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   Table of Contents      
ORIGINAL ARTICLE
Year : 2001  |  Volume : 49  |  Issue : 2  |  Page : 109-113

Scleral suspension pars-plana lensectomy for ectopia lentis followed by suture fixation of intraocular lens


Department of Ophthalmology, Sultan Qaboos University Hospital, Oman

Correspondence Address:
Sandip Mitra
Dept. of Ophthalmology, P.O.Box 38, SQUH Alkhod, Muscat zip 123
Oman
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Source of Support: None, Conflict of Interest: None


PMID: 15884515

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  Abstract 

Purpose: To describe a simple technique of scleral suspension-pars plana lensectomy (SS-PPL) in acquired and congenital ectopia lentis and scleral fixation of intraocular lens (IOL).
Materials and Methods: Twenty eyes of 16 patients (12 unilateral and 4 bilateral cases of "essential familial lens subluxation") aged 10-40 years (mean 25 years) underwent SS-PPL with implantation of scleral fixated IOL. Indications for surgery were best-corrected visual acuity <6/18, bisection of pupil by the lens, and lens-induced glaucoma. Prerequisites for SS-PPL were, visibility of part of the lens in the pupillary area and soft lens.
Results: Postoperative visual acuity ranged from 6/6 - 6/36. Lens tilt in 3 cases(15%) and small decentration in 2 cases(10%) were seen; however these did not seriously compromise the visual result. Scant vitreous bleeding on the first postoperative day was seen in 3 cases (15%).
Conclusion: The advantages of the scleral suspension of subluxated lens prior to lensectomy include stabilization; it allows proper viewing of the lens, avoids injury to the iris and cliary body during lensectomy and reduces the possibility of dislocation of the lens.

Keywords: Scleral suspension, pars plana lensectomy, ectopia lentis, intraocular lens


How to cite this article:
Mitra S, Ganesh A. Scleral suspension pars-plana lensectomy for ectopia lentis followed by suture fixation of intraocular lens. Indian J Ophthalmol 2001;49:109-13

How to cite this URL:
Mitra S, Ganesh A. Scleral suspension pars-plana lensectomy for ectopia lentis followed by suture fixation of intraocular lens. Indian J Ophthalmol [serial online] 2001 [cited 2019 Mar 23];49:109-13. Available from: http://www.ijo.in/text.asp?2001/49/2/109/22644



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LT - LENS TILT; AU - ANTERIOR UVEITIS; LD - LENS DECENTRATION MVH - MILD VITREOUS HAEMORRHAGE

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LT - LENS TILT; AU - ANTERIOR UVEITIS; LD - LENS DECENTRATION MVH - MILD VITREOUS HAEMORRHAGE

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Conventional surgical management of congenital and acquired ectopia lentis is frequently associated with high incidence of complications including dropped lens, vitreous loss, iris, ciliary body or retinal trauma. These contribute to poor visual prognosis.[1] Pars-plana lensectomy has greatly improved surgical results.[2] However, a problem frequently encountered with this procedure is dislocation of the lens during lensectomy. Suspension of the subluxated lens from the sclera prior to pars-plana lensectomy is likely to reduce the risk of dropped nuclear fragments during surgery. Subsequent implantation of posterior chamber intraocular lens by scleral fixation provides rapid and improved visual rehabilitation.


  Materials and Methods Top


This study consists of 20 eyes of 16 patients (12 unilateral and 4 bilateral) of ectopia lentis. All were diagnosed to have "essential familial lens subluxation", aged 10-40 years (mean 25 years). All patients underwent a scleral suspension-pars-plana lensectomy (SS-PPL) and implantation of scleral - fixated intraocular lens (IOL). The prerequisites for inclusion of cases in this study were that part of the lens must be visible in the pupillary area and the lens must be soft [Figure - 1]. Indications for surgery were best-corrected visual acuity <6/18 (all cases), bisection of the pupil by the lens with resultant diplopia, and lens-induced glaucoma.


  Surgical Technique Top


A 3 mm x 2.5 mm scleral flap was raised at 3 and 9 o' clock, starting at the limbus. A10-0 polypropylene 8 circle suture, was introduced 1.5 mm from the limbus under the dissected scleral flap and passed through the subluxated lens [Figure - 2]. From the opposite end, a 28 G needle was introduced 1.5 mm from the limbus under the scleral flap through the subluxated lens. The needle carrying the suture, was introduced into the 28 G needle and the latter was pulled back along with the suture. Another suture was placed 1.5 mm from the first suture and passed in a similar manner. The ends of the sutures were manipulated to partially bring the subluxated lens towards the pupil and stabilize it [Figure - 3]. Three scleral ports were then made. The infero-temporal port was used for infusion, and superior ports were used to introduce the endoilluminator and vitrectomy probe. A small opening was made in the anterior capsule using a microvitrectomy blade and hydrodissection was done through this opening. Lensectomy (Coal miner technique)[2] was started using a cut rate of 750 per minute and vacuum of 100 mm of Hg. The endoilluminator was used to stabilize and direct the lens towards the vitrectomy probe. Once the probe was close to the suspending sutures, the cut rate was increased to 800 per minute and vacuum was reduced to 70-80mm Hg. After the lensectomy was completed, the retinal periphery was examined by indirect ophthalmoscope to rule out any tear. Prophylactic periperal laser retinopexy was done barraging the 3 and 9 o' clock areas. A 6.5 mm limbal incision was made and the suspending sutures were retracted out through the limbus. The retracted sutures were divided and used to fixate scleral intraocular lens [Figure - 4]. Sutures were the tightened under the flap, knots were rotated inside the eye and scleral flaps were sutured using 7-0 vicryl sutures. The section was closed using a 10-0 monofilament nylon suture. IOL power was calculated using SRKII formula and adding + 0.50 D.[3]

Postoperative examinations were done at day 1, one week, one, three and six months. Best corrected visual acuity, biomicroscopy; Goldmann tonometry and indirect ophthalmoscopy were performed in each following visits.

Post-operatively, all cases received topical dexamethasone phosphate solution 0.1% every 4 hourly for the first 4 days, tapered to 8th hourly for one week and continued 12th hourly for 3 weeks, tropicamide 1% twice daily for one week and fucithalmic viscous eye preparation (Fusi die acid) twice daily. Cases with vitritis and /or vitreous haemorrhage were started on systemic prednisolone 1 mg/kg weight for 2 weeks and rapidly tapered at 10 mg/kg per week.


  Results Top


The mean age of patients was 25 years (range 10-40 years). The best corrected visual acuity recorded on the first day, at one week, at three months and at the end of six months is mentioned in [Table - 1]. At one month following surgery, visual acuity was 6/6 in 5 cases (25%) and 6/12 in 7 cases (35%). 4 bilateral congenital cases had amblyopia with 6/18 vision in 4 cases (20%) and 6/36 in 4 cases (20%). No reduction in the visual acuity was noted at the six-month follow-up examination. There was no case of dislocated nuclear fragments and accidental injury to the iris or ciliary body in our study. Scant vitreous bleeding on the first postoperative day was seen in 3 cases (15%); these cases also had anterior uveitis [Table - 1] which cleared within a week. Scleral suture erosion was not seen in any of the 20 eyes. Lens tilt in 3 cases (15%) and small decentration in 2 cases (10%) were seen [Table - 1], however these did not seriously compromise the visual outcome.


  Discussion Top


Pars-plana lensectomy is a standard procedure for ectopia lentis.[4] Indications for surgery include visual acuity less than 6/18, monocular diplopia, forward sub-luxation of the lens to the anterior chamber, or rapidly progressing posterior subluxation of the lens.[5] However, the procedure is associated with certain complications such as; dropped lens fragments[2], accidental small cuts at the pupillary border[1], retinal detachment and vitreous haemorrhage. The procedure may be difficult due to increased mobility of the lens while performing lensectomy. The technique of SS-PPL helps to create an artificial zonular attachment of the ectopic lens to the ciliary sulcus through scleral fixation sutures, thereby reducing the chance of dropped lens or lenticular fragments during lensectomy. By manipulating the sutures the lens is made more visible in the pupilary area, aiding the process of lensectomy and avoiding accidental damage of the pupil, ciliary body and retina. Further, preplaced scleral sutures facilitate subsequent fixation of an IOL.

Although passage of a needle through the capsule carries the risk of leakage of lens protein into the vitreous and postoperative inflammation, we observed mild vitreous bleeding and moderate vitritis in 3 cases only. This was well controlled with topical dexamethasone phosphate solution 0.1% two-hourly for the first 4 days, tapered to six-hourly for one week and continued eight-hourly for 3 weeks. Systemic Prednisolone 1mg/kg weight was also given for 2 weeks. There was no need for prolonged steroid therapy and we did not observe any side effect of steroids and recurrence of inflammation after steroids were discontinued[9].

By making a scleral flap and simultaneously burying the scleral sutures of the scleral - fixated IOL, we were able to avoid complications like suture erosions,[6] infection[7] and accidental cutting of the fixation suture.[8] [Table - 2] is comparison of our technique with other contemporary reports of sutured IOL.

In conclusion, we have reported a novel and simple surgical technique of SS-PPL for the management of ectopia lentis. This technique with subsequent implantation of scleral fixated IOL yields good functional and anatomical results and minimizes complications associated with conventional lensectomy in ectopia lentis.[13]

 
  References Top

1.
Guo X M, Chen YZ, Zeng LH. Pars plana lensectomy and anterior vitrectomy for the treatment of congenital subluxated lenses. Chung Hua Ko Tsa Chih 1994;30:271-73.  Back to cited text no. 1
    
2.
Kanski JJ, Crick MD. Lensectomy.Trans Ophthalmol Soc UK 1977;97:52-57.  Back to cited text no. 2
    
3.
Mittelviefhaus H, Janknecht P. Postoperative refraction and anterior chamber depth after compliacted cataract surgery with vitreous loss and transscleral suture fixation of the postreior chamber lenses. Ophthalmic Surgery 1993;24:542-45.  Back to cited text no. 3
    
4.
Reese PD, Weingeist T A. Pars plana management of ectopia lentis in children. Arch Ophthalmol 1987;105:1202-4.  Back to cited text no. 4
    
5.
Halpert M, BenEzra D. Surgery of the hereditary subluxated lens in children. Ophthalmology 1996;103:681-86.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.
Solomon K, Gussler JR, Gussler C, Van Meter WS. Incidence and management of complications of transsclerally sutured posterior chamber lenses. J Cataract Refract Surgery1993;19:488-93.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.
Teichmarm KD, Teichmann IA. The torque & tilt gamble. J Cataract Refractive Surg1997;23:413-18.  Back to cited text no. 7
    
8.
Cahane M, Chen V, Avil I. Dislocation of scleral-fixated, posterior chamber intraocular lens after fixation suture removal. J Cataract Refract Surgery 1994;20:186-87.  Back to cited text no. 8
    
9.
Zimmerman TJ, Kooner KS, Sharir M, Fechtner RD. Textbook of Ocular Pharmacology. New York: Lippincott-Raven,1997. pp 68-73.  Back to cited text no. 9
    
10.
Epley KD, Levine ES, Katz HR. A simplified techique for stable transscleral sutured fixation posterior chamber intraocular lenses. Ophthalmic Surgery and Lasers 1999;30:398-402.  Back to cited text no. 10
    
11.
Bourke RD, Gray PJ, Rosen PH, Cooling RJ. Retinal detachment complicating scleral-sutured posterior chamber intraocular lens surgery. Eye 1996;10:501-8.  Back to cited text no. 11
    
12.
Uthoff D, Teichmann K D. Secondary implantation of scleral - fixated intraocular lenses. J Cataract Refract Surgery 1998;24:945-50.  Back to cited text no. 12
    
13.
Kumar M, Arora R, Sanga L, Sota L D. Scleral-fixated intra-ocular lens implantation in unilateral aphakic children. Ophthalmology 1999;106:2184-89.  Back to cited text no. 13
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
 
 
    Tables

  [Table - 1], [Table - 2]


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