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Aspiration Technique in the Management of the Dislocated Lens
808
AMERICAN JOURNAL OF OPHTHALMOLOGY
3. Smith, J. L., David, N. J., Hart, L. N., Levenson, D. S. and Tillett, C. W. : Hemangioma of the choroid. Arch. Ophth. 69:51, 1963. 4. Justice, J., Jr., and Sever, R. J. : Technique of Fluorescein Fundus Photography. Neuro-ophthalmology : Symposium of University of Miami (J. L. Smith, ed.). St. Louis, Mosby, 1965, v. 2, p. 82. 5. Gitter, A. K., Meyer, D., Sarin, L. K, Keeney, A. H. and Justice, J., Jr. : Fluorescein and ultra sound in diagnosis of intraocular tumors. Am. J. Ophth. 66:719, 1968. 6. Norton, E. W. D., Smith, J. L., Curtin, V. T. and Justice, J., Jr. : Fluorescein f undus photogra phy: An aid in the differential diagnosis of poste rior ocular lesions. Tr. Am. Acad. Ophth. Otolaryng. 68:7SS, 1964. 7. Norton, E. W. D., Gass, J. D., Smith, J. L., Curtin, V. T., David, N. J. and Justice, J., Jr. : Flu orescein in the study of macular disease. Tr. Am. Acad. Ophth. Otolaryng. 69:631, 1965. 8. Hill, D. W. : Some clinical applications of fluorescence retinal photography. Tr. Ophth. Soc. U.K. 86:125, 1966. 9. Snyder, W. B., Allen, L. and Frazier, O. : Fluorescence angiography of ocular tumors. Tr. Am. Acad. Ophth. Otolaryng. 71:820, 1967. 10. Oosterhuis, J. A. and Van Waveren, C. W. :
NOVEMBER, 1969
Fluorescein photography in malignant melanoma. Ophthalmologica 156:101, 1968. 11. Charamis, J., Katsourakis, N. and Mandras, G. : The study of the cerebroretinal circulation by intravenous fluorescein injection. Am. J. Ophth. 61:1078, 1966. 12. Sollom, A. W. : Fluorescence in malignant melanomas of the choroid. Ophthalmologica 156:117, 1968. 13. Norton, E. W. D. and Gutman, F. : Fluores cein angiography and hemangiomas of the choroid. Arch. Ophth. 78:121, 1967. 14. Reese, A. B. and Howard, G. M. : Flat uveal melanomas. Am. J. Ophth. 64:1021, 1967. 15. François. J. : Diagnostic des melanomas ma lins de la choroïde. Ophthalmologica 151:114, 1966. 16. Thomas, C. L, Storaasli, J. P. and Friedeil, H. L. : Radioactive phosphorus in the detection of intraocular neoplasms. Am. J. Roentgen. 95:935, 1965. 17. Goldberg, R. E. and Sarin, L. K. : Ultrason ics in Ophthalmology. Philadelphia, Saunders, 1967, pp. 11, 65,114. 18. Goldberg, R. E., Sarin, L. K., Meyer, D. and Gitter, K. A. : Applications of ultrasonography, in ophthalmology. Tr. Am. Acad. Ophth. Otolaryng. 71:880, 1967.
A S P I R A T I O N T E C H N I Q U E IN T H E MANAGEMENT O F T H E DISLOCATED L E N S A. E. MAUMENEE, M.D., AND STEPHEN J. RYAN, M.D.
Baltimore, Maryland Extraction of subluxated lens in children has been considered such a hazardous proce dure that many surgeons are reluctant to operate except under compelling circum stances.1·2 Children may have subluxated lenses either from trauma or in association with disorders such as Marian's syndrome, Marchesani's syndrome or homocystinuria. This report presents a small series of pa tients with subluxated lenses removed by the aspiration technique, which has been repopularized in recent years for surgery of con genital cataracts.3·4 Contrary to an appar-
ently prevalent impression, the aspiration technique lends itself well to removal of cataractous and noncataractous subluxated lenses in patients of pre-adult ages. In the nine cases reported here, the indi cation for surgery was either impaired visual acuity or lens-induced glaucoma. The pur pose of this paper is to report the advantages of the aspiration technique in the manage ment of the dislocated lens in young persons, since many surgeons still prefer intracapsular cataract extraction when the removal of a dislocated lens is indicated.
METHOD From the Wilmer Ophthalmological Institute of the Johns Hopkins University and Hospital. In children the operation is performed Reprint requests to A. E. Maumenee, M.D., The Wilmer Institute, Johns Hopkins Hospital, Balti under general anesthesia, although in the more, Maryland 21205. young adult it might be performed occasion-
ASPIRATION TECHNIQUE
VOL. 68, NO. 5
ally under local anesthesia. The operating microscope greatly facilitates the procedure. If there is poor dilatation of the pupil, a Franceschetti corepraxy is performed in the manner described by Maumenee and Gold berg.5 This is particularly important in cer tain syndromes such as Marian's syndrome or rubella embryopathy when there is fibrosis of the sphincter or aplasia of the pupil lary dilator. The initial incision is made through clear cornea at the limbus. It should be noted that an incision which is too shelving results in difficulty performing the iridectomy and as pirating the lens in the same quadrant. For aspiration of the usual fixed congenital cata ract, the Barkan goniotomy knife is pre ferred because it maintains a formed cham ber while the lens is being stirred. However, in the aspiration of the dislocated lens the Smith-Green, Wheeler or Ziegler knife may be used. This knife initially penetrates the limbus and then the lens ; stirring of the dis located lens is contraindicated. After incis ing the lens capsule, the knife is withdrawn. An 18-gauge, slightly blunted needle is then placed through the corneal incision and the lens material is aspirated into a 2-cc LuerLok syringe. This material can usually be removed without either stirring of the lens or irrigation since the cortex in young per sons, especially those with dislocated lenses, is usually quite soft. Formed vitreous cannot be aspirated through an 18-gauge needle. A 9.0 silk or 10.0 monofilament suture is placed in the wound and the first half of a surgeon's knot is tied. The anterior chamber is then filled with air through an additional tangential Ziegler puncture. A Barraquer sweep is inserted through the same opening and the area under the initial opening is swept to be sure there is no vitreous or cap sule adherent to the wound. The tangential Ziegler puncture does not usually need su turing. RESULTS
The operation was performed for reasons
809
of decreased visual acuity in the nine eyes of five patients (table 1). Preoperative and postoperative visual acuities were obtained in all but one of these eyes. In that case the child was too young. In the others, preopera tive visual acuity was 20/40 in one of the eyes, 20/70 in two, 20/200 in one and less than 20/200 in four. Postoperatively the vi sual acuity was 20/25 in three eyes, 20/40 in two, 20/50 in two and 20/70 in one. In the lenses that were aspirated for rea sons of increased intraocular pressure, post operative visual acuity was 20/25 in three eyes and 20/30 in one. This indicates the ex cellent postoperative visual results that may be obtained by aspiration of dislocated lens. Of the four lenses that were aspirated for elevated pressure, the intraocular pressure is now controlled without medication in three of the four eyes, whereas one eye still re quires pilocarpine and Diamox. Postopera tive examination and gonioscopy of the eye with persistent glaucoma indicates that the elevated pressure is secondary to probably préexistent peripheral anterior synechias and damage to the chamber angle. Three of the nine eyes operated upon for reduced visual acuity required a subsequent single discission, and two of the four eyes operated upon for glaucoma required a repeat discission. One eye developed a small hyphema at the time of the initial aspiration. This rapidly resolved in the first two postop erative days. Otherwise, no significant com plications were encountered in this small se ries. DISCUSSION
Jarrett reviewed the past experience at the Wilmer Institute in the management of subluxated lenses in all age groups. 1 He empha sized that better visual results were obtained by routine methods of lens extraction in pa tients with Marian's syndrome than in pa tients with trauma. Yet in the 26 eyes with Marfan's syndrome in Jarrett's series, vision was improved in only 15 eyes, whereas it was unchanged in seven eyes and worse, in
00 O
TABLE 1 SUBLUXATED LENSES ASPIRATED AT THE WiLMER INSTITUTE
Patient Age (yr) Sex
Diagnosis
Indication for Extraction
Preoperative Vision
Operative Date and Procedure Postoperative Vision
D.C. 6M
Marian's syndrome
Decreased acuity
5-19-61 R.E.,-18.0D + 7.0Dax90° = 20/200 L.E., -18.0D+2.5D ax 9 0 ° = 12/200
5-23-61 Aspiration, R.E. 12-61 Aspiration, L.E.
12-68 R.E., 20/25 L.E., 20/25
W.S. 23 F
Family history of ectopia lentis but no systemic disease
Decreased acuity
9-21-62 R.E., -6.0D+5.0Dax 98° = 20/70-2 L.E.,-4.0D = 3/400
1-6-66 Aspiration, L.E. 6-13-66 Aspiration, R.E.
7-19-66 R.E., 20/25 L.E., 20/70
A.C. 6M
Family history of ectopia lentis but no systemic disease
Decreased acuity
9-15-64 R.E., + 1 2 . 0 D = 20/70 L.E., +14.75 D = 20/40
2-17-64 Aspiration
1-9-65 R.E., 20/40 L.E., 20/50
C.M.M. 3M
Family history of ectopia lentis but no systemic disease
Decreased acuity
Too young. Completely dislocated lens
3-31-69 Aspiration
4-17-69 Clear pupil
Marchesani's syndrome
Glaucoma Tension: R.E., 29 mm Hg; L.E , 32 mm Hg
R.E., 2 0 / 6 0 + L.E., hand movements at 4 ft Clear dislocated lens
1-22-69 Peripheral iridectomy, L.E., followed by vitreous loss. 1-28-69 Aspiration, R.E.
4-8-69 R.E., 2 0 / 3 0 + Tension: R.E., 17; L.E., 24; Pilocarpine and Diamox
Glaucoma Tension: R.E., 43 mm Hg; L.E., 37 mm Hg
Clear dislocated lens
2-12-69 Aspiration. L.E. 2-17-69 Peripheral iridectomy, L.E., and sweep
4-8-69 L.E., 20/25 Tension: R.E., 12 mm Hg; L.E., 17 mm Hg
L.O. 18 F
0.0. 12 M
Marchesani's syndrome
F.C. 5F
Marian's syndrome
C.K. 8F
No family history
Decreased acuity
Glaucoma Tension: R.E., 40 mm Hg; L.E., 40 mm Hg
R.E., 20/200 L.E., 20/200 R.E., 20/40 L.E., 20/40
4-13-67 Discission, R.E. 11-27-67 Modified 4-18-67 Lavage, L.E.
11-67 R.E., 20/50 L.E., 20/40
2-20-65 Aspiration, L.E. 4-27-65 Aspiration, R.E. 6-65 Discission of membrane
12-68 R.E., 20/25 L.E., 20/25 Tension controlled without medica tion
> M
2 ri >
o a » > r o O >-d H
> g
O f
o o < 2
o < a
M
to
VOL. 68, NO. 5
ASPIRATION TECHNIQUE
four. In our small series, visual improve ment was obtained in 11 of the 12 eyes in which this determination could be measured. As in congenital cataracts, the simplicity and atraumatic nature of the aspiration tech nique for snbluxated lenses, particularly with regard to the vitreous, make it an ideal procedure. Since there is minimal trauma to the eye, the procedure would seem less likely to produce vitreous reaction, retinal detach ment and other undesirable sequelae, com pared to cases in which a large incision and intracapsular extraction have been per formed. Scheie3,G has reported good results with aspiration of dislocated lenses in six eyes. He advocates a single procedure for mature congenital cataractous lens but recommends a discission of immature cataracts, to be fol lowed by aspiration in three days to two weeks. He does not suggest a difference of technique for dislocated lenses. Our experi ence shows that relatively clear, dislocated lenses in persons up to 20 years of age can be aspirated in a single procedure without difficulty. No postoperative complications from retained lens material have been en countered. On the other hand, the high inci dence of vitreous loss which accompanies in tracapsular extraction of subluxated lenses has a well-known and significant range of postoperative complications.1·2 We are well aware of the potential postoperative compli cations associated with a mixture of lens material and vitreous, but such complications have not been encountered in this series. The management of glaucoma associated with a dislocated lens will depend on the cause of the glaucoma. Lenticular pupillary
811
block, phacoanaphylactic or phacolytic glau coma should be treated by aspiration of the lens. However, glaucoma secondary to pe ripheral anterior synechias or recession of the chamber angle after contusion injury will require either medical therapy or some type of antiglaucomatous procedure. It is thus apparent that careful preoperative eval uation, including gonioscopy, is necessary to determine the cause of the elevated intraocu lar pressure. In this small series, good vision was ob tained in all four eyes operated on for glau coma, and in only one of them is medical treatment required to control the pressure. SUMMARY
The removal of dislocated lenses in chil dren and young adults by a single-stage aspi ration operative technique has been de scribed. Good results were achieved in 13 eyes, nine of which were operated on for de creased vision and four for glaucoma. REFERENCES
1. Jarrett, W. H. : Dislocation of the lens: A study of 166 hospitalized cases. Arch. Ophth. 78:289, 1967. 2. Chandler, P. A. : Choice of treatment in dislo cation of the lens. Arch. Ophth. 71:76S, 1964. 3. Scheie, H. G. : Aspiration of congenital or soft cataracts : A new technique. Am. J. Ophth. 50:1048, 1960. 4. Ryan, S. J., Blanton, F. M. and von Noorden, G. K. : Surgery of congenital cataract. Am. J. Ophth. 60 :383, 196S. 5. Maumenee, A. E. and Goldberg, M. F. : Push-pull cataract aspiration and Franceschetti corepraxy. Arch. Ophth. 74:72, 1965. 6. Scheie, H. G., Rubenstein, R. A. and Kent, R. B. : Aspiration of congenital or soft cataracts : Further experience. Am. J. Ophth. 63 :3, 1967.
AMERICAN JOURNAL OF OPHTHALMOLOGY
3. Smith, J. L., David, N. J., Hart, L. N., Levenson, D. S. and Tillett, C. W. : Hemangioma of the choroid. Arch. Ophth. 69:51, 1963. 4. Justice, J., Jr., and Sever, R. J. : Technique of Fluorescein Fundus Photography. Neuro-ophthalmology : Symposium of University of Miami (J. L. Smith, ed.). St. Louis, Mosby, 1965, v. 2, p. 82. 5. Gitter, A. K., Meyer, D., Sarin, L. K, Keeney, A. H. and Justice, J., Jr. : Fluorescein and ultra sound in diagnosis of intraocular tumors. Am. J. Ophth. 66:719, 1968. 6. Norton, E. W. D., Smith, J. L., Curtin, V. T. and Justice, J., Jr. : Fluorescein f undus photogra phy: An aid in the differential diagnosis of poste rior ocular lesions. Tr. Am. Acad. Ophth. Otolaryng. 68:7SS, 1964. 7. Norton, E. W. D., Gass, J. D., Smith, J. L., Curtin, V. T., David, N. J. and Justice, J., Jr. : Flu orescein in the study of macular disease. Tr. Am. Acad. Ophth. Otolaryng. 69:631, 1965. 8. Hill, D. W. : Some clinical applications of fluorescence retinal photography. Tr. Ophth. Soc. U.K. 86:125, 1966. 9. Snyder, W. B., Allen, L. and Frazier, O. : Fluorescence angiography of ocular tumors. Tr. Am. Acad. Ophth. Otolaryng. 71:820, 1967. 10. Oosterhuis, J. A. and Van Waveren, C. W. :
NOVEMBER, 1969
Fluorescein photography in malignant melanoma. Ophthalmologica 156:101, 1968. 11. Charamis, J., Katsourakis, N. and Mandras, G. : The study of the cerebroretinal circulation by intravenous fluorescein injection. Am. J. Ophth. 61:1078, 1966. 12. Sollom, A. W. : Fluorescence in malignant melanomas of the choroid. Ophthalmologica 156:117, 1968. 13. Norton, E. W. D. and Gutman, F. : Fluores cein angiography and hemangiomas of the choroid. Arch. Ophth. 78:121, 1967. 14. Reese, A. B. and Howard, G. M. : Flat uveal melanomas. Am. J. Ophth. 64:1021, 1967. 15. François. J. : Diagnostic des melanomas ma lins de la choroïde. Ophthalmologica 151:114, 1966. 16. Thomas, C. L, Storaasli, J. P. and Friedeil, H. L. : Radioactive phosphorus in the detection of intraocular neoplasms. Am. J. Roentgen. 95:935, 1965. 17. Goldberg, R. E. and Sarin, L. K. : Ultrason ics in Ophthalmology. Philadelphia, Saunders, 1967, pp. 11, 65,114. 18. Goldberg, R. E., Sarin, L. K., Meyer, D. and Gitter, K. A. : Applications of ultrasonography, in ophthalmology. Tr. Am. Acad. Ophth. Otolaryng. 71:880, 1967.
A S P I R A T I O N T E C H N I Q U E IN T H E MANAGEMENT O F T H E DISLOCATED L E N S A. E. MAUMENEE, M.D., AND STEPHEN J. RYAN, M.D.
Baltimore, Maryland Extraction of subluxated lens in children has been considered such a hazardous proce dure that many surgeons are reluctant to operate except under compelling circum stances.1·2 Children may have subluxated lenses either from trauma or in association with disorders such as Marian's syndrome, Marchesani's syndrome or homocystinuria. This report presents a small series of pa tients with subluxated lenses removed by the aspiration technique, which has been repopularized in recent years for surgery of con genital cataracts.3·4 Contrary to an appar-
ently prevalent impression, the aspiration technique lends itself well to removal of cataractous and noncataractous subluxated lenses in patients of pre-adult ages. In the nine cases reported here, the indi cation for surgery was either impaired visual acuity or lens-induced glaucoma. The pur pose of this paper is to report the advantages of the aspiration technique in the manage ment of the dislocated lens in young persons, since many surgeons still prefer intracapsular cataract extraction when the removal of a dislocated lens is indicated.
METHOD From the Wilmer Ophthalmological Institute of the Johns Hopkins University and Hospital. In children the operation is performed Reprint requests to A. E. Maumenee, M.D., The Wilmer Institute, Johns Hopkins Hospital, Balti under general anesthesia, although in the more, Maryland 21205. young adult it might be performed occasion-
ASPIRATION TECHNIQUE
VOL. 68, NO. 5
ally under local anesthesia. The operating microscope greatly facilitates the procedure. If there is poor dilatation of the pupil, a Franceschetti corepraxy is performed in the manner described by Maumenee and Gold berg.5 This is particularly important in cer tain syndromes such as Marian's syndrome or rubella embryopathy when there is fibrosis of the sphincter or aplasia of the pupil lary dilator. The initial incision is made through clear cornea at the limbus. It should be noted that an incision which is too shelving results in difficulty performing the iridectomy and as pirating the lens in the same quadrant. For aspiration of the usual fixed congenital cata ract, the Barkan goniotomy knife is pre ferred because it maintains a formed cham ber while the lens is being stirred. However, in the aspiration of the dislocated lens the Smith-Green, Wheeler or Ziegler knife may be used. This knife initially penetrates the limbus and then the lens ; stirring of the dis located lens is contraindicated. After incis ing the lens capsule, the knife is withdrawn. An 18-gauge, slightly blunted needle is then placed through the corneal incision and the lens material is aspirated into a 2-cc LuerLok syringe. This material can usually be removed without either stirring of the lens or irrigation since the cortex in young per sons, especially those with dislocated lenses, is usually quite soft. Formed vitreous cannot be aspirated through an 18-gauge needle. A 9.0 silk or 10.0 monofilament suture is placed in the wound and the first half of a surgeon's knot is tied. The anterior chamber is then filled with air through an additional tangential Ziegler puncture. A Barraquer sweep is inserted through the same opening and the area under the initial opening is swept to be sure there is no vitreous or cap sule adherent to the wound. The tangential Ziegler puncture does not usually need su turing. RESULTS
The operation was performed for reasons
809
of decreased visual acuity in the nine eyes of five patients (table 1). Preoperative and postoperative visual acuities were obtained in all but one of these eyes. In that case the child was too young. In the others, preopera tive visual acuity was 20/40 in one of the eyes, 20/70 in two, 20/200 in one and less than 20/200 in four. Postoperatively the vi sual acuity was 20/25 in three eyes, 20/40 in two, 20/50 in two and 20/70 in one. In the lenses that were aspirated for rea sons of increased intraocular pressure, post operative visual acuity was 20/25 in three eyes and 20/30 in one. This indicates the ex cellent postoperative visual results that may be obtained by aspiration of dislocated lens. Of the four lenses that were aspirated for elevated pressure, the intraocular pressure is now controlled without medication in three of the four eyes, whereas one eye still re quires pilocarpine and Diamox. Postopera tive examination and gonioscopy of the eye with persistent glaucoma indicates that the elevated pressure is secondary to probably préexistent peripheral anterior synechias and damage to the chamber angle. Three of the nine eyes operated upon for reduced visual acuity required a subsequent single discission, and two of the four eyes operated upon for glaucoma required a repeat discission. One eye developed a small hyphema at the time of the initial aspiration. This rapidly resolved in the first two postop erative days. Otherwise, no significant com plications were encountered in this small se ries. DISCUSSION
Jarrett reviewed the past experience at the Wilmer Institute in the management of subluxated lenses in all age groups. 1 He empha sized that better visual results were obtained by routine methods of lens extraction in pa tients with Marian's syndrome than in pa tients with trauma. Yet in the 26 eyes with Marfan's syndrome in Jarrett's series, vision was improved in only 15 eyes, whereas it was unchanged in seven eyes and worse, in
00 O
TABLE 1 SUBLUXATED LENSES ASPIRATED AT THE WiLMER INSTITUTE
Patient Age (yr) Sex
Diagnosis
Indication for Extraction
Preoperative Vision
Operative Date and Procedure Postoperative Vision
D.C. 6M
Marian's syndrome
Decreased acuity
5-19-61 R.E.,-18.0D + 7.0Dax90° = 20/200 L.E., -18.0D+2.5D ax 9 0 ° = 12/200
5-23-61 Aspiration, R.E. 12-61 Aspiration, L.E.
12-68 R.E., 20/25 L.E., 20/25
W.S. 23 F
Family history of ectopia lentis but no systemic disease
Decreased acuity
9-21-62 R.E., -6.0D+5.0Dax 98° = 20/70-2 L.E.,-4.0D = 3/400
1-6-66 Aspiration, L.E. 6-13-66 Aspiration, R.E.
7-19-66 R.E., 20/25 L.E., 20/70
A.C. 6M
Family history of ectopia lentis but no systemic disease
Decreased acuity
9-15-64 R.E., + 1 2 . 0 D = 20/70 L.E., +14.75 D = 20/40
2-17-64 Aspiration
1-9-65 R.E., 20/40 L.E., 20/50
C.M.M. 3M
Family history of ectopia lentis but no systemic disease
Decreased acuity
Too young. Completely dislocated lens
3-31-69 Aspiration
4-17-69 Clear pupil
Marchesani's syndrome
Glaucoma Tension: R.E., 29 mm Hg; L.E , 32 mm Hg
R.E., 2 0 / 6 0 + L.E., hand movements at 4 ft Clear dislocated lens
1-22-69 Peripheral iridectomy, L.E., followed by vitreous loss. 1-28-69 Aspiration, R.E.
4-8-69 R.E., 2 0 / 3 0 + Tension: R.E., 17; L.E., 24; Pilocarpine and Diamox
Glaucoma Tension: R.E., 43 mm Hg; L.E., 37 mm Hg
Clear dislocated lens
2-12-69 Aspiration. L.E. 2-17-69 Peripheral iridectomy, L.E., and sweep
4-8-69 L.E., 20/25 Tension: R.E., 12 mm Hg; L.E., 17 mm Hg
L.O. 18 F
0.0. 12 M
Marchesani's syndrome
F.C. 5F
Marian's syndrome
C.K. 8F
No family history
Decreased acuity
Glaucoma Tension: R.E., 40 mm Hg; L.E., 40 mm Hg
R.E., 20/200 L.E., 20/200 R.E., 20/40 L.E., 20/40
4-13-67 Discission, R.E. 11-27-67 Modified 4-18-67 Lavage, L.E.
11-67 R.E., 20/50 L.E., 20/40
2-20-65 Aspiration, L.E. 4-27-65 Aspiration, R.E. 6-65 Discission of membrane
12-68 R.E., 20/25 L.E., 20/25 Tension controlled without medica tion
> M
2 ri >
o a » > r o O >-d H
> g
O f
o o < 2
o < a
M
to
VOL. 68, NO. 5
ASPIRATION TECHNIQUE
four. In our small series, visual improve ment was obtained in 11 of the 12 eyes in which this determination could be measured. As in congenital cataracts, the simplicity and atraumatic nature of the aspiration tech nique for snbluxated lenses, particularly with regard to the vitreous, make it an ideal procedure. Since there is minimal trauma to the eye, the procedure would seem less likely to produce vitreous reaction, retinal detach ment and other undesirable sequelae, com pared to cases in which a large incision and intracapsular extraction have been per formed. Scheie3,G has reported good results with aspiration of dislocated lenses in six eyes. He advocates a single procedure for mature congenital cataractous lens but recommends a discission of immature cataracts, to be fol lowed by aspiration in three days to two weeks. He does not suggest a difference of technique for dislocated lenses. Our experi ence shows that relatively clear, dislocated lenses in persons up to 20 years of age can be aspirated in a single procedure without difficulty. No postoperative complications from retained lens material have been en countered. On the other hand, the high inci dence of vitreous loss which accompanies in tracapsular extraction of subluxated lenses has a well-known and significant range of postoperative complications.1·2 We are well aware of the potential postoperative compli cations associated with a mixture of lens material and vitreous, but such complications have not been encountered in this series. The management of glaucoma associated with a dislocated lens will depend on the cause of the glaucoma. Lenticular pupillary
811
block, phacoanaphylactic or phacolytic glau coma should be treated by aspiration of the lens. However, glaucoma secondary to pe ripheral anterior synechias or recession of the chamber angle after contusion injury will require either medical therapy or some type of antiglaucomatous procedure. It is thus apparent that careful preoperative eval uation, including gonioscopy, is necessary to determine the cause of the elevated intraocu lar pressure. In this small series, good vision was ob tained in all four eyes operated on for glau coma, and in only one of them is medical treatment required to control the pressure. SUMMARY
The removal of dislocated lenses in chil dren and young adults by a single-stage aspi ration operative technique has been de scribed. Good results were achieved in 13 eyes, nine of which were operated on for de creased vision and four for glaucoma. REFERENCES
1. Jarrett, W. H. : Dislocation of the lens: A study of 166 hospitalized cases. Arch. Ophth. 78:289, 1967. 2. Chandler, P. A. : Choice of treatment in dislo cation of the lens. Arch. Ophth. 71:76S, 1964. 3. Scheie, H. G. : Aspiration of congenital or soft cataracts : A new technique. Am. J. Ophth. 50:1048, 1960. 4. Ryan, S. J., Blanton, F. M. and von Noorden, G. K. : Surgery of congenital cataract. Am. J. Ophth. 60 :383, 196S. 5. Maumenee, A. E. and Goldberg, M. F. : Push-pull cataract aspiration and Franceschetti corepraxy. Arch. Ophth. 74:72, 1965. 6. Scheie, H. G., Rubenstein, R. A. and Kent, R. B. : Aspiration of congenital or soft cataracts : Further experience. Am. J. Ophth. 63 :3, 1967.