Visual outcome and surgical results in children with Marfan syndrome

Scleral-fixated vs Iris-fixated intraocular lens in pediatric ectopia lentis: A systematic review

Numerous intraocular lens (IOLs) options are available for treating pediatric ectopia lentis, and this paper reviews recent literature on pediatric ectopia lentis treatment with iris-fixated and scleral-fixated IOLs. A comprehensive search was undertaken on PubMed, Embase, ProQuest, Cochrane, Wiley, SCOPUS, and EBSCO. Studies published in the last ten years that met the inclusion criteria were included in this review. Seventeen studies exhibiting low to moderate risk of bias were included in this review, with eight on iris-fixated IOL (IFIOL), six on scleral-fixated IOL (SFIOL), and three on both IOLs. From the included studies, these data were extracted and compared: best-corrected visual acuity, endothelial cell density, postoperative complications, IOL stability, and intraocular pressure. IFIOL and SFIOL show comparable lens stability, offer good visual rehabilitation, and demonstrate equivalent safety profiles. There is no discerning superiority between IFIOL and SFIOL in treating pediatric ectopia lentis. The choice of which IOL to implant depends on the surgeon's preference.

Visual prognosis and complications of congenital ectopia lentis: study protocol for a hospital-based cohort in Zhongshan Ophthalmic Center

INTRODUCTION

Congenital ectopia lentis (CEL) is a rare ocular disease characterised by the dislocation or displacement of the lens. Patients with mild lens dislocations can be treated with conservative methods (eg, corrective eyeglasses or contact lenses). In contrast, patients with severe CEL usually require surgical management. However, few studies have focused on the visual prognosis and complications in conservative and surgical management of patients. This study aims to investigate the prognosis and complications in patients with CEL with conservative and surgical management, which is vital for CEL management, especially the choice of surgical timing and surgical method.

METHODS AND ANALYSIS

A cohort study will be conducted at Zhongshan Ophthalmic Center. We plan to recruit 604 participants diagnosed with CEL and aged ≥3 years old. Patients with mild lens subluxation and stable visual conditions will be included in the non-surgical group and follow-up at 1, 2 and 3 years after enrolment. Patients with severe lens subluxation who accept CEL surgery will be included in the surgical group. Different surgical techniques, including phacoemulsification, in-the-bag intraocular lens implantation (with or without capsular tension ring) and trans-scleral fixation, will be used depending on the severity of dislocation. Patients will be followed up at 3 months, and 1, 2 and 3 years postoperatively. Over a 5-year follow-up period, patients will receive a detailed ocular examination, including optometry, biological measurement, specular microscopy, ultrasound biomicroscopy, anterior segment and posterior segment optical coherence tomography (OCT), OCT angiography, echocardiography and questionnaires on vision-related quality of life. The primary outcome is the change of best-corrected visual acuity and the incidence of complications in both groups.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the ethics committee of the Zhongshan Ophthalmic Center (number: 2022KYPJ207). Study findings will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05654025.

[Endocapsular fixation of intraocular lens in patients with ectopia lentis and Marfan syndrome (case study)]

Modern trends in advancement of phaco surgery techniques in patients with ectopia lentis (including patients with Marfan syndrome) are characterized by the transition from complete removal of the lens (lensectomy) to aspiration of the lens substance and attempts to preserve and reposition the capsular bag. This case study analyzes the results of surgical treatment of bilateral ectopia lentis in a 6-year-old patient with Marfan syndrome. The specifics of microinvasive phaco surgery consisted in capsular bag preservation and endocapsular fixation of the intraocular lens. The article presents the results of ophthalmological observation over a seven-year period.

Epidemiology of ectopia lentis and outcomes after surgery in a Danish population

PURPOSE

To describe the causes of ectopia lentis (EL) and the outcomes after surgery in a Danish population.

SETTING

The Eye Clinic Rigshospitalet and Kennedy Center in Copenhagen.

DESIGN

Retrospective cohort study.

METHODS

Medical records of patients with nontraumatic EL born after 1980 and seen at the Eye Clinic Rigshospitalet and Kennedy Center from 1983 to 2019 were reviewed. Clinical information regarding family history, comorbidities, genetic workup, ophthalmological examinations, and surgical history was retrieved.

RESULTS

72 patients (38 males), of whom 68 had bilateral EL (94.4%) were identified. Marfan syndrome (MFS) was found in 34 (47.2%) and biallelic variants in ADAMTSL4 in 4 (5.6%). Surgery was performed in 38 (52.8%) patients, 66 eyes, with a median age at the time of first eye surgery of 8.4 years (range 0.8 to 39.0 years) and a follow-up of 2.3 years (range 0 to 25.7 years). Intraocular lenses were implanted in 9 (23.7%) (11 eyes). Corrected distance visual acuity improved from 0.7 to 0.2 logMAR (median) in right eyes and from 0.7 to 0.3 logMAR in left eyes postoperatively. 21 patients (56.8%), 42 eyes, did not experience any surgery-related complications. 3 patients (3 eyes) experienced a perioperative tear in the posterior capsule. Temporary postoperative ocular hypertension was reported in 3 patients (7.9%) (3 eyes), and 2 patients (5.4%) (2 eyes) developed persistent ocular hypertension. There were no cases of postoperative retinal detachment.

CONCLUSIONS

The main reason for EL was MFS. Surgery improved visual acuity, and postoperative ocular hypertension was the most common complication, whereas retinal detachment was not observed.

Longitudinal Changes of Axial Length and Associated Factors in Congenital Ectopia Lentis Patients

Purpose

To investigate the longitudinal changes and associated factors of axial length (AL) in congenital ectopia lentis (CEL) patients.

Methods

In this retrospective study, medical records of CEL patients were reviewed from January 2014 to December 2019 at the Zhongshan Ophthalmic (ZOC) in China. Patients were divided into the surgery group and the nonsurgery group. Data of refractive power, best-corrected visual acuity (BCVA), and intraocular pressure (IOP) as well as ocular biometrics including AL, corneal curvature, white-to-white (WTW), and central corneal thickness (CCT) were collected at baseline and each follow-up visit. Multiple linear regression was performed to assess the potential associated factors for axial length growth in congenital ectopia lentis patients.

Results

Compared with the nonsurgery group, the change rate of AL among children aged 3 to 6 years old was slower in the surgery group (0.443 ± 0.340 mm/year vs. 0.278 ± 0.227 mm/year, P < 0.05). However, no statistically significant difference for the change rate of AL was detected between the surgery group and the nonsurgery group (P > 0.05) among patients aged 7 years or older. For the surgery group, the results of the linear regression model showed that a higher change rate of AL was associated with younger age (older age: β = −0.009, 95% CI: −0.014 to −0.003, and P=0.002) and worse baseline BCVA (logMAR) (β = 0.256, 95% CI: 0.072 to 0.439, and P=0.007). As for the nonsurgery group, younger baseline age (older age: β = −0.027, 95% CI: −0.048 to −0.007, and P=0.01) and longer baseline AL (β = 0.073, 95% CI: 0.023 to 0.122, and P=0.006) were associated with a higher change rate of AL.

Conclusions

The AL change rate was clearly associated with age both in the surgery group and in the nonsurgery group. Intervention strategies such as surgery should be performed earlier for CEL that meets the surgical criteria. Worse baseline BCVA and longer baseline AL are associated factors that would affect the growth rate of AL in the surgery and nonsurgery group, respectively.

Accuracy of intraocular lens power calculation formulas for eyes with scleral-sutured intraocular lens in congenital ectopia lentis

Purpose

To compare the accuracy of intraocular lens calculation formulas in eyes with congenital ectopia lentis (CEL) that underwent scleral-fixated intraocular lens (IOL) implantation.

Setting

Zhongshan Ophthalmic Center, Guangzhou, China.

Design

Retrospective, consecutive case-series study.

Methods

A total of 158 eyes from 158 patients diagnosed from December 12, 2017 to November 16, 2020 with congenital ectopia lentis and undergoing a lensectomy and a Rayner 920H or 970C model IOL scleral-fixation were retrospectively reviewed. The prediction errors (PEs) of the spherical equivalent of eight formulas, Barrett Universal II (BUII), Emmetropia Verifying Optical (EVO), Haigis, Hoffer Q, Holladay 1, Kane, Hill-Radial Basis Function 3.0 (RBF 3.0) and SRK/T were compared.

Results

For CEL patients with sclera-sutured IOL, all eight formulas yielded myopic PEs without constants optimization. After such optimization, the performance of each formula ranked by median absolute error (MedAE) from lowest to highest in diopter, was SRK/T (0.47), EVO (0.48), Kane (0.52), BUII (0.53), Hoffer Q (0.58), Holladay 1 (0.59), Haigis (0.61), and RBF 3.0 (0.62). The EVO and SRK/T formulas had the highest prediction accuracy concerning the percentage of cases within the +/- 0.50 D range of PE and within +/- 1.00 D range of PE in eyes experienced sclera-sutured IOL surgery, respectively.

Conclusion

All formulas with unoptimized constants produced myopic PEs. After optimization, the SRK/T and EVO formula were the two recommended formulas due to having the lowest MedAE and the highest percentage of PE in the range of +/- 0.50 D for CEL patients with sclera-sutured IOL implantations.

Adapted Bag-in-the-Lens Implantation Technique in Children with Congenital Ectopia Lentis

BACKGROUND

Subluxation of the crystalline lens in childhood confronts the surgeon with a dilemma: to operate or to wait and see. Surgery is usually not performed when the subluxation is still limited. However, postponing the surgery increases the surgical difficulty as the capsular bag becomes more difficult to use as a means of support for the intraocular lens (IOL). A large number of children already present a pronounced subluxation at first presentation. In this paper, we describe a technique to optimise centration and fixation of the bag-in-the-lens (BIL) IOL in children younger than 7 years of age with congenital ectopia lentis.

METHODS

Between October 2019 and December 2020, we performed lens extraction using a combination of bean-shaped segments to support the BIL IOL and a 6 - 0 polypropylene loop fixated at the sclera, following the Yamane technique, for the purpose of centration. We used this technique for seven eyes of four patients. The patients were between 2 and 6 years old; 3 boys and 1 girl. A definite diagnosis of Marfan syndrome was made for two children; for the other two, there was no proven underlying pathology. The luxation was upwards in all cases. The degree of luxation was severe in all eyes. The preoperative refraction values showed high astigmatism values for all eyes, ranging from 6.5 to 11.25 dioptres. Three out of the four patients were myopic, ranging from - 1.5 to - 9 dioptres.

RESULTS

The surgery could be performed without major complications in all eyes. Good centration was obtained, which remained stable in the postoperative period. Refraction improved with greatly diminished degrees of astigmatism (ranging from 0.25 to 3 dioptres) and myopia (spheres ranging from - 2 to + 1.75 dioptres).

CONCLUSION

Our novel technique incorporated the BIL technique with the addition of bean-shaped segments and a polypropylene 6/0 suture fixated at the sclera. In this way, we were able to obtain good centration and stability of the implanted IOL, as well as a good refractive outcome in all cases.

CLEAR - Medical use of contact lenses

The medical use of contact lenses is a solution for many complex ocular conditions, including high refractive error, irregular astigmatism, primary and secondary corneal ectasia, disfiguring disease, and ocular surface disease. The development of highly oxygen permeable soft and rigid materials has extended the suitability of contact lenses for such applications. There is consistent evidence that bandage soft contact lenses, particularly silicone hydrogel lenses, improve epithelial healing and reduce pain in persistent epithelial defects, after trauma or surgery, and in corneal dystrophies. Drug delivery applications of contact lens hold promise for improving topical therapy. Modern scleral lens practice has achieved great success for both visual rehabilitation and therapeutic applications, including those requiring retention of a tear reservoir or protection from an adverse environment. This report offers a practical and relevant summary of the current evidence for the medical use of contact lenses for all eye care professionals including optometrists, ophthalmologists, opticians, and orthoptists. Topics covered include indications for use in both acute and chronic conditions, lens selection, patient selection, wear and care regimens, and recommended aftercare schedules. Prevention, presentation, and management of complications of medical use are reviewed.

Accuracy of intraocular lens calculation formulas for eyes with insufficient capsular support

Background

There is no consensus on which intraocular lens (IOL) power calculation formula provides the best refractive prediction in patients with inadequate capsular support whose anterior ocular anatomic structure differs from that of normal subjects. Therefore, the purpose of this study was to analyze the accuracy and performance of IOL calculation formulas (SRK/T, Holladay 1, Hoffer Q, Haigis, and Barrett Universal II) in predicting postoperative refractive prediction error (PE) for this subgroup of patients.

Methods

A total of 110 eyes from 110 patients with insufficient capsular support who underwent scleral fixation of an IOL at the Zhongshan Ophthalmic Center from July 1, 2016 to November 30, 2019 were enrolled in this retrospective study. Preoperative optical biometrics were measured with the IOL Master 500 (Carl Zeiss, Oberkochen, Germany). The performance of each formula in predicting PE was compared, and the effect of keratometry and axial length (AL) on PE was evaluated for each formula using univariate and multivariate linear regression analysis.

Results

The mean age of the included participants was 12.54±9.66 years. The Sanders, Retzlaff, and Manus/theoretical (SRK/T) (-0.25 D) and Holladay 1 (-0.28 D) formulas tended to have minimal postoperative PE compared to the Hoffer Q (-0.62 D), Haigis (-0.67 D), and Barrett Universal II (-0.62 D) formulas (P=0.005). All formulas individually resulted in <70% of eyes within ±1.00 D of the PE. Nevertheless, after constants were optimized, these formulas led to 7.3% to 13.6% of increase within ±1.00 D of the PE. Keratometry and AL were significantly associated with PE for each formula, but the relationship was weakest for SRK/T.

Conclusions

In eyes with insufficient capsular support, postoperative PE was minimal for the SRK/T formula, which suggested SRK/T to be the best choice, especially when the keratometry and AL of patients are extremely large or small.

Visual outcome and surgical results in children with Marfan syndrome

IMPORTANCE

To determine visual and surgical results in children with Marfan syndrome.

BACKGROUND

Marfan syndrome involves ocular complications which can lead to visual disturbance and amblyopia. Data about the visual and surgical results in children with Marfan syndrome is vital for the clinical management of these patients.

DESIGN

Retrospective data analysis.

PARTICIPANTS

Eighty-two eyes of 41 patients with a genetically proved diagnosis of Marfan syndrome.

METHODS

Medical records of patients with Marfan syndrome were reviewed between 2007 and 2017. Ocular complications, visual acuity (VA) of patients with/without lensectomy and surgical method were evaluated.

MAIN OUTCOME MEASURES

VA outcomes of patients with Marfan syndrome with/without surgical repair of ectopia lentis.

RESULTS

In 27 (66%) of the 41 patients a bilateral subluxation of the lens was visible and 14 (52%) patients received lensectomy. The mean age at initial presentation was 12.3 ± 9 years and mean follow-up was 3 years (range 1-7). VA varied from 1.2 to -0.1 logMAR at first examination. At initial presentation, mean VA was 0.1 ± 0.7 logMAR in patients with a normal lens status (n = 14) and 0.3 ± 0.5 logMAR in patients with subluxation of the lens (n = 27) (P < .01). VA improved from 0.2 ± 0.5 logMAR to 0.1 ± 0.5 logMAR (P = .06) in children with subluxation of the lens who did not need a lensectomy (n = 12) and from 0.5 ± 0.5 logMAR to 0.2 ± 0.5 logMAR (P = .02) in patients who were referred to lensectomy with/without secondary lens implantation.

CONCLUSIONS AND RELEVANCE

In Marfan syndrome subluxation of the lens was found in the majority of children. Improvement of VA resulted in children with subluxation of the lens and following lensectomy.