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Management of the Dislocated Crystalline Lens with a Perfluorocarbon Liquid
Management of the Dislocated Crystalline Lens With a Perfluorocarbon Liquid Michael
J. Shapiro, M.D., Kenneth I. Resnick, M.D., Sang H. Kim, M.D., and Aaron Weinberg, M.D.
Vitreoretinal surgery allows the effective removal of soft to moderately dense crystalline lens fragments, using the vitrectomy probe and the ultrasonic fragmentation probe. Hard lenses cannot be removed with these instruments. Previously described techniques for removal of hard lenses include trapping the lens anteriorly with needles, cryoextraction of the lens in an air-filled eye, and manipulation with sodium hyaluronate. These methods are difficult and dangerous in some cases. We used perftuorocarbon liquid to facilitate the safe removal of a surgically luxated hard crystalline lens. Injection of the perftuorocarbon liquid ftoated the lens off the retinal surface and into the anterior vitreous cavity. In this location, the lens was delivered by using standard extracapsular cataract extraction techniques. This technique allowed removal of the hard crystalline lens with minimal manipulation, and was helpful in the setting of poor media clarity. DISLOCATION OF THE crystalline lens during cataract surgery often leads to severe uveitis, glaucoma, and vitreous condensation. If untreated, vision may be permanently lost.' Treatment of dislocated lenses and lens fragments has improved with the advance in vitrectomy techniques. Soft to moderately hard lenses are safely treated with the vitrectomy probe, ultrasonic fragmentation probe, and microvitreous forceps.!" Nonetheless, removal of hard lenses
Accepted for publication July 10, 1991. From the Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago Eye Center, University of Illinois at Chicago College of Medicine, Chicago, Illinois. This study was supported in part by the Lions of Illinois. This study was presented at the annual meeting of the Association for Research in Vision and Ophthalmology, April 30, 1991, Sarasota, Florida. Reprint requests to Michael Shapiro, M.D., Department of Ophthalmology (MjC 649), Lions of Illinois Eye Research Institute, 1905 W. Taylor St., Chicago, IL 60612.
©AMEIuCAN JOURNAL OF OPHTHALMOLOGY
112:401-405,
remains hazardous. Several techniques prone to failure and complication have been reported. They include posterior cryoextraction in an air-filled eye,3.5 double-needle trapping after placing the patient in a face-down position," and sodium hyaluronate manipulation of the hard lens into the anterior vitreous cavity," We used a technique that employed the special properties of perfluorocarbon liquids to facilitate the safe removal of a hard crystalline lens from the retinal surface. Moreover, we successfully applied this technique in a difficult and dangerous situation, an eye with partial corneal opacification and poor view of the retinal detail.
Case Report A 75-year-old man was referred because of a dislocated crystalline lens one day after cataract surgery in the right eye. Fifty years earlier he had suffered a corneal chemical burn of the right eye. Visual acuity was hand motion in the right eye and 20/40 in the left eye. Examination of the right eye disclosed a superior limbal incision with intact sutures. The superior cornea had a pannus extending 2.5 mm over the cornea. Additionally, two opaque scars were in the superior nasal paracentral area. The corneal epithelium and stroma were edematous, with severe striae of Descemet's membrane. Intraocular pressure as determined by Goldmann applanation was 47 mm Hg. Although the view of the anterior chamber was poor, lens remnants could be seen in the pupil. No fundus detail was visible with indirect ophthalmoscopy. Examination of the left eye disclosed a well-positioned, posterior chamber intraocular lens in an otherwise healthy eye. Informed consent was obtained from the patient. Because of the superior pannus, the surgical approach was from the temporal aspect of the eye. A 6-mm infusion cannula was placed at OCTOBER,
1991
401
402
AMERICAN JOURNAL OF OPHTHALMOLOGY
the 2:00 o'clock position and the other sclerotomies were made at the 10:00 and 8:00 o'clock positions. The vitreous probe was brought into the eye, and the central cortical lens remnants and anterior vitreous gel were removed. The peripheral rim of vitreous gel, lens cortex, and capsule were removed using scleral depression. After the vitrectomy was completed, the nucleus with parts of the cortex was found resting on the retina. At this time, a silicone-tipped cannula was brought into the eye and perfluorooctane was injected. The lens was lifted off the retina (Fig. 1). Additional injection of perfluoro-octane liquid enlarged the globule and floated the lens anteriorly. The lens was partially wedged between the globule and the inferior ciliary body (Fig. 2). Brushing with the softtipped cannula against the lens moved it centrally behind the pupil (Fig. 3). Visualization was inadequate to attempt ultrasonic fragmentation. Therefore, a temporal corneal limbal incision was made. The lens was delivered with a lens loop under gentle pressure from the balanced saline (0.64% NaCl) solution infusion (Fig. 4). After closing the limbal incision, the endoilluminator and silicone-tipped extrusion needle were brought into the eye, and the perfluoro-octane was removed. The lens specimen was brunescent. After surgery, the retina remained attached. The pressures declined to 20 mm Hg without treatment. The cornea had a mild bullous keratopathy, and postoperatively the uncorrected improvement in visual acuity improved to 3/ 200.
Discussion
Vitreous surgery for removal of dislocated crystalline lenses is usually performed when severe inflammation and glaucoma are present. Commonly, this glaucoma is phacolytic. Typical phacolytic glaucoma was observed and reported in the leaking hypermature lens. The release of soluble lens proteins induced a phagocytic response. The free protein and the macrophages distended with protein, blocked the trabecular meshwork outflow, and caused the intraocular pressure to increase. In cases of frank capsule rupture, the early pressure increase from residual cortex is caused by the soluble proteins with little contribution from
October, 1991
Fig. 1 (Shapiro and associates). Cross-sectional illustration of the operative situation after removal of the anterior cortical lens remnants and the vitreous gel, showing the liquid perfluorocarbon floating the lens off the retinal surface during injection above the optic nerve.
macrophages. Therefore, the term lens particle glaucoma has been applied. If untreated, lensinduced inflammation may also induce a persistent glaucoma caused by peripheral anterior synechiae, a dense pupillary membrane, vitreous opacification, cystoid macular edema, and retinal detachment.' Additionally, corneal manipulation is often increased in cases of surgical dislocation, frequently resulting in endothelial injury. Therefore, patients commonly have inflammation, glaucoma, vitreous opacification, and bullous keratopathy at initial examination. The poor outcome of untreated eyes and the complexity of the problems at initial examination make the management of the surgically dislocated crystalline lens both imperative and challenging. Many techniques have been described for the removal of dislocated crystalline lenses. The critical factors that determine the surgical approach include the amount of lens material, extent of dislocation, degree of mobility, density of the lens, and media clarity. Accompanying factors including retinal detachment, vitreous incarceration, and iris trauma must also be considered before and during surgery. Small amounts of lens material are common-
Vol. 112, No.4
Management of Luxated Lenses With Perfluorocarbon Liquids
Fig. 2 (Shapiro and associates). Intraoperative illustration showing the globule wedging the lens under the iris. ly found in many postoperative eyes. They appear to be well tolerated within the capsule. Small fragments are often tolerated posteriorly as well. In these cases, medical treatment of inflammation and glaucoma often allows resorption of the residual material without surgery. Larger lens fragments and multiple lens fragments often are not medically manageable and require surgical removal. Dislocated lenses with intact capsules may be left undisturbed until complications develop. Small fragments are removed with the vitreous probe and ultrasonic fragmentation probe.v' The technique for removal of large fragments and whole lenses depends on location, hardness, and media clarity. Mobile lens fragments from either subluxated or luxated lenses may be coaxed into the anterior chamber or vitreous cavity by placing the patient in a face-down position during surgery. The patient is retained in a face-down position until the lens is seen in the anterior chamber or vitreous cavity. Specially developed needles are then passed across the eye at the level of the pars plana. The patient is then rotated to a supine position and the lens is removed. This technique may be applied to hard as well as soft lenses. The disadvantages of this method include its limitation to mobile lenses, logistic difficulty with patient rotation and maintenance of the sterile field, and blind passage of
403
dangerous instruments through the eye in an inconvenient position. Serious complications have been reported." Residual zonular attachments may also hold subluxated lenses anteriorly. After the vitreous connections are cleared from the lens, the surgeon may choose a pars plana or anterior approach on the basis of the density of the lens. Soft to moderately dense crystalline lenses are commonly removed with the vitrectomy probe and ultrasonic fragmentation probe. In cases of moderately dense lenses for which ultrasound power is inadequate, a crush technique may help. This is a bimanual technique by which the lens is mechanically crushed between the endoilluminator and the ultrasonic fragmentation probe or vitrectomy probe. Typically, the moderately dense lens is lifted into the center of the vitreous cavity, using aspiration. It is fragmented or crushed and the remaining fragments fall back onto the retina. This process is repeated many times until the fragments can be aspirated.v" The retina can be traumatized during this procedure from the falling lens fragments, from the high energy of the ultrasonic fragmentation probe, or even from the vitreous probe. Eventually, all the lens material may be removed. Ultrasonic fragmentation and the crush technique are ineffective and dangerous for hard
Fig. 3 (Shapiro and associates). Intraoperative illustration showing manipulation of the lens from under the iris, using a brushing movement with a flexible silicone-tipped extrusion needle.
404
October, 1991
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 4 (Shapiro and associates). Intraoperative illustration showing the lens being removed using a lens loop and gentle pressure from the 0.64% balanced saline solution infusion.
lenses. The hard lens requires elevation into the anterior chamber and removal through a limbal or corneal wound. Techniques have been described for removal of the poorly mobile posterior luxated lens. Use of a cryoprobe in an air-filled eye" requires excellent visibility in order to monitor the position of the probe and the iceball. Misapplication of the probe becomes a concern at the time of engaging the lens on the retina, as well as during anterior manipulation of the enlarging iceball to the corneoscleral limbus. Initial visibility is poor in many cases and the view is further impaired when the eye is filled with air. Although the problem of corneal opacity may be resolved using a cryoprobe in an open-sky approach.' this surgery is complicated by new visibility problems common in open-sky vitrectomy. Therefore, misapplication of the probe remains a considerable risk. Use of sodium hyaluronate has been reported and is much less hazardous than the previous techniques." The sodium hyaluronate is carefully injected under the lens in order to buoy it up. This technique requires clear media to direct the viscous material correctly and remove the sodium hyaluronate safely. Because the infusion must be off during injection of the viscous material, the eye may
become hypotonous and miosis will sometimes result. Additionally, the sodium hyaluronate may also induce glaucoma. All the techniques described for removal of the poorly mobile hard lens require clear visualization of the lens and retina. Most of the techniques are hazardous or prone to failure because of the surgical complexity. The mild corneal scarring and opacification as we found in our case would require the addition of an open-sky approach or keratoprosthesis with pars plana approach to already difficult methods of lens removal. Because of their density, inert behavior, and low Viscosity, liquid perfluorocarbons have been used for the attachment of giant retinal tears and other retinal detachments.t" These same properties allow safe removal of hard lenses from eyes with suboptimal visualization. The crystalline lens is floated off the retina with minimal instrumentation. This allows the lens to be brought safely into the anterior vitreous cavity. In this location, the lens can be removed through the anterior chamber. Our concern for mechanical abrasion of the corneal endothelium with the heavy perfluorocarbon liquid motivated us to minimize its contact with the cornea. Therefore, we used gentle pressure from the balanced saline (0.64% NaCl) solution infusion and manually delivered it with a lens loop rather than expel the lens by increasing the perfluorocarbon globule into the anterior chamber. After closing the limbal wound, the liquid perfluorocarbon is easily removed. Its relatively high density causes it to pool posteriorly at the optic nerve and its low viscosity allows the use of a small-gauge extrusion needle. We found that this method greatly simplifies the removal of dislocated hard lenses and is preferable to the available alternative techniques.
References 1. Epstein, D. L.: Chandler and Grant's Glaucoma, ed. 3. Philadelphia, Lea & Febiger, 1986, pp. 320331. 2. Hutton, W. L., Snyder, W. B., and Vaiser, A.: Management of surgically dislocated intravitreallens fragments by pars plana vitrectomy. Ophthalmology 85:176,1978. 3. Charles, S.: Vitreous Microsurgery, ed. 2. Baltimore, Williams & Wilkins, 1987, pp. 48-51.
Vol. 112, No.4
Management of Luxated Lenses With Perfluorocarbon Liquids
4. Peyman, G. A., and Schulman, J. A.: lntravitreal Surgery. Principles and Practice. East Norwalk, Connecticut, Appleton-Century-Crofts, 1986, pp. 126130. 5. Barraquer, J.: Surgery of the dislocated lens. Trans. Am. Acad. Ophthalmol. Otolaryngol. 76:44, 1975. 6. Calhoun, F. P., and Hagler, W. S.: Experience with Jose Barraquer method of extracting a dislocated lens. Am. J. Ophthalmol. 50:701, 1960. 7. Haymet, B. T.: Removal of a dislocated hyper-
405
mature lens from the posterior vitreous. Aust. N.Z. J. Ophthalmol. 18:103, 1990. 8. Chang, S., Lincoff, H., Zimmerman, N. J., and Fuchs, W.: Giant retinal tears. Surgical techniques and results using perfluorocarbon liquids. Arch. Ophthalmol. 107:761, 1989. 9. Chang, S., Reucci, V., Zimmerman, N. J., Heinemann, M., and Coleman, D. J.: Perfluorocarbon liquids in the management of traumatic retinal detachments. Ophthalmology 96:785, 1989.
OPHTHALMIC MINIATURE
I had pictures painted on the walls of the waiting room. In one of these Imhotep the Wise, the god of doctors, was shown giving me instruction. I was painted small before him, as the custom is, but below the picture was an inscription that ran thus: Wisest and most skillful of thy disciples is Sinuhe, Son of Senmut, He Who Is Alone. Another picture showed me making sacrifice to Ammon, that I might be seen to do him honor and win the confidence of my patients. But in a third, great Pharaoh looked down upon me from the heavens in the shape of a bird, while his servants weighed out gold for me and clothed me in new robes. Mika Waltari, The Egyptian Helsinki, WSOY, 1983, p. 65
J. Shapiro, M.D., Kenneth I. Resnick, M.D., Sang H. Kim, M.D., and Aaron Weinberg, M.D.
Vitreoretinal surgery allows the effective removal of soft to moderately dense crystalline lens fragments, using the vitrectomy probe and the ultrasonic fragmentation probe. Hard lenses cannot be removed with these instruments. Previously described techniques for removal of hard lenses include trapping the lens anteriorly with needles, cryoextraction of the lens in an air-filled eye, and manipulation with sodium hyaluronate. These methods are difficult and dangerous in some cases. We used perftuorocarbon liquid to facilitate the safe removal of a surgically luxated hard crystalline lens. Injection of the perftuorocarbon liquid ftoated the lens off the retinal surface and into the anterior vitreous cavity. In this location, the lens was delivered by using standard extracapsular cataract extraction techniques. This technique allowed removal of the hard crystalline lens with minimal manipulation, and was helpful in the setting of poor media clarity. DISLOCATION OF THE crystalline lens during cataract surgery often leads to severe uveitis, glaucoma, and vitreous condensation. If untreated, vision may be permanently lost.' Treatment of dislocated lenses and lens fragments has improved with the advance in vitrectomy techniques. Soft to moderately hard lenses are safely treated with the vitrectomy probe, ultrasonic fragmentation probe, and microvitreous forceps.!" Nonetheless, removal of hard lenses
Accepted for publication July 10, 1991. From the Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago Eye Center, University of Illinois at Chicago College of Medicine, Chicago, Illinois. This study was supported in part by the Lions of Illinois. This study was presented at the annual meeting of the Association for Research in Vision and Ophthalmology, April 30, 1991, Sarasota, Florida. Reprint requests to Michael Shapiro, M.D., Department of Ophthalmology (MjC 649), Lions of Illinois Eye Research Institute, 1905 W. Taylor St., Chicago, IL 60612.
©AMEIuCAN JOURNAL OF OPHTHALMOLOGY
112:401-405,
remains hazardous. Several techniques prone to failure and complication have been reported. They include posterior cryoextraction in an air-filled eye,3.5 double-needle trapping after placing the patient in a face-down position," and sodium hyaluronate manipulation of the hard lens into the anterior vitreous cavity," We used a technique that employed the special properties of perfluorocarbon liquids to facilitate the safe removal of a hard crystalline lens from the retinal surface. Moreover, we successfully applied this technique in a difficult and dangerous situation, an eye with partial corneal opacification and poor view of the retinal detail.
Case Report A 75-year-old man was referred because of a dislocated crystalline lens one day after cataract surgery in the right eye. Fifty years earlier he had suffered a corneal chemical burn of the right eye. Visual acuity was hand motion in the right eye and 20/40 in the left eye. Examination of the right eye disclosed a superior limbal incision with intact sutures. The superior cornea had a pannus extending 2.5 mm over the cornea. Additionally, two opaque scars were in the superior nasal paracentral area. The corneal epithelium and stroma were edematous, with severe striae of Descemet's membrane. Intraocular pressure as determined by Goldmann applanation was 47 mm Hg. Although the view of the anterior chamber was poor, lens remnants could be seen in the pupil. No fundus detail was visible with indirect ophthalmoscopy. Examination of the left eye disclosed a well-positioned, posterior chamber intraocular lens in an otherwise healthy eye. Informed consent was obtained from the patient. Because of the superior pannus, the surgical approach was from the temporal aspect of the eye. A 6-mm infusion cannula was placed at OCTOBER,
1991
401
402
AMERICAN JOURNAL OF OPHTHALMOLOGY
the 2:00 o'clock position and the other sclerotomies were made at the 10:00 and 8:00 o'clock positions. The vitreous probe was brought into the eye, and the central cortical lens remnants and anterior vitreous gel were removed. The peripheral rim of vitreous gel, lens cortex, and capsule were removed using scleral depression. After the vitrectomy was completed, the nucleus with parts of the cortex was found resting on the retina. At this time, a silicone-tipped cannula was brought into the eye and perfluorooctane was injected. The lens was lifted off the retina (Fig. 1). Additional injection of perfluoro-octane liquid enlarged the globule and floated the lens anteriorly. The lens was partially wedged between the globule and the inferior ciliary body (Fig. 2). Brushing with the softtipped cannula against the lens moved it centrally behind the pupil (Fig. 3). Visualization was inadequate to attempt ultrasonic fragmentation. Therefore, a temporal corneal limbal incision was made. The lens was delivered with a lens loop under gentle pressure from the balanced saline (0.64% NaCl) solution infusion (Fig. 4). After closing the limbal incision, the endoilluminator and silicone-tipped extrusion needle were brought into the eye, and the perfluoro-octane was removed. The lens specimen was brunescent. After surgery, the retina remained attached. The pressures declined to 20 mm Hg without treatment. The cornea had a mild bullous keratopathy, and postoperatively the uncorrected improvement in visual acuity improved to 3/ 200.
Discussion
Vitreous surgery for removal of dislocated crystalline lenses is usually performed when severe inflammation and glaucoma are present. Commonly, this glaucoma is phacolytic. Typical phacolytic glaucoma was observed and reported in the leaking hypermature lens. The release of soluble lens proteins induced a phagocytic response. The free protein and the macrophages distended with protein, blocked the trabecular meshwork outflow, and caused the intraocular pressure to increase. In cases of frank capsule rupture, the early pressure increase from residual cortex is caused by the soluble proteins with little contribution from
October, 1991
Fig. 1 (Shapiro and associates). Cross-sectional illustration of the operative situation after removal of the anterior cortical lens remnants and the vitreous gel, showing the liquid perfluorocarbon floating the lens off the retinal surface during injection above the optic nerve.
macrophages. Therefore, the term lens particle glaucoma has been applied. If untreated, lensinduced inflammation may also induce a persistent glaucoma caused by peripheral anterior synechiae, a dense pupillary membrane, vitreous opacification, cystoid macular edema, and retinal detachment.' Additionally, corneal manipulation is often increased in cases of surgical dislocation, frequently resulting in endothelial injury. Therefore, patients commonly have inflammation, glaucoma, vitreous opacification, and bullous keratopathy at initial examination. The poor outcome of untreated eyes and the complexity of the problems at initial examination make the management of the surgically dislocated crystalline lens both imperative and challenging. Many techniques have been described for the removal of dislocated crystalline lenses. The critical factors that determine the surgical approach include the amount of lens material, extent of dislocation, degree of mobility, density of the lens, and media clarity. Accompanying factors including retinal detachment, vitreous incarceration, and iris trauma must also be considered before and during surgery. Small amounts of lens material are common-
Vol. 112, No.4
Management of Luxated Lenses With Perfluorocarbon Liquids
Fig. 2 (Shapiro and associates). Intraoperative illustration showing the globule wedging the lens under the iris. ly found in many postoperative eyes. They appear to be well tolerated within the capsule. Small fragments are often tolerated posteriorly as well. In these cases, medical treatment of inflammation and glaucoma often allows resorption of the residual material without surgery. Larger lens fragments and multiple lens fragments often are not medically manageable and require surgical removal. Dislocated lenses with intact capsules may be left undisturbed until complications develop. Small fragments are removed with the vitreous probe and ultrasonic fragmentation probe.v' The technique for removal of large fragments and whole lenses depends on location, hardness, and media clarity. Mobile lens fragments from either subluxated or luxated lenses may be coaxed into the anterior chamber or vitreous cavity by placing the patient in a face-down position during surgery. The patient is retained in a face-down position until the lens is seen in the anterior chamber or vitreous cavity. Specially developed needles are then passed across the eye at the level of the pars plana. The patient is then rotated to a supine position and the lens is removed. This technique may be applied to hard as well as soft lenses. The disadvantages of this method include its limitation to mobile lenses, logistic difficulty with patient rotation and maintenance of the sterile field, and blind passage of
403
dangerous instruments through the eye in an inconvenient position. Serious complications have been reported." Residual zonular attachments may also hold subluxated lenses anteriorly. After the vitreous connections are cleared from the lens, the surgeon may choose a pars plana or anterior approach on the basis of the density of the lens. Soft to moderately dense crystalline lenses are commonly removed with the vitrectomy probe and ultrasonic fragmentation probe. In cases of moderately dense lenses for which ultrasound power is inadequate, a crush technique may help. This is a bimanual technique by which the lens is mechanically crushed between the endoilluminator and the ultrasonic fragmentation probe or vitrectomy probe. Typically, the moderately dense lens is lifted into the center of the vitreous cavity, using aspiration. It is fragmented or crushed and the remaining fragments fall back onto the retina. This process is repeated many times until the fragments can be aspirated.v" The retina can be traumatized during this procedure from the falling lens fragments, from the high energy of the ultrasonic fragmentation probe, or even from the vitreous probe. Eventually, all the lens material may be removed. Ultrasonic fragmentation and the crush technique are ineffective and dangerous for hard
Fig. 3 (Shapiro and associates). Intraoperative illustration showing manipulation of the lens from under the iris, using a brushing movement with a flexible silicone-tipped extrusion needle.
404
October, 1991
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 4 (Shapiro and associates). Intraoperative illustration showing the lens being removed using a lens loop and gentle pressure from the 0.64% balanced saline solution infusion.
lenses. The hard lens requires elevation into the anterior chamber and removal through a limbal or corneal wound. Techniques have been described for removal of the poorly mobile posterior luxated lens. Use of a cryoprobe in an air-filled eye" requires excellent visibility in order to monitor the position of the probe and the iceball. Misapplication of the probe becomes a concern at the time of engaging the lens on the retina, as well as during anterior manipulation of the enlarging iceball to the corneoscleral limbus. Initial visibility is poor in many cases and the view is further impaired when the eye is filled with air. Although the problem of corneal opacity may be resolved using a cryoprobe in an open-sky approach.' this surgery is complicated by new visibility problems common in open-sky vitrectomy. Therefore, misapplication of the probe remains a considerable risk. Use of sodium hyaluronate has been reported and is much less hazardous than the previous techniques." The sodium hyaluronate is carefully injected under the lens in order to buoy it up. This technique requires clear media to direct the viscous material correctly and remove the sodium hyaluronate safely. Because the infusion must be off during injection of the viscous material, the eye may
become hypotonous and miosis will sometimes result. Additionally, the sodium hyaluronate may also induce glaucoma. All the techniques described for removal of the poorly mobile hard lens require clear visualization of the lens and retina. Most of the techniques are hazardous or prone to failure because of the surgical complexity. The mild corneal scarring and opacification as we found in our case would require the addition of an open-sky approach or keratoprosthesis with pars plana approach to already difficult methods of lens removal. Because of their density, inert behavior, and low Viscosity, liquid perfluorocarbons have been used for the attachment of giant retinal tears and other retinal detachments.t" These same properties allow safe removal of hard lenses from eyes with suboptimal visualization. The crystalline lens is floated off the retina with minimal instrumentation. This allows the lens to be brought safely into the anterior vitreous cavity. In this location, the lens can be removed through the anterior chamber. Our concern for mechanical abrasion of the corneal endothelium with the heavy perfluorocarbon liquid motivated us to minimize its contact with the cornea. Therefore, we used gentle pressure from the balanced saline (0.64% NaCl) solution infusion and manually delivered it with a lens loop rather than expel the lens by increasing the perfluorocarbon globule into the anterior chamber. After closing the limbal wound, the liquid perfluorocarbon is easily removed. Its relatively high density causes it to pool posteriorly at the optic nerve and its low viscosity allows the use of a small-gauge extrusion needle. We found that this method greatly simplifies the removal of dislocated hard lenses and is preferable to the available alternative techniques.
References 1. Epstein, D. L.: Chandler and Grant's Glaucoma, ed. 3. Philadelphia, Lea & Febiger, 1986, pp. 320331. 2. Hutton, W. L., Snyder, W. B., and Vaiser, A.: Management of surgically dislocated intravitreallens fragments by pars plana vitrectomy. Ophthalmology 85:176,1978. 3. Charles, S.: Vitreous Microsurgery, ed. 2. Baltimore, Williams & Wilkins, 1987, pp. 48-51.
Vol. 112, No.4
Management of Luxated Lenses With Perfluorocarbon Liquids
4. Peyman, G. A., and Schulman, J. A.: lntravitreal Surgery. Principles and Practice. East Norwalk, Connecticut, Appleton-Century-Crofts, 1986, pp. 126130. 5. Barraquer, J.: Surgery of the dislocated lens. Trans. Am. Acad. Ophthalmol. Otolaryngol. 76:44, 1975. 6. Calhoun, F. P., and Hagler, W. S.: Experience with Jose Barraquer method of extracting a dislocated lens. Am. J. Ophthalmol. 50:701, 1960. 7. Haymet, B. T.: Removal of a dislocated hyper-
405
mature lens from the posterior vitreous. Aust. N.Z. J. Ophthalmol. 18:103, 1990. 8. Chang, S., Lincoff, H., Zimmerman, N. J., and Fuchs, W.: Giant retinal tears. Surgical techniques and results using perfluorocarbon liquids. Arch. Ophthalmol. 107:761, 1989. 9. Chang, S., Reucci, V., Zimmerman, N. J., Heinemann, M., and Coleman, D. J.: Perfluorocarbon liquids in the management of traumatic retinal detachments. Ophthalmology 96:785, 1989.
OPHTHALMIC MINIATURE
I had pictures painted on the walls of the waiting room. In one of these Imhotep the Wise, the god of doctors, was shown giving me instruction. I was painted small before him, as the custom is, but below the picture was an inscription that ran thus: Wisest and most skillful of thy disciples is Sinuhe, Son of Senmut, He Who Is Alone. Another picture showed me making sacrifice to Ammon, that I might be seen to do him honor and win the confidence of my patients. But in a third, great Pharaoh looked down upon me from the heavens in the shape of a bird, while his servants weighed out gold for me and clothed me in new robes. Mika Waltari, The Egyptian Helsinki, WSOY, 1983, p. 65