- Email: [email protected]
Combined cataract surgery and 25-gauge sutureless vitrectomy for posterior lentiglobus
TECHNIQUE
Combined cataract surgery and 25-gauge sutureless vitrectomy for posterior lentiglobus Javier Moreno-Montan˜e´s, MD, PhD, Jesu´s Barrio-Barrio, MD, PhD, Alfredo Garcı´a-Layana, MD, PhD
Combined cataract surgery and sutureless vitrectomy were performed in a 2-year-old boy with posterior lentiglobus. After an anterior capsulotomy was made, the lens nucleus was aspirated without hydrodissection to avoid posterior capsule rupture. The cortex was carefully aspirated because the central posterior capsule moved up and down during irrigation and aspiration. A pars plana vitrectomy was then performed with the sutureless 25-gauge system for an anterior vitrectomy with a posterior capsulotomy. A C27 diopter AcrySof intraocular lens (IOL) (Alcon) was implanted with the haptics in the bag and the optic behind the posterior capsulotomy with optic capture. Two months postoperatively, the IOL was centered and there were no complications. This surgical technique is easy and effective. It avoids complications, facilitates IOL implantation behind the posterior capsule, and improves the external appearance of the eye immediately postoperatively. J Cataract Refract Surg 2007; 33:380–382 Q 2007 ASCRS and ESCRS
Posterior lenticonus or lentiglobus is a round or oval protrusion in the axial area of the posterior capsule. The diameters vary. Most cases are unilateral and sporadic, and there is little published evidence that it is a familial condition. Posterior lentiglobus is usually diagnosed in infancy, although the posterior prominence may increase with age. Observation of an ‘‘oil drop’’ in the middle of the light reflex facilitates the diagnosis. It is theorized that central thinning of the posterior capsule may be the reason for the development of the disorder. Complicated cataract is frequently associated with the anomaly; it is often progressive and is restricted to the subcapsular region of the lens. Cataract surgery is necessary to avoid amblyopia in children.1 We report the surgical procedure in a case of acquired posterior lentiglobus using a 25-gauge pars plana vitrectomy system. To our knowledge, this is the
Accepted for publication October 1, 2006. From the Department of Ophthalmology, Clı´nica Universitaria de Navarra, Universidad de Navarra, Pamplona, Spain. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Dr. Javier Moreno-Montan˜e´s, Department of Ophthalmology, Clı´nica Universitaria, Universidad de Navarra, Apartado 4209, 31080-Pamplona, Spain. E-mail: [email protected].
380
Q 2007 ASCRS and ESCRS Published by Elsevier Inc.
first report of surgery for lentiglobus using a sutureless 25-gauge posterior vitrectomy procedure. SURGICAL TECHNIQUE A 2-year-old boy was examined for intermittent esotropia in the right eye. Ocular examination revealed posterior capsule opacification (PCO) with a round, well-delineated image that resembled an oil drop with a protruding axial posterior capsule of approximately 4 mm 4 mm (Figure 1). The best corrected visual acuity (BCVA) in the eye was 0.1 with the Cardiff acuity test at 0.5 m. The intraocular pressure (IOP) was 10 mm Hg in both eyes. The left eye was normal. The patient did not have a history of ocular trauma or systemic defects or a family history of lentiglobus. Surgery under general anesthesia was considered to remove the lens opacification. A superior 3.0 mm clear corneal incision was made. The anterior capsule was stained with 0.2 mL of trypan blue 0.1% (VisionBlue) to cut a complete circular capsulotomy. However, the capsulorhexis was difficult because of the thin, elastic anterior capsule and the result was an incomplete anterior capsulotomy. Hydrodissection was not attempted to avoid rupturing the thin posterior central capsule in the area of the lentiglobus. Careful nucleus and cortex aspiration were performed because the central posterior capsule moved up and down during irrigation/aspiration (I/A) (Figure 2). The aspiration was made using the 0886-3350/07/$dsee front matter doi:10.1016/j.jcrs.2006.10.069
TECHNIQUE: COMBINED CATARACT SURGERY AND VITRECTOMY FOR LENTIGLOBUS
381
Figure 1. Posterior capsule opacification with a round, well-delineated image resembling an oil drop in the right eye. Posterior protrusion of the axial posterior capsule is observed.
Figure 2. Consecutive images of cortex aspiration. The central posterior capsule moves down (left arrows) and up (right arrows) during fluid movement in the anterior chamber when I/A is performed.
Millennium Microsurgical System (Bausch & Lomb Surgical). The posterior capsule was intact after I/A. A pars plana vitrectomy with a transconjunctival sutureless vitrectomy system (TSV-25, Bausch & Lomb Surgical) was performed. An infusion cannula was inserted into the anterior chamber to push down the posterior capsule, and a superior sclerotomy 2.0 mm posterior to the limbus was made using a trocar cannula, with a resultant small subconjunctival hemorrhage. A 25-gauge vitrectomy cutter was introduced into the vitreous through this superior trocar. The central and weak posterior capsule was removed with the vitrectomy cutter at a rate of 1200 cuts per minute, vacuum aspiration of 600 mm Hg, and a bottle height of 60 cm (Figure 3). A posterior capsulotomy approximately 4.0 mm in diameter was created. The vitrectomy was uneventful. An AcrySof SA60AT intraocular lens (IOL) (Alcon) was implanted. The IOL power was C27.00 diopters
(D), corresponding to 85% of the IOL biometric power calculated for emmetropia. The haptics were placed in the capsular bag, and the optic was situated behind the posterior capsulotomy with optic entrapment. The superior trocar was removed and the clear corneal incision sutured. Triamcinolone acetonide 0.5 mL was injected into the posterior sub-Tenon’s space. The postoperative course was uneventful. Tobramycin and prednisolone 0.1% drops were used 6 times daily for 2 weeks and prednisolone drops 3 times daily for another 2 weeks. Two months postoperatively, the IOL was centered and the anterior chamber and vitreous were clear without complications in the superior scleral incision of the vitrectomy (Figure 4). The postoperative refraction was C5.50 D. The BCVA was 0.6 with the Cardiff acuity test at 1 m. The patient is now maintained on a 6-hour daily regimen of patching of the left eye, and he is wearing a contact lens in the right eye.
Figure 3. Vitrectomy with the 25-gauge system. The infusion cannula is inserted through the corneal incision into the anterior chamber to push down the posterior capsule and facilitate the vitrectomy.
Figure 4. Two months after surgery, the anterior chamber and vitreous are clear without complications, inflammation, synechia, or IOL displacement.
382
TECHNIQUE: COMBINED CATARACT SURGERY AND VITRECTOMY FOR LENTIGLOBUS
DISCUSSION There are various surgical techniques for removing the posterior capsule in cases with a congenital cataract and lentiglobus or lenticonus. Simons and Flynn2 suggest a pars plana lensectomy and insertion of an IOL into the ciliary sulcus. Other authors suggest standard phacoemulsification and IOL implantation in the bag in adults3 or in cases of a small lenticonus.4 We think combined cataract surgery and a sutureless 25-gauge vitrectomy was the technique of choice in our patient. The cataract surgery is similar to other types of pediatric cataract surgery. Although a posterior capsulotomy and anterior vitrectomy could be performed through the clear corneal incision, it is not easy to manipulate the concave posterior capsule from the anterior chamber in cases with a marked protrusion. However, if an infusion cannula is inserted into the anterior chamber, the fluid pushes the posterior capsule down and elimination of the posterior capsule is facilitated during vitrectomy. In addition, with a 25-gauge tip, it is easier to remove a weak posterior capsule than a normal or opacified posterior capsule.5 Finally, with this vitrectomy, we can make a posterior capsulotomy that is adequate for IOL implantation with optic entrapment if there is a discontinuous anterior capsulotomy. Other pediatric cases in which the TSV-25 vitrectomy system was used have had good results.5,6 Lee et al.5 performed sutureless vitrectomy in 1 case to remove PCO after cataract surgery with no complications. Lam et al.6 used this vitrectomy in 10 pseudophakic eyes with PCO, making a posterior capsulotomy. The authors report that only 1 eye had persistent postoperative hypotony, but the hypotony had also been present preoperatively. The Seidel test detected no substantial leakage from the sclerotomy sites postoperatively. Fujii et al.7 used this sutureless vitrectomy in 4 eyes with retinopathy of prematurity and in 1 eye with Norrie disease. Some complications resulting from the sutureless vitrectomy technique in adult eyes have been reported.7 However, in these reports, 2 or 3 scleral incisions were made.5–7 In the current case, only 1 scleral incision was made because the irrigation cannula was placed in the anterior chamber; thus, the possibility of scleral incision leakage was low. Nevertheless, a careful examination during the postoperative period is important in children to observe whether a conjunctival bleb or conjunctival chemosis has developed.
Our combined surgical procedure has some advantages in a pediatric population. The vitrectomy requires only 1 incision, which decreases the risk for intraoperative hemorrhage, obviates the conjunctival peritomy, eliminates the sutures, which avoids the postoperative discomfort from suture irritation, and decreases the surgical time compared with a 20-gauge vitrectomy. In addition, smaller instruments are easier to manipulate in the eyes of children, which are smaller than adult eyes.5,6 In summary, the TSV-25 vitrectomy system combined with clear corneal cataract surgery seems to be a safe and effective approach, with no complications, to manage posterior lentiglobus in children. Although the follow-up in our case is short, we think the surgical technique resulted in very little surgical trauma, similar to standard pediatric cataract surgery, facilitated IOL implantation behind the posterior capsule, and improved the external appearance of the eye immediately after the procedure. REFERENCES 1. Khalil M, Saheb N. Posterior lenticonus. Ophthalmology 1984; 91:1429–1430; 43A 2. Simons BD, Flynn HW Jr. A pars plana approach for cataract surgery in posterior lenticonus. Am J Ophthalmol 1997; 124:695–696 3. Sukhija J, Saini JS, Jain AK. Phacoemulsification and intraocular lens implantation in an Alport’s syndrome patient with bilateral anterior and posterior lenticonus. J Cataract Refract Surg 2003; 29:1834–1836 4. Osher RH, Marques FF, Marques DMV, Cionni RJ. Focal multistriae: postoperative finding in posterior lenticonus patients. J Cataract Refract Surg 2003; 29:2029–2031 5. Lee HK, ChY Kim, Kwon OW, et al. Removal of dense posterior capsule opacification after congenital cataract extraction using the transconjunctival sutureless vitrectomy system. J Cataract Refract Surg 2004; 30:1626–1628 6. Lam DSC, Fan DSP, Mohamed S, et al. 25-gauge transconjunctival sutureless vitrectomy system in the surgical management of children with posterior capsular opacification. Clin Exp Ophthalmol 2005; 33:495–498 7. Fujii GY, de Juan E Jr, Humayun MS, et al. Initial experience using the transconjunctival sutureless vitrectomy system for vitreoretinal surgery. Ophthalmology 2002; 109:1814–1820
First author: Javier Moreno-Montan˜e´s, MD, PhD
Combined cataract surgery and 25-gauge sutureless vitrectomy for posterior lentiglobus Javier Moreno-Montan˜e´s, MD, PhD, Jesu´s Barrio-Barrio, MD, PhD, Alfredo Garcı´a-Layana, MD, PhD
Combined cataract surgery and sutureless vitrectomy were performed in a 2-year-old boy with posterior lentiglobus. After an anterior capsulotomy was made, the lens nucleus was aspirated without hydrodissection to avoid posterior capsule rupture. The cortex was carefully aspirated because the central posterior capsule moved up and down during irrigation and aspiration. A pars plana vitrectomy was then performed with the sutureless 25-gauge system for an anterior vitrectomy with a posterior capsulotomy. A C27 diopter AcrySof intraocular lens (IOL) (Alcon) was implanted with the haptics in the bag and the optic behind the posterior capsulotomy with optic capture. Two months postoperatively, the IOL was centered and there were no complications. This surgical technique is easy and effective. It avoids complications, facilitates IOL implantation behind the posterior capsule, and improves the external appearance of the eye immediately postoperatively. J Cataract Refract Surg 2007; 33:380–382 Q 2007 ASCRS and ESCRS
Posterior lenticonus or lentiglobus is a round or oval protrusion in the axial area of the posterior capsule. The diameters vary. Most cases are unilateral and sporadic, and there is little published evidence that it is a familial condition. Posterior lentiglobus is usually diagnosed in infancy, although the posterior prominence may increase with age. Observation of an ‘‘oil drop’’ in the middle of the light reflex facilitates the diagnosis. It is theorized that central thinning of the posterior capsule may be the reason for the development of the disorder. Complicated cataract is frequently associated with the anomaly; it is often progressive and is restricted to the subcapsular region of the lens. Cataract surgery is necessary to avoid amblyopia in children.1 We report the surgical procedure in a case of acquired posterior lentiglobus using a 25-gauge pars plana vitrectomy system. To our knowledge, this is the
Accepted for publication October 1, 2006. From the Department of Ophthalmology, Clı´nica Universitaria de Navarra, Universidad de Navarra, Pamplona, Spain. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Dr. Javier Moreno-Montan˜e´s, Department of Ophthalmology, Clı´nica Universitaria, Universidad de Navarra, Apartado 4209, 31080-Pamplona, Spain. E-mail: [email protected].
380
Q 2007 ASCRS and ESCRS Published by Elsevier Inc.
first report of surgery for lentiglobus using a sutureless 25-gauge posterior vitrectomy procedure. SURGICAL TECHNIQUE A 2-year-old boy was examined for intermittent esotropia in the right eye. Ocular examination revealed posterior capsule opacification (PCO) with a round, well-delineated image that resembled an oil drop with a protruding axial posterior capsule of approximately 4 mm 4 mm (Figure 1). The best corrected visual acuity (BCVA) in the eye was 0.1 with the Cardiff acuity test at 0.5 m. The intraocular pressure (IOP) was 10 mm Hg in both eyes. The left eye was normal. The patient did not have a history of ocular trauma or systemic defects or a family history of lentiglobus. Surgery under general anesthesia was considered to remove the lens opacification. A superior 3.0 mm clear corneal incision was made. The anterior capsule was stained with 0.2 mL of trypan blue 0.1% (VisionBlue) to cut a complete circular capsulotomy. However, the capsulorhexis was difficult because of the thin, elastic anterior capsule and the result was an incomplete anterior capsulotomy. Hydrodissection was not attempted to avoid rupturing the thin posterior central capsule in the area of the lentiglobus. Careful nucleus and cortex aspiration were performed because the central posterior capsule moved up and down during irrigation/aspiration (I/A) (Figure 2). The aspiration was made using the 0886-3350/07/$dsee front matter doi:10.1016/j.jcrs.2006.10.069
TECHNIQUE: COMBINED CATARACT SURGERY AND VITRECTOMY FOR LENTIGLOBUS
381
Figure 1. Posterior capsule opacification with a round, well-delineated image resembling an oil drop in the right eye. Posterior protrusion of the axial posterior capsule is observed.
Figure 2. Consecutive images of cortex aspiration. The central posterior capsule moves down (left arrows) and up (right arrows) during fluid movement in the anterior chamber when I/A is performed.
Millennium Microsurgical System (Bausch & Lomb Surgical). The posterior capsule was intact after I/A. A pars plana vitrectomy with a transconjunctival sutureless vitrectomy system (TSV-25, Bausch & Lomb Surgical) was performed. An infusion cannula was inserted into the anterior chamber to push down the posterior capsule, and a superior sclerotomy 2.0 mm posterior to the limbus was made using a trocar cannula, with a resultant small subconjunctival hemorrhage. A 25-gauge vitrectomy cutter was introduced into the vitreous through this superior trocar. The central and weak posterior capsule was removed with the vitrectomy cutter at a rate of 1200 cuts per minute, vacuum aspiration of 600 mm Hg, and a bottle height of 60 cm (Figure 3). A posterior capsulotomy approximately 4.0 mm in diameter was created. The vitrectomy was uneventful. An AcrySof SA60AT intraocular lens (IOL) (Alcon) was implanted. The IOL power was C27.00 diopters
(D), corresponding to 85% of the IOL biometric power calculated for emmetropia. The haptics were placed in the capsular bag, and the optic was situated behind the posterior capsulotomy with optic entrapment. The superior trocar was removed and the clear corneal incision sutured. Triamcinolone acetonide 0.5 mL was injected into the posterior sub-Tenon’s space. The postoperative course was uneventful. Tobramycin and prednisolone 0.1% drops were used 6 times daily for 2 weeks and prednisolone drops 3 times daily for another 2 weeks. Two months postoperatively, the IOL was centered and the anterior chamber and vitreous were clear without complications in the superior scleral incision of the vitrectomy (Figure 4). The postoperative refraction was C5.50 D. The BCVA was 0.6 with the Cardiff acuity test at 1 m. The patient is now maintained on a 6-hour daily regimen of patching of the left eye, and he is wearing a contact lens in the right eye.
Figure 3. Vitrectomy with the 25-gauge system. The infusion cannula is inserted through the corneal incision into the anterior chamber to push down the posterior capsule and facilitate the vitrectomy.
Figure 4. Two months after surgery, the anterior chamber and vitreous are clear without complications, inflammation, synechia, or IOL displacement.
382
TECHNIQUE: COMBINED CATARACT SURGERY AND VITRECTOMY FOR LENTIGLOBUS
DISCUSSION There are various surgical techniques for removing the posterior capsule in cases with a congenital cataract and lentiglobus or lenticonus. Simons and Flynn2 suggest a pars plana lensectomy and insertion of an IOL into the ciliary sulcus. Other authors suggest standard phacoemulsification and IOL implantation in the bag in adults3 or in cases of a small lenticonus.4 We think combined cataract surgery and a sutureless 25-gauge vitrectomy was the technique of choice in our patient. The cataract surgery is similar to other types of pediatric cataract surgery. Although a posterior capsulotomy and anterior vitrectomy could be performed through the clear corneal incision, it is not easy to manipulate the concave posterior capsule from the anterior chamber in cases with a marked protrusion. However, if an infusion cannula is inserted into the anterior chamber, the fluid pushes the posterior capsule down and elimination of the posterior capsule is facilitated during vitrectomy. In addition, with a 25-gauge tip, it is easier to remove a weak posterior capsule than a normal or opacified posterior capsule.5 Finally, with this vitrectomy, we can make a posterior capsulotomy that is adequate for IOL implantation with optic entrapment if there is a discontinuous anterior capsulotomy. Other pediatric cases in which the TSV-25 vitrectomy system was used have had good results.5,6 Lee et al.5 performed sutureless vitrectomy in 1 case to remove PCO after cataract surgery with no complications. Lam et al.6 used this vitrectomy in 10 pseudophakic eyes with PCO, making a posterior capsulotomy. The authors report that only 1 eye had persistent postoperative hypotony, but the hypotony had also been present preoperatively. The Seidel test detected no substantial leakage from the sclerotomy sites postoperatively. Fujii et al.7 used this sutureless vitrectomy in 4 eyes with retinopathy of prematurity and in 1 eye with Norrie disease. Some complications resulting from the sutureless vitrectomy technique in adult eyes have been reported.7 However, in these reports, 2 or 3 scleral incisions were made.5–7 In the current case, only 1 scleral incision was made because the irrigation cannula was placed in the anterior chamber; thus, the possibility of scleral incision leakage was low. Nevertheless, a careful examination during the postoperative period is important in children to observe whether a conjunctival bleb or conjunctival chemosis has developed.
Our combined surgical procedure has some advantages in a pediatric population. The vitrectomy requires only 1 incision, which decreases the risk for intraoperative hemorrhage, obviates the conjunctival peritomy, eliminates the sutures, which avoids the postoperative discomfort from suture irritation, and decreases the surgical time compared with a 20-gauge vitrectomy. In addition, smaller instruments are easier to manipulate in the eyes of children, which are smaller than adult eyes.5,6 In summary, the TSV-25 vitrectomy system combined with clear corneal cataract surgery seems to be a safe and effective approach, with no complications, to manage posterior lentiglobus in children. Although the follow-up in our case is short, we think the surgical technique resulted in very little surgical trauma, similar to standard pediatric cataract surgery, facilitated IOL implantation behind the posterior capsule, and improved the external appearance of the eye immediately after the procedure. REFERENCES 1. Khalil M, Saheb N. Posterior lenticonus. Ophthalmology 1984; 91:1429–1430; 43A 2. Simons BD, Flynn HW Jr. A pars plana approach for cataract surgery in posterior lenticonus. Am J Ophthalmol 1997; 124:695–696 3. Sukhija J, Saini JS, Jain AK. Phacoemulsification and intraocular lens implantation in an Alport’s syndrome patient with bilateral anterior and posterior lenticonus. J Cataract Refract Surg 2003; 29:1834–1836 4. Osher RH, Marques FF, Marques DMV, Cionni RJ. Focal multistriae: postoperative finding in posterior lenticonus patients. J Cataract Refract Surg 2003; 29:2029–2031 5. Lee HK, ChY Kim, Kwon OW, et al. Removal of dense posterior capsule opacification after congenital cataract extraction using the transconjunctival sutureless vitrectomy system. J Cataract Refract Surg 2004; 30:1626–1628 6. Lam DSC, Fan DSP, Mohamed S, et al. 25-gauge transconjunctival sutureless vitrectomy system in the surgical management of children with posterior capsular opacification. Clin Exp Ophthalmol 2005; 33:495–498 7. Fujii GY, de Juan E Jr, Humayun MS, et al. Initial experience using the transconjunctival sutureless vitrectomy system for vitreoretinal surgery. Ophthalmology 2002; 109:1814–1820
First author: Javier Moreno-Montan˜e´s, MD, PhD