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Surgical management of late dislocated lens capsular bag with intraocular lens and endocapsular tension ring
J CATARACT REFRACT SURG - VOL 32, MARCH 2006
Surgical management of late dislocated lens capsular bag with intraocular lens and endocapsular tension ring Marcus C.C. Lim, MRCS(Ed), Aliza H.E. Jap, FRCS(Ed), Edmund Y.M. Wong, FRCS(Ed)
A case of late spontaneous dislocation of the lens capsular bag (CB) with foldable acrylic intraocular lens (IOL) and endocapsular tension ring (CTR) and its surgical management is reported in a 52-year-old man. The dislocation occurred 2 years 3 months after phacoemulsification cataract surgery in which a CTR was used for zonular instability. A 3-port pars plana vitrectomy was performed. Because it was not possible to grasp the IOL–CTR–CB complex, perfluorocarbon liquid was used to attempt to float it up. This was unsuccessful, so a scleral indenter was used to apply external pressure on the sclera to tilt the IOL–CTR–CB complex into a position where it could be grasped with a forceps and removed through a corneal section. A scleral-fixated IOL was placed, and the patient achieved a best corrected visual acuity of 6/9. The procedure was safe and effective without intraocular complications. J Cataract Refract Surg 2006; 32:533–535 Q 2006 ASCRS and ESCRS
First introduced in 1991,1 the capsular tension ring (CTR) provides support to the capsular bag during partial breakdown of zonular support, permitting safe phacoemulsification and insertion of an intraocular lens (IOL). The CTR does this by providing even support to the circular edge of the capsular bag (CB) and evenly distributing the forces on the intact zonules, as well as preventing capsular collapse and vitreous presentation during surgery.2 However, even after implantation of a CTR, subluxation of the entire IOL–CB–CTR complex can occur.3 We report a patient who presented with late spontaneous dislocation of the entire IOL–CB–CTR complex. To our knowledge, there have been no case reports of late spontaneous dislocations of entire IOL–CB–CTR complexes. We describe a surgical technique to remove the complex from the retinal surface, and sclerally fixate a posterior chamber IOL. Accepted for publication August 10, 2005. From the Singapore National Eye Centre (Lim, Jap, Wong), Singapore and the Department of Ophthalmology (Jap, Wong), Changi General Hospital, Singapore. No author has a financial or proprietary interest in any material or method mentioned. Reprint requests to Marcus C. C. Lim, MRCS(Ed), Singapore National Eye Centre, 11, Third Hospital Avenue, Singapore 168751. E-mail: [email protected]. Q 2006 ASCRS and ESCRS Published by Elsevier Inc.
CASE REPORT A 52-year-old Chinese man with no medical history of note, trauma, or signs of pseudoexfoliation and overt lens subluxation had phacoemulsification surgery for cortical, anterior, and posterior subcapsular cataract in the left eye. No abnormalities were detected in the right eye. The preoperative best corrected visual acuity (BCVA) was 6/24. Under retrobulbar anesthesia, a temporal corneal tunnel was made. After a continuous curvilinear capsulorhexis was created, vitreous was noted prolapsing subincisionally. No unusual movement of the lens was noted. A limited anterior vitrectomy was done, and phacoemulsification was completed with no further vitreous loss. The posterior capsule was intact. A CTR (Alcon ReFORM) was inserted with a Geuder G-32955 CTR injector into the capsular bag. Residual cortical matter was removed with the irrigation/aspiration tip. An acrylic IOL (AcrySof MA60BM, Alcon) was inserted subsequently in the capsular bag. Recovery was uneventful, and 6 weeks postoperatively, the BCVA was 6/9 with a well-centered and stable IOL. The patient subsequently failed to come for follow-up. Two years 3 months later, the patient presented with a week’s history of sudden blurring of vision in the left eye. On examination, the entire capsular bag with the posterior chamber IOL and CTR intact was seen resting as a flat disc on the inferior retina and was freely mobile. The entire IOL–CTR–CB complex had spontaneously dislocated into the vitreous cavity. The patient had 3-port pars plana vitrectomy (PPV) 3.0 mm posterior to the limbus. A core vitrectomy was performed, and the posterior vitreous detachment was created with vacuum. The retina was checked for pathology. Because of the close apposition of the IOL–CTR–CB complex to the retina and the flatness of the capsular bag owing to the tension exerted by the CTR within the capsular bag, it was not possible to directly grasp the complex 0886-3350/06/$-see front matter doi:10.1016/j.jcrs.2005.12.070
533
CASE REPORTS: DISLOCATED CAPSULAR BAG, IOL, AND TENSION RING
with a forceps or float it up with perfluorocarbon liquid (PFCL) (Purified Perfluoro-n-octane Liquid, Alcon). Hence, a scleral indenter was used to apply external pressure on the sclera, tilting the IOL–CTR–CB into a position in which it could be grasped with a pair of de Juan forceps (Grieshaber, Alcon) (Figure 1). The entire capsular bag was removed through a new 7.0 mm corneal section, and a 1-piece poly(methyl methacrylate) posterior chamber IOL was fixated sclerally with 10-0 polypropylene (Prolene). The corneal wound was closed with interrupted 10-0 nylon sutures. The PFCL was exchanged with a balanced salt solution. After inspection of the peripheral retina, the sclerotomy wounds were closed with 7-0 polyglactin (Vicryl). A subconjunctival injection of gentamicin, dexamethasone, and cefazolin was given. The patient was put on topical antibiotics and steroids. Eight months after the procedure, the visual acuity was 6/9 and the sclerally fixated IOL remained centered and stable. DISCUSSION
Dislocation of the entire IOL–CB complex without CTRs has been described in patients without ocular disease,4,5 in association with pseudoexfoliation syndrome,2,6,7 contusion,8 and capsule contraction syndrome.9 Shigeeda et al.5 reported 4 patients without ocular disease who had spontaneous dislocations of the IOL–CB complex a mean of 5.5 years after surgery. In pseudoexfoliation syndrome patients, the mean time to dislocation has been reported at 7 years 1 month, occurring up to 9 years after cataract surgery.7 In IOL–CB complex dislocations without CTRs, the risk for dislocation is presumably the result of inadequate support of preexisting zonular weakness. Late luxations of entire IOL–CB–CTR complexes have not been described before. This is presumably because the
Figure 1. Diagram shows retrieval of dislocated IOL–CTR–CB complex (arrow) by scleral indentation and a forceps.
534
CTR evenly distributes the forces on the intact zonules, centers the IOL and reduces the risk for dislocation of the capsular bag. Our patient presumably had zonular weakness or dehiscence because there had been vitreous presentation early during the initial cataract surgery. This probably contributed to the luxation of the entire capsular bag later, in spite of the CTR, even though the patient denied trauma postsurgery. There is a single case report of a subluxated IOL–CB–CTR complex that was repositioned by using transscleral sutures passing over and under the CTR, through both anterior and posterior capsules to secure the IOL–CB to the sulcus.3 This differs from our case, which was a luxation; ie, complete dislocation. In other reports of CTR dislocations into the vitreous, 1 was caused by extension of an existing posterior capsular tear.10 Ma et al.11 report 2 cases. In the first, a ruptured capsular bag containing the crystalline lens and a CTR dislocated during cataract surgery. In the second, the crystalline lens and CTR dislocated into the vitreous during cataract surgery. Lang et al.12 also report a case of CTR dislocation immediately after cataract surgery resulting from posterior capsular rupture Three-port PPV in combination with various techniques has been used widely to retrieve CTRs from the vitreous.10–12 In all these reports, the CTR was removed with a forceps. Perfluorocarbon liquid has been useful to float dislocated IOLs so that they can be grasped more easily.10,13 In our case, the flatness of the intact capsular bag containing the IOL, caused by tension exerted by the CTR in situ, prevented direct grasp with a forceps and the PFCL from floating it up. The PFCL floated on top of the IOL–CB– CTR complex, so we used a scleral indenter to indent the sclera externally and maneuver the IOL–CB–CTR complex into a position in which it could be grasped with a forceps. Removal of the CTR from the eye has been achieved through sclerotomies and limbal or corneal sections, which are used for IOL explantation. In our case, we removed the CTR whole through a corneal section. In some cases, the CTR is cut with scissors before explantation.11 Ma et al.11 also used a Geuder CTR injector inserted through a sclerotomy to withdraw the CTR inside the CTR injector. As in these reports, our patient was made phakic with a scleral-sutured IOL. Between us (E.W., A.J.), we have used 7 CTRs, all in the past 5 years. The other 6 cases were and still are uneventful. To our knowledge, there have been no case reports of luxation of the entire IOL–CB complex after a CTR has been implanted. This complication may become more common with increased use of CTRs. In such cases, we have shown that 3-port PPV and external indentation is a safe and useful method for retrieving the IOL–CB–CTR complex, especially when PFCL fails to float up the complex.
J CATARACT REFRACT SURG - VOL 32, MARCH 2006
CASE REPORTS: DISLOCATED CAPSULAR BAG, IOL, AND TENSION RING
REFERENCES 1. Hara T, Hara T, Yamada Y. ‘‘Equator ring’’ for maintenance of the completely circular contour of the capsular bag equator after cataract removal. Ophthalmic Surg 1991; 22:358–359 2. Gimbel HV, Sun R, Heston JP. Management of zonular dialysis in phacoemulsification and IOL implantation using the capsular tension ring. Ophthalmic Surg Lasers 1997; 28:273–281 3. Moreno-Montan˜e´s J, Heras H, Ferna´ndez-Hortelano A. Surgical treatment of a dislocated intraocular lens-capsular bag-capsular tension ring complex. J Cataract Refract Surg 2005; 31:270–273 4. Nishi O, Nishi K, Sakanishi K, Yamada Y. Explantation of endocapsular posterior chamber lens after spontaneous posterior dislocation. J Cataract Refract Surg 1996; 22:272–275 5. Shigeeda T, Nagahara M, Kato S, et al. Spontaneous posterior dislocation of intraocular lenses fixated in the capsular bag. J Cataract Refract Surg 2002; 28:1689–1693 6. Fine IH, Hoffman RS. Phacoemulsification in the presence of pseudoexfoliation: challenges and options. J Cataract Refract Surg 1997; 23:160–165
7. Jehan FS, Mamalis N, Crandall AS. Spontaneous late dislocation of intraocular lens within the capsular bag in pseudoexfoliation patients. Ophthalmology 2001; 108:1727–1731 8. Zech J-C, Tannie´re P, Denis P, Trepsat C. Posterior chamber intraocular lens dislocation with the bag. J Cataract Refract Surg 1999; 25:1168– 1169 9. Davison JA. Capsule contraction syndrome. J Cataract Refract Surg 1993; 19:582–589 10. Bhattacharjee H, Bhattacharjee K, Das D, et al. Management of a posteriorly dislocated endocapsular tension ring and a foldable acrylic intraocular lens. J Cataract Refract Surg 2004; 30:243–246 11. Ma PE, Kaur H, Petrovic V, Hay D. Technique for removal of a capsular tension ring from the vitreous. Ophthalmology 2003; 110:1142–1144 12. Lang Y, Fineberg E, Garzozi HJ. Vitrectomy to remove a posteriorly dislocated endocapsular tension ring. J Cataract Refract Surg 2001; 27:474–476 13. Lewis H, Sanchez G. The use of perfluorocarbon liquids in the repositioning of posteriorly dislocated intraocular lenses. Ophthalmology 1993; 100:1055–1059
J CATARACT REFRACT SURG - VOL 32, MARCH 2006
535
Surgical management of late dislocated lens capsular bag with intraocular lens and endocapsular tension ring Marcus C.C. Lim, MRCS(Ed), Aliza H.E. Jap, FRCS(Ed), Edmund Y.M. Wong, FRCS(Ed)
A case of late spontaneous dislocation of the lens capsular bag (CB) with foldable acrylic intraocular lens (IOL) and endocapsular tension ring (CTR) and its surgical management is reported in a 52-year-old man. The dislocation occurred 2 years 3 months after phacoemulsification cataract surgery in which a CTR was used for zonular instability. A 3-port pars plana vitrectomy was performed. Because it was not possible to grasp the IOL–CTR–CB complex, perfluorocarbon liquid was used to attempt to float it up. This was unsuccessful, so a scleral indenter was used to apply external pressure on the sclera to tilt the IOL–CTR–CB complex into a position where it could be grasped with a forceps and removed through a corneal section. A scleral-fixated IOL was placed, and the patient achieved a best corrected visual acuity of 6/9. The procedure was safe and effective without intraocular complications. J Cataract Refract Surg 2006; 32:533–535 Q 2006 ASCRS and ESCRS
First introduced in 1991,1 the capsular tension ring (CTR) provides support to the capsular bag during partial breakdown of zonular support, permitting safe phacoemulsification and insertion of an intraocular lens (IOL). The CTR does this by providing even support to the circular edge of the capsular bag (CB) and evenly distributing the forces on the intact zonules, as well as preventing capsular collapse and vitreous presentation during surgery.2 However, even after implantation of a CTR, subluxation of the entire IOL–CB–CTR complex can occur.3 We report a patient who presented with late spontaneous dislocation of the entire IOL–CB–CTR complex. To our knowledge, there have been no case reports of late spontaneous dislocations of entire IOL–CB–CTR complexes. We describe a surgical technique to remove the complex from the retinal surface, and sclerally fixate a posterior chamber IOL. Accepted for publication August 10, 2005. From the Singapore National Eye Centre (Lim, Jap, Wong), Singapore and the Department of Ophthalmology (Jap, Wong), Changi General Hospital, Singapore. No author has a financial or proprietary interest in any material or method mentioned. Reprint requests to Marcus C. C. Lim, MRCS(Ed), Singapore National Eye Centre, 11, Third Hospital Avenue, Singapore 168751. E-mail: [email protected]. Q 2006 ASCRS and ESCRS Published by Elsevier Inc.
CASE REPORT A 52-year-old Chinese man with no medical history of note, trauma, or signs of pseudoexfoliation and overt lens subluxation had phacoemulsification surgery for cortical, anterior, and posterior subcapsular cataract in the left eye. No abnormalities were detected in the right eye. The preoperative best corrected visual acuity (BCVA) was 6/24. Under retrobulbar anesthesia, a temporal corneal tunnel was made. After a continuous curvilinear capsulorhexis was created, vitreous was noted prolapsing subincisionally. No unusual movement of the lens was noted. A limited anterior vitrectomy was done, and phacoemulsification was completed with no further vitreous loss. The posterior capsule was intact. A CTR (Alcon ReFORM) was inserted with a Geuder G-32955 CTR injector into the capsular bag. Residual cortical matter was removed with the irrigation/aspiration tip. An acrylic IOL (AcrySof MA60BM, Alcon) was inserted subsequently in the capsular bag. Recovery was uneventful, and 6 weeks postoperatively, the BCVA was 6/9 with a well-centered and stable IOL. The patient subsequently failed to come for follow-up. Two years 3 months later, the patient presented with a week’s history of sudden blurring of vision in the left eye. On examination, the entire capsular bag with the posterior chamber IOL and CTR intact was seen resting as a flat disc on the inferior retina and was freely mobile. The entire IOL–CTR–CB complex had spontaneously dislocated into the vitreous cavity. The patient had 3-port pars plana vitrectomy (PPV) 3.0 mm posterior to the limbus. A core vitrectomy was performed, and the posterior vitreous detachment was created with vacuum. The retina was checked for pathology. Because of the close apposition of the IOL–CTR–CB complex to the retina and the flatness of the capsular bag owing to the tension exerted by the CTR within the capsular bag, it was not possible to directly grasp the complex 0886-3350/06/$-see front matter doi:10.1016/j.jcrs.2005.12.070
533
CASE REPORTS: DISLOCATED CAPSULAR BAG, IOL, AND TENSION RING
with a forceps or float it up with perfluorocarbon liquid (PFCL) (Purified Perfluoro-n-octane Liquid, Alcon). Hence, a scleral indenter was used to apply external pressure on the sclera, tilting the IOL–CTR–CB into a position in which it could be grasped with a pair of de Juan forceps (Grieshaber, Alcon) (Figure 1). The entire capsular bag was removed through a new 7.0 mm corneal section, and a 1-piece poly(methyl methacrylate) posterior chamber IOL was fixated sclerally with 10-0 polypropylene (Prolene). The corneal wound was closed with interrupted 10-0 nylon sutures. The PFCL was exchanged with a balanced salt solution. After inspection of the peripheral retina, the sclerotomy wounds were closed with 7-0 polyglactin (Vicryl). A subconjunctival injection of gentamicin, dexamethasone, and cefazolin was given. The patient was put on topical antibiotics and steroids. Eight months after the procedure, the visual acuity was 6/9 and the sclerally fixated IOL remained centered and stable. DISCUSSION
Dislocation of the entire IOL–CB complex without CTRs has been described in patients without ocular disease,4,5 in association with pseudoexfoliation syndrome,2,6,7 contusion,8 and capsule contraction syndrome.9 Shigeeda et al.5 reported 4 patients without ocular disease who had spontaneous dislocations of the IOL–CB complex a mean of 5.5 years after surgery. In pseudoexfoliation syndrome patients, the mean time to dislocation has been reported at 7 years 1 month, occurring up to 9 years after cataract surgery.7 In IOL–CB complex dislocations without CTRs, the risk for dislocation is presumably the result of inadequate support of preexisting zonular weakness. Late luxations of entire IOL–CB–CTR complexes have not been described before. This is presumably because the
Figure 1. Diagram shows retrieval of dislocated IOL–CTR–CB complex (arrow) by scleral indentation and a forceps.
534
CTR evenly distributes the forces on the intact zonules, centers the IOL and reduces the risk for dislocation of the capsular bag. Our patient presumably had zonular weakness or dehiscence because there had been vitreous presentation early during the initial cataract surgery. This probably contributed to the luxation of the entire capsular bag later, in spite of the CTR, even though the patient denied trauma postsurgery. There is a single case report of a subluxated IOL–CB–CTR complex that was repositioned by using transscleral sutures passing over and under the CTR, through both anterior and posterior capsules to secure the IOL–CB to the sulcus.3 This differs from our case, which was a luxation; ie, complete dislocation. In other reports of CTR dislocations into the vitreous, 1 was caused by extension of an existing posterior capsular tear.10 Ma et al.11 report 2 cases. In the first, a ruptured capsular bag containing the crystalline lens and a CTR dislocated during cataract surgery. In the second, the crystalline lens and CTR dislocated into the vitreous during cataract surgery. Lang et al.12 also report a case of CTR dislocation immediately after cataract surgery resulting from posterior capsular rupture Three-port PPV in combination with various techniques has been used widely to retrieve CTRs from the vitreous.10–12 In all these reports, the CTR was removed with a forceps. Perfluorocarbon liquid has been useful to float dislocated IOLs so that they can be grasped more easily.10,13 In our case, the flatness of the intact capsular bag containing the IOL, caused by tension exerted by the CTR in situ, prevented direct grasp with a forceps and the PFCL from floating it up. The PFCL floated on top of the IOL–CB– CTR complex, so we used a scleral indenter to indent the sclera externally and maneuver the IOL–CB–CTR complex into a position in which it could be grasped with a forceps. Removal of the CTR from the eye has been achieved through sclerotomies and limbal or corneal sections, which are used for IOL explantation. In our case, we removed the CTR whole through a corneal section. In some cases, the CTR is cut with scissors before explantation.11 Ma et al.11 also used a Geuder CTR injector inserted through a sclerotomy to withdraw the CTR inside the CTR injector. As in these reports, our patient was made phakic with a scleral-sutured IOL. Between us (E.W., A.J.), we have used 7 CTRs, all in the past 5 years. The other 6 cases were and still are uneventful. To our knowledge, there have been no case reports of luxation of the entire IOL–CB complex after a CTR has been implanted. This complication may become more common with increased use of CTRs. In such cases, we have shown that 3-port PPV and external indentation is a safe and useful method for retrieving the IOL–CB–CTR complex, especially when PFCL fails to float up the complex.
J CATARACT REFRACT SURG - VOL 32, MARCH 2006
CASE REPORTS: DISLOCATED CAPSULAR BAG, IOL, AND TENSION RING
REFERENCES 1. Hara T, Hara T, Yamada Y. ‘‘Equator ring’’ for maintenance of the completely circular contour of the capsular bag equator after cataract removal. Ophthalmic Surg 1991; 22:358–359 2. Gimbel HV, Sun R, Heston JP. Management of zonular dialysis in phacoemulsification and IOL implantation using the capsular tension ring. Ophthalmic Surg Lasers 1997; 28:273–281 3. Moreno-Montan˜e´s J, Heras H, Ferna´ndez-Hortelano A. Surgical treatment of a dislocated intraocular lens-capsular bag-capsular tension ring complex. J Cataract Refract Surg 2005; 31:270–273 4. Nishi O, Nishi K, Sakanishi K, Yamada Y. Explantation of endocapsular posterior chamber lens after spontaneous posterior dislocation. J Cataract Refract Surg 1996; 22:272–275 5. Shigeeda T, Nagahara M, Kato S, et al. Spontaneous posterior dislocation of intraocular lenses fixated in the capsular bag. J Cataract Refract Surg 2002; 28:1689–1693 6. Fine IH, Hoffman RS. Phacoemulsification in the presence of pseudoexfoliation: challenges and options. J Cataract Refract Surg 1997; 23:160–165
7. Jehan FS, Mamalis N, Crandall AS. Spontaneous late dislocation of intraocular lens within the capsular bag in pseudoexfoliation patients. Ophthalmology 2001; 108:1727–1731 8. Zech J-C, Tannie´re P, Denis P, Trepsat C. Posterior chamber intraocular lens dislocation with the bag. J Cataract Refract Surg 1999; 25:1168– 1169 9. Davison JA. Capsule contraction syndrome. J Cataract Refract Surg 1993; 19:582–589 10. Bhattacharjee H, Bhattacharjee K, Das D, et al. Management of a posteriorly dislocated endocapsular tension ring and a foldable acrylic intraocular lens. J Cataract Refract Surg 2004; 30:243–246 11. Ma PE, Kaur H, Petrovic V, Hay D. Technique for removal of a capsular tension ring from the vitreous. Ophthalmology 2003; 110:1142–1144 12. Lang Y, Fineberg E, Garzozi HJ. Vitrectomy to remove a posteriorly dislocated endocapsular tension ring. J Cataract Refract Surg 2001; 27:474–476 13. Lewis H, Sanchez G. The use of perfluorocarbon liquids in the repositioning of posteriorly dislocated intraocular lenses. Ophthalmology 1993; 100:1055–1059
J CATARACT REFRACT SURG - VOL 32, MARCH 2006
535