|Year : 1969 | Volume
| Issue : 6 | Page : 259-262
A technique for removal of a posteriorly dislocated lens
AM Gokhale, PA Dikshit
Department of Ophthalmology, Topiwala National Medical College and B. Y. L. Nair Hospital, Bombay-8, India
A M Gokhale
Department of Ophthalmology, Topiwala National Medical College and B. Y. L. Nair Hospital, Bombay-8
|How to cite this article:|
Gokhale A M, Dikshit P A. A technique for removal of a posteriorly dislocated lens. Indian J Ophthalmol 1969;17:259-62
|How to cite this URL:|
Gokhale A M, Dikshit P A. A technique for removal of a posteriorly dislocated lens. Indian J Ophthalmol [serial online] 1969 [cited 2013 May 25];17:259-62. Available from: http://www.ijo.in/text.asp?1969/17/6/259/38551
| Introduction|| |
It has been a common experience with ophthalmic surgeon that a posteriorly dislocated lens, either partial or total, cannot be removed without vitreous loss and its subsequent complications. In the past, several methods have been tried to remove such a lens:
1) Removal of the lens by a vectis.
2) By the use of an intracapsular forceps.
3) By an Erisiphake.
4) La Carrere double diathermy needles.
In all of them, there is the risk of vitreous loss and further dislocation of the lens. In the case of cryosurgery, the instrument may not be easily available and not only the lens but the vitreous also may be frozen, attached to the cryopencil and may come out.
These methods are normally employed with or without:
i) Use of Flieringa's rings.
ii) Use of such hypotensive drugs as: (a) Acetazolamide (Diamox) tablets, (b) Oral glycerol and (c) Intravenous mannitol, urea, etc.
With the above difficulties in view, this article deals with a method of removal of a posteriorly dislocated lens intracapsularly by giving a support posteriorly without causing serious or permanent eye damage. The idea is to fix the lens from behind with minimum trauma and then remove it intracapsularly with ease and without vitreous loss.
| Instrument|| |
The instrument devised is simple, inexpensive and easily available, Some trials were made before the final pattern of the instrument was decided upon. At first, two separate cutting needles (ordinary straight needles used for skin suturing in surgery) were used [Figure - 1]. These needles are shown lying in the patient's eye. After some modifications, a very handy instrument got evolved. It is like a hair pin consisting of two parallel triangular cutting needles (such as used for skin suturing) about 3 cm long and 3 mm apart. They are kept in parallel position by a cross metal bar [Figure - 2]. The instrument in position in an eye is shown in [Figure - 3].
| Operation|| |
The patient is prepared for the usual cataract operation. The operation can be done very satisfactorily under local anaesthesia. It is preferable to reduce the intraocular tension before surgery by giving 400 cc of 20 per cent w/v Mannitol by intravenous drip, half an hour before the start of the operation. Also half an hour before the operation, an intravenous injection of 50 mgm of Pethidine and 25 mgm of Promethazine hydrochloride is given to keep the patient quiet and relaxed.
(2) Operative Technique
One preplaced suture with 6-0 silk at 12 O'Clock position is taken after perpendicularly incising the limbus to half its thickness.
The needles are introduced gently 6 mm behind the limbus from the temporal side in the horizontal meridian. A firm grip with a fixation forceps behind the position of puncture will facilitate introduction of the needles. The needles should be in the same vertical plane i.e., both needles are 6 mm away from the limbus. The needles are easily seen entering the eyeball behind the limb us. They are pushed through till they just engage firmly in the sclera on the opposite side. They need not perforate the sclera and come out of the eye on the other side. This minimises the trauma. The lens is now firmly anchored and cannot slip back. The section is now completed, with a cataract knife. An iridectomy, preferably keyhole type is performed. The lens is now easily removed either by an intracapsular forceps or even by an erisiphake. The preplaced suture is tied immediately. The iris and the wound are toileted very carefully with an iris repositor. Additional postplaced sutures may be taken if so desired, though they are not found essential. Sterile air is introduced in the anterior chamber. A sub-conjunctival injection of penicillin is given. Now with an iris repositor working as counter pressure aganst the surface of the eye ball, the needles are gently and slowly pulled out. The patient is sent in the wards with both his eyes bandaged.
In some cases a preliminary surface diathermy at the site of puncture may facilitate the introduction of needles and also may prevent possible retinal detachment.
In all, nine eyes in eight cases have been operated so far by us and followed for three to ten months. In seven cases, one eye was operated and in one both. The results were found to be satisfactory and the lens could easily be removed without vitreous loss. A floating lens can be trapped by making the patient prone, inserting the instrument as described above in the same position and then making him supine.
Vitreous hemorrhage was noticed in all cases but it cleared up of its own. Absorption, however, can be hastened by giving iodides (intramuscularly or intravenously) and high doses of Vitamin C e.g. 500 mgm.
| Case Reports|| |
Case I : K. S. P. (Male), 40 years, had a traumatic dislocated lens in right eye with vision of 2 feet and tension 19 mm. He was operated on 6-3-1967 with 2 separate needles, entering the eye ball, 8 mm behind the limbus. Both needles made counter puncture through the sclera on the other side [Figure - 1]. This was the first case in the series.
Results : On 29-3-1967, the vision was counting fingers from 1 foot. There were vitreous haze and a detached retina. On 18-4-1967 scleral diathermy with U shaped barrage at 9 O'Clock was done. On 2-12-1967, the vision with glasses had improved to 6/24 with the retina completely in apposition.
Case 2 : S.N.F. (Female), 52 years, had a black cataract in the right eye, with dislocated lens. Vision was reduced to moving body and the tension 16 mm. She was operated upon on 21-3-1967 with the double needles [Figure - 3] used for the first time. They were inserted 6 mm behind the limbus. The needle points were just embedded in the sclera on the opposite side. Mannitol was used for the first time.
Results : Vitreous opacities persisted for over 4 months. On 3-11-67 vision with + 10.00 sph and + 1.5 cyl was 6/24. Fundus showed vitreous haze confined to the lower half.
Case 3: Y.T.K. (Male), 17 years, was a case of Marfan's syndrome with dislocated lenses down and out. In this case, both eyes were operated. The right eye vision was finger counting at 3 inches. There was a shallow detachment of retina. The tension was 15 mm. The left eye vision was finger counting from 2 feet.
Fundus-Circumpapillary choroiditis. Tension was 18 mm. Both eyes were operated after intravenous injection of mannitol and by the use of the pair of needles. In the right eye, vitreous was in front of the lens but was not lost after careful manipulations with needles, intracapsular forceps and lens hook.
Results : The right eye showed an uneventful recovery but slowly became phthisical as it already had detachment of retina. In the left eye, there was no glow for one month. Then the vitreous cleared up with treatment. The vision on 15-7-67 and then again on 20-9-67 was 6/24 with + 8.0 sph and + 2.0 cyl.
Case 4 : M. N. P. (Male) 70 years. The left eye was already lost. The right eye vision was counting fingers from 6 inches and its tension was 17 mm. He was operated on the right eye on 14-9-67 with the method described.
Results : On 23-1-68, with + 6.0 sph., vision was 6/36. Corneal and vitreous haze were present but the disc was normal.
Case 5: G. N. (Male) 28 years. In the right eye, there was optic atrophy with an old detachment of retina. Vision was just perception of light. In the left eye, there was a traumatic subluxated lens. The vision was finger counting from 2 feet and there was a retinal detachment. He was operated on the left eye on 23-11-67. The lens was removed without any complications. When the fundus was examined on 5-1-68 the retina was found to be almost totally detached. Circling operation for detachment was done on 1-3-68.
Results : Vision was finger counting from 2 feet. The disc was normal the detachment had settled, and the patient could see better. On 23-3-68, with + 10.50 sphere, his vision was counting fingers from 5 metres.
Case 6: B. R. (Male) 32 years. He had subluxated lens with visions of moving body only. Tension was 17 mm. He was operated on 31-10-67 and recovery was uneventful.
Result : On 18-1-68 his vision had improved to counting fingers from 1 foot. On 8-3-68, with + 12.0 sph. his vision was 6/36.
Case 7: S. S. (Female) 60 years, had in the right eye a traumatic dislocated lens with Uveitis. The vision was finger counting from 6 inches and the tension was 17 mm. She was operated on 17-11-67.
Results : On 12-1-68, her vision was 6/60 with + 11.5 sph. The fundus was still hazy. Patient has not turned up for further follow-up.
Case 8: C. M. (Female) 52 years, had her right lens dislocated which was floating freely in vitreous. There was corneal haze. The vision was finger counting at 6 inches and tension was 21 mm. She was operated on 25-1-68. The lens was trapped by making her lie on her face. The needles were introduced with the patient in prone position. Then she was made supine and then the lens was easily removed. Attempts to trap the lens by only one needle had failed.
Results : Vision on 20-4-68 was 6/60 with + 9.00 sph.
| Summary|| |
To trap posteriorly dislocated lens an instrument is devised from simple, inexpensive triangular straight cutting needles used for suturing skin. They make slit like apertures in the sclera, instead of larger rounded ones, which minimise trauma and hasten healing. Hypotensive drugs such as mannitol are found useful to make the eye soft and prevent vitreous loss. Puncture of the sclera should be 6-7 mm from the limbus. Reports on nine eyes, so operated are provided.
| Acknowledgment|| |
Our thanks are due to Dr. A. R. Patel for his useful suggestions in the construction of the needle.
| References|| |
|1.||Adler, S.: British Journal of Ophthalmology, February 1967, 51, 2. pp. 7385. |
|2.||Stallard, M. B.: Eye Surgery, IV Ed. 1965, John Wright and Sons Ltd. Bristol. |
[Figure - 1], [Figure - 2], [Figure - 3]