all hospitalized CEL patients, and those 0-3 year old constituted the lowest proportion (8.82%) of the total number. The number of CEL increased from 18 to 72 and the hospital based prevalence increased from 8.60% to 18.10% from 2006 to 2015, and the average age at surgery decreased from 9 years old in 2006 to 7.6 years old in 2015.

CONCLUSION

The results reveal upward trends in both the number of CEL hospitalizations and hospital based prevalence of CEL in this 10-year study period, but a reduction in the age at surgery, which may reflect the increase of public awareness of children's eye care in China.

Intraoperative intracameral pilocarpine after capsular tension ring and capsule/iris hook insertion in pediatric eyes with subluxated cataract

Capsular tension rings and iris hooks have proved to be useful devices in cataract surgery in cases of zonular weakness and dialysis. We describe the use of intracameral pilocarpine-induced pupillary miosis to couple the iris and the capsulorhexis edge with iris hooks during phacoemulsification in pediatric cases with posttraumatic subluxated cataractous lens. The coupled iris and capsule act as a single unit, eliminating the space between them and significantly reducing the possibility of vitreous or ophthalmic viscosurgical device passing through the zonular defect.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

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.

Cataract

Cataract is the leading cause of reversible blindness and visual impairment globally. Blindness from cataract is more common in populations with low socioeconomic status and in developing countries than in developed countries. The only treatment for cataract is surgery. Phacoemulsification is the gold standard for cataract surgery in the developed world, whereas manual small incision cataract surgery is used frequently in developing countries. In general, the outcomes of surgery are good and complications, such as endophthalmitis, often can be prevented or have good ouctomes if properly managed. Femtosecond laser-assisted cataract surgery, an advanced technology, can automate several steps; initial data show no superiority of this approach over current techniques, but the results of many large clinical trials are pending. The greatest challenge remains the growing 'backlog' of patients with cataract blindness in the developing world because of lack of access to affordable surgery. Efforts aimed at training additional cataract surgeons in these countries do not keep pace with the increasing demand associated with ageing population demographics. In the absence of strategie that can prevent or delay cataract formation, it is important to focus efforts and resources on developing models for efficient delivery of cataract surgical services in underserved regions. For an illustrated summary of this Primer, visit: http://go.nature.com/eQkKll.

All about capsular tension rings

PURPOSE OF REVIEW

To discuss capsular tension devices and recent evidence regarding their use.

RECENT FINDINGS

The capsular tension ring, modified capsular tension ring, and capsular tension segment are well established tools for use during phacoemulsification when zonular instability is present. Recent research has provided additional evidence of their benefits in decreasing intraoperative and postoperative complications.

SUMMARY

Endocapsular support devices allow for cataract surgery success in the setting of zonular instability.

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.

Phacoemulsification using iris hooks and scleral fixation of the intraocular lens in patients with secondary glaucoma associated with lens subluxation

PURPOSE

We described the techniques and results of phacoemulsification using iris hook and scleral fixation of intraocular lens (IOL) in patients with secondary glaucoma associated with lens subluxation.

METHODS

Eight eyes of seven patients with secondary glaucoma associated with lens dislocation, who had undergone the surgery, were retrospectively reviewed.

RESULTS

At a mean of 23.5 months+/-13.6 (SD) after the surgery, the mean best-corrected visual acuity improved from 0.24+/-0.21 to 0.83+/-0.3, and mean intraocular pressure (IOP) was changed from 38.4+/-11.4 to 15.5+/-1.8 mmHg at the final examination. There were no vitreoretinal complications except cystoid macular oedema in one eye.

CONCLUSION

The technique appears to be safe and effective in terms of visual rehabilitation and controlling IOP in patients with secondary glaucoma associated with lens subluxation.

Solutions chirurgicales à la luxation du complexe ICP — sac capsulaire — anneau de tension capsulaire

INTRODUCTION

The spontaneous luxation of the intraocular lens-capsular bag-capsular tension ring complex is a serious but fortunately rare complication. The authors report a combined surgical procedure to reposition the complex in a patient who was operated on for bilateral lens subluxation 4 years before and whose enophthalmia made surgery difficult.

CASE REPORT

Two surgical techniques can be considered to reposition the complex and avoid explantation. The McCannel modified stitch can capture the complex with the help of a transcorneal point and then a transscleral suture on the 12 o'clock meridian, despite the enophthalmia of the patient; the Moreno transscleral stitch. Both techniques suture the complex to the ciliary sulcus.

CONCLUSION

Moreno's technique is easy and safe for the endothelium and must therefore be attempted first. In case of failure, the McCannel modified stitch remains a useful and satisfying procedure allowing transscleral fixation of the complex to the sulcus at the cost of a minimal corneal trauma.

Iris fixation of foldable intraocular lenses for ectopia lentis in children

PURPOSE

To describe a technique for iris fixation of acrylic intraocular lenses (IOLs) in ectopia lentis and evaluate the medium-term anatomical and functional results in children.

SETTING

Pediatric Ophthalmology Department, Fondation Rothschild, Paris, France.

METHODS

This retrospective study included 17 eyes of 9 children. The technique consisted of lens ablation, leaving in place the capsule in the zone of nonruptured zonule, and an IOL placement in the remaining sulcus with 2 iris sutures. The age of patients, postoperative complications, follow-up, anatomical results, final refraction, and visual acuity were noted.

RESULTS

Median age was 4.8 years. One case of postoperative hyphema and 1 case of aseptic endophthalmitis occurred and resolved after treatment. The anatomical outcome was favorable in all cases, with centered IOLs and round pupils. Mean follow-up was 16.3 months. Mean final refraction was +0.18 diopter, and mean final best corrected visual acuity was 20/32 (range 20/50 to 20/20).

CONCLUSIONS

The results suggest that iris fixation of foldable IOLs for ectopia lentis in children can lead to good anatomical and functional results. The use of the remaining part of the sulcus is helpful in reaching correct positioning of the IOL. The complication rate is similar to that with other techniques described in the literature, whereas the small incision and the absence of transscleral sutures could simplify the short-term and long-term evolution.

Management of posteriorly dislocated endocapsular tension ring and intraocular lens complex

We report a case of late posteriorly dislocated endocapsular tension ring (ECR) and intraocular lens (IOL) complex into the vitreous cavity that behaved as a single 13 mm disc. A 3-port pars plana vitrectomy was performed, and perfluorocarbon liquid was used to retrieve the ECR-IOL complex to the retropupillary area. A 3-point scleral fixation was performed to reposition the inseparable ECR-IOL complex.

Techniques of intraocular lens suspension in the absence of capsular/zonular support

Implantation of intraocular lenses has become the standard of care in the aphakic state. Ideally, the lens is placed in the capsular bag, which affords stable fixation at a position closest to the nodal point of the eye. However, there will always be instances where this will not be possible. Congenital weakness of the lens zonules in various conditions, trauma, and surgical complications of cataract surgery are just some examples. In this article, we review the methods that have been devised to allow intraocular lens implantation in the absence of capsular or zonular support. These include anterior chamber angle and iris-fixated lenses, as well as posterior chamber iris- and scleral-sutured lenses. The various lenses are described, and the techniques involved, advantages and disadvantages, complications, and results of each method are discussed. It is hoped that this article will provide a comprehensive overview of ways to deal with a problem that can still result in a very good visual outcome for the patient. This is particularly relevant given the many recent developments and refinements of methods in implanting intraocular lenses.

Surgical Repositioning of Dislocated Capsular Tension Rings

PURPOSE

To present techniques and results of surgical repositioning of subluxed and dislocated capsular tension rings (CTRs).

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Eleven patients with a previously implanted CTR in-the-bag for zonular weakness who presented with CTR-intraocular lens (IOL)-capsular bag decentration who underwent surgical repositioning.

METHODS

Data from 11 patients who underwent surgical repositioning were evaluated retrospectively for underlying diagnosis, interval between initial surgery and decentration, surgical technique, clinical results, and complications.

MAIN OUTCOME MEASURES

Capsular tension ring-IOL-capsular bag centration, final best-corrected visual acuity (BCVA), and surgical complications.

RESULTS

Of the 11 patients with CTR decentration, 3 had it early in the postoperative period, and 8 had it late. Mean (+/- standard deviation) durations from cataract extraction and CTR implantation to surgical repositioning were 6.1+/-7.9 months for those with decentration early and 49.6+/-15.3 months for late decentrations (overall range, 0.7-74.7). Of the 11 patients, 7 had pseudoexfoliation, and 4 of the 7 had associated glaucoma. Nine patients had subluxation of the CTR-IOL-capsular bag complex, which was managed by an anterior segment approach. A pars plana vitrectomy and levitation of the CTR was required in 2 patients due to complete dislocation of the CTR into the posterior vitreous. Surgical techniques for repositioning included single, double, or 3-point scleral suture loop fixation of the CTR through the capsular bag complex (8 eyes); use of the capsular tension segment (CTS) placed within the capsular bag for scleral suture fixation (2); or iris suture fixation of the IOL haptics (1). All patients achieved successful anatomical repositioning of the CTR-IOL-capsular bag complex. Mean preoperative BCVA improved from 20/100 to 20/40 postoperatively. After repositioning surgery, BCVA improved in 7 patients, was maintained in 2, and worsened in 2 (due to advanced glaucoma).

CONCLUSION

Postoperative CTR subluxation or dislocation is a risk for patients with severe or progressive zonulopathy. Decentrations may be effectively managed with scleral suture fixation of the CTR through the capsular bag or the use of the CTS.

Intralenticular bimanual irrigation: aspiration for subluxated lens in Marfan's syndrome

We describe a new technique of aspiration of subluxated lens in young patients with Marfan's syndrome. Two small circular anterior capsulorhexis (1.5 mm to 2.0 mm) openings were created, and bimanual irrigation/aspiration was performed by introducing the irrigation cannula through 1 capsular opening and the aspiration cannula through the other. The irrigation cannula served the dual purpose of hydrating the lens matter and holding the lens in central position to ensure complete aspiration of the lens matter. The lens capsule was later removed and anterior vitrectomy performed by a vitrectomy cutter. This new technique of intralenticular irrigation/aspiration is effective and safe in performing lens aspiration in extensively dislocated crystalline lens in Marfan's syndrome.

Surgical treatment of a dislocated intraocular lens–capsular bag–capsular tension ring complex

We describe a surgical technique for managing late dislocation of an intraocular lens-capsular bag-capsular tension ring (IOL-CB-CTR) complex. Two 10-0 polypropylene sutures are placed transsclerally over and under the CTR through the anterior and posterior capsules to capture the CTR, which then is retracted and sutured through the sclera. The same maneuver is performed 180 degrees away. This simple, easy, effective procedure can be performed with a small corneal incision and does not require extraction of the IOL-CB complex. Although the CTR does not completely prevent IOL-CB dislocation, it provides the possibility of suturing the IOL-CB to the sulcus without replacing the IOL.

Management of a posteriorly dislocated endocapsular tension ring and a foldable acrylic intraocular lens

We report a rare case of late spontaneous extension of a posterior capsule tear from lateral traction of an endocapsular ring, resulting in dislocation of the capsular tension ring and acrylic intraocular lens (IOL) into the vitreous cavity. A 3-port pars plana vitrectomy was performed to explant the prostheses; the eye was made pseudophakic by placement of a scleral-fixated posterior chamber IOL. The combined triple procedure was safe and effective.

Isolated microspherophakia with optic disc colobomata

We describe a case of isolated bilateral microspherophakia with optic disc colobomata. A satisfactory outcome was achieved following uneventful lensectomy and scleral fixation of an intraocular lens.

Intraoperative and postoperative complications of Cionni endocapsular ring implantation

PURPOSE

To analyze the intraoperative and postoperative complications of Cionni ring implantation in eyes with a subluxated lens or zonular weakness.

SETTING

Departamento de Oftalmología, Clínica Universitaria de Navarra, Universidad de Navarra, Pamplona, Spain.

METHODS

This case series comprised 7 eyes of 5 patients with a subluxated lens or zonular weakness secondary to Marfan's syndrome (n = 2), traumatic cataract (n = 2), or megalocornea (n = 1) or of unknown etiology (n = 2). An AcrySof (Alcon) foldable intraocular lens (IOL) was implanted in all eyes. A 2-eyelet Cionni ring was implanted in 1 eye and a 1-eyelet Cionni ring, in 6 eyes. The Cionni ring was secured in position with a transscleral suture knotted to the ring's hook, avoiding peripheral perforation of the capsular bag.

RESULTS

In 1 eye, corectopia was inadvertently produced by passing the suture needle through the iris root; lens subluxation temporarily increased during ring rotation and implantation. However, after the transscleral suture was tightened, capsular bag centration was excellent. In the eye with megalocornea, traction from the 2 hooks tore the edge of the anterior capsule rim. The most frequent postoperative complication was posterior capsule opacification, which occurred in 5 eyes, 2 of which required a neodymium:YAG posterior capsulotomy. After 1 year, the Cionni ring continued to provide excellent stability and capsular bag and IOL positioning in all cases.

CONCLUSIONS

Results indicate that Cionni ring implantation is an acceptable procedure to correct limited lens subluxation, preserves the capsular bag, and has few significant complications.

Chronic cystoid macular edema in an eye with a capsule defect and posteriorly dislocated capsular tension ring

A 72-year-old man presented with visual deterioration and cystoid macular edema (CME) 9 months after cataract surgery elsewhere. A slitlamp examination showed a large posterior capsule defect and a slightly decentered intraocular lens (IOL). In addition, a curved poly(methyl methacrylate) (PMMA) haptic-like structure was seen behind the IOL in the superoanterior vitreous cavity. The foreign body was entangled by vitreous fibers and moved in accordance with ocular motility. A broken PMMA haptic was suspected. During vitrectomy for removal of the suspected IOL haptic, an intact, posteriorly dislocated capsular tension ring (CTR) was found. It was cut in 2 and excised carefully via the sclerectomies. Postoperatively, the CME resolved and vision improved.

Management of bilateral anterior dislocation of a lens in a child with Marfan's syndrome

A 13-year-old boy with Marfan's syndrome presented with bilateral, acute, complete anterior dislocation of the crystalline lens. The lens substance was aspirated intracapsularly after 2 linear capsulotomies were created. The empty capsular bag was removed from the eye as a vitrectome was used to severe the adhesions between the capsule and vitreous face through 1 paracentesis and a forceps was used to pull the capsule through the other paracentesis. Aphakia was corrected by glasses and contact lenses. Two years after surgery, the best corrected visual acuity was 20/32 in both eyes.

Suture fixation of a foldable acrylic intraocular lens for ectopia lentis

A 5-year-old boy with severe ectopia lentis had bilateral lensectomy and suture fixation of a foldable acrylic intraocular lens (IOL) through a 3.0 mm clear corneal incision. Sodium hyaluronate (Healon GV) enhanced stability of the crystalline lens during aspiration and maintenance of the anterior chamber during passage of the needles through the ciliary sulcus. The haptic design of the single-piece AcrySof (Alcon) IOL permitted secure fixation of the suture to the haptic. The patient experienced rapid visual rehabilitation, achieving an uncorrected visual acuity of 20/40 in both eyes.

Intravitreal phacoemulsification with pars plana vitrectomy and posterior chamber intraocular lens suture fixation for dislocated crystalline lenses

This technique to manage a dislocated crystalline lens comprises intravitreal phacoemulsification with transscleral suture fixation of a posterior chamber intraocular lens (IOL). The dislocated lens in the vitreous cavity is removed using a standard phaco handpiece with the assistance of a fiber-optic light pipe. Then, the IOL is implanted. The technique was used in 10 eyes of 8 patients with lens luxation or subluxation. The postoperative best corrected visual acuity was 20/25 or better except in 1 eye, and no serious complications were observed. Increased intraocular pressure before surgery in 4 eyes was normalized in 3 eyes.

The capsular tension ring: designs, applications, and techniques

Originally, the open poly(methyl methacrylate) (PMMA) capsular tension ring (CTR) was designed to compensate for zonular defects or to stretch the posterior capsule in highly myopic eyes not receiving an intraocular lens (IOL). We address the variety of subsequent designs, applications, and techniques that have evolved. With pre-existing or intraoperative zonular defects, a standard CTR may be inserted before or at any time during cataract removal to maintain or re-establish an extended capsular diaphragm. For profound zonular dialysis or weakness, a CTR was designed for scleral fixation. Capsular tension rings with integrated tinted sector shields have been developed to compensate for sector iris colobomas or aniridia. The CTR has also been used as a measuring gauge for in vivo quantification of capsule dimensions and postoperative capsular shrinkage. The CTR has improved control during primary posterior capsulorhexis and prevented oval distortion along the lens axis postoperatively. During combined cataract and vitreous surgery, a CTR prevents capsule damage and provides undisturbed peripheral visualization before IOL implantation. Capsular tension rings may also influence capsule opacification formation. A special band-shaped CTR with sharp edges was developed to inhibit lens epithelial cell migration and avoid capsulorhexis-optic contact.