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   Table of Contents      
CASE REPORT
Year : 2019  |  Volume : 67  |  Issue : 1  |  Page : 155-157

Femtosecond laser-assisted successful management of subluxated cataractous lens with vitreous in anterior chamber


Cornea, Cataract and Refractive Surgery Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Date of Submission07-May-2018
Date of Acceptance23-Aug-2018
Date of Web Publication21-Dec-2018

Correspondence Address:
Prof. Jeewan S Titiyal
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_764_18

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  Abstract 


Femtosecond laser-assisted cataract surgery was performed in a case of posttraumatic cataract with six clock hours subluxation and vitreous in the anterior chamber (AC). Femtosecond laser pretreatment allowed a closed-chamber creation of corneal incisions, capsulotomy, and lens fragmentation with minimal sudden lens-diaphragm movements and zonular stress. Integrated imaging systems allowed customization of the size and position of capsulotomy and nuclear fragmentation, based on the extent and site of subluxation. Presence of vitreous in AC did not hamper femtosecond laser application. Triamcinolone-assisted vitrectomy was performed before phacoemulsification and after implanting the intraocular lens (IOL). Postoperative uncorrected visual acuity was 20/20 with a stable IOL.

Keywords: Femtosecond laser-assisted cataract surgery, femtosecond laser-assisted cataract surgery in subluxated lens, laser cataract surgery, subluxated lens


How to cite this article:
Titiyal JS, Kaur M, Rathi A, Falera R. Femtosecond laser-assisted successful management of subluxated cataractous lens with vitreous in anterior chamber. Indian J Ophthalmol 2019;67:155-7

How to cite this URL:
Titiyal JS, Kaur M, Rathi A, Falera R. Femtosecond laser-assisted successful management of subluxated cataractous lens with vitreous in anterior chamber. Indian J Ophthalmol [serial online] 2019 [cited 2019 Jun 16];67:155-7. Available from: http://www.ijo.in/text.asp?2019/67/1/155/248164



Management of subluxated lens is surgically challenging with an increased risk of intraoperative complications such as posterior capsular rent and vitreous loss.[1] Modifications of surgical techniques such as low-fluidic phacoemulsification and capsular tension rings may aid in the successful management of mild–moderate subluxation.[1] Optimal outcomes with preservation of the capsular bag have been reported in cases with varying degrees of subluxation undergoing femtosecond laser-assisted cataract surgery (FLACS).[2],[3]

Management of subluxated lens is further complicated by the presence of a cataractous lens and vitreous in the anterior chamber (AC). We herein describe FLACS to manage a case of posttraumatic cataract with temporal subluxation and vitreous in AC.


  Case Report Top


A 42-year-old female presented with sudden onset diminution of vision in the right eye associated with trauma sustained by a cricket ball 9 months ago.

On examination, the uncorrected distance visual acuity (UDVA) was 2/60 in the right eye and 20/20 in the left eye. The right eye had a subluxated cataractous lens (nuclear sclerosis grade III, Lens Opacities Classification System (LOCS) III classification) with six clock hours of subluxation (6–12 o'clock) and vitreous in AC. There was no change in subluxation in sitting and supine positions. The pupil was circular with normal iris pattern and pupillary reactions. The AC was deep, regular, and the capsular bag was intact. The left eye was phakic with a clear lens. The intraocular pressure (IOP) was 16 mmHg in the right eye and 14 mmHg in the left eye. Posterior segment was normal in both eyes. A clinical diagnosis of posttraumatic subluxated cataractous lens with vitreous in AC was made in the right eye.

The right eye was planned for FLACS (LenSx v2.23, Alcon LenSx, Inc., Aliso Viejo, California) with intraocular lens implantation after obtaining written informed consent [Video 1]. A 4.9-mm capsulotomy was planned with a 2.2-mm temporal clear corneal incision and two 1.1-mm side ports at 90° and 240°. Chop pattern of lens fragmentation was selected (three incisions, 6 mm length). Integrated optical coherence tomography (OCT) was used to review the treatment parameters. The capsulotomy position was shifted away from the site of subluxation, its diameter was decreased to 4.7 mm, and the length of the nucleotomy incisions was reduced to 5.4 mm to maintain a safe pupillary edge clearance of 0.5 mm. A blob of vitreous in AC was observed in the OCT images, and the cavitation bubbles were enmeshed in the vitreous during femtosecond laser application [Figure 1]a and [Figure 1]b.
Figure 1: Femtosecond laser-assisted cataract surgery in posttraumatic subluxated cataract: (a) femtosecond laser-assisted cataract surgery planning (arrows: vitreous in anterior chamber), (b) laser application (arrows: cavitation bubbles), (c) capsulotomy removed, (d) nylon hooks inserted (arrows: posterior limbal stab incisions), (e) limited anterior vitrectomy, (f) phacoemulsification, (g) I/A, (h) capsular tension ring inserted, (i) limited vitrectomy, and (j) postoperative well-centered intraocular lens

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After femtosecond laser application, posterior limbal stab incisions were made for the insertion of nylon hooks. The corneal incisions were opened and a cohesive ophthalmic viscosurgical device (OVD) (Healon, AMO Inc., California) was injected to maintain the AC. Trypan blue was injected to stain the anterior capsule and the capsulotomy was removed with a microforceps in a circumferential manoeuver akin to capsulorhexis to release any residual adhesions [Figure 1]c. The capsular bag was stabilized using five nylon hooks inserted through the previously created posterior limbal stab incisions [Figure 1]d. Three nylon hooks were inserted temporally to provide support in the region of subluxation and the remaining two hooks were inserted in the opposite quadrant in order to provide counter traction and stabilize the capsular bag. Triamcinolone-assisted vitrectomy was performed to remove the vitreous present in the AC to prevent undue traction during surgery [Figure 1]e. Low fluidics phacoemulsification was performed, and active fluidics helped to maintain a stable IOP (46 mmHg) during phacoemulsification [Figure 1]f. A bimanual irrigation aspiration was performed to prevent undue stress on the zonules [Figure 1]g. Capsular tension ring was implanted [Figure 1]h followed by implantation of a single piece acrylic foldable IOL (Power + 21D) in the bag. Triamcinolone was injected to identify any remnant vitreous strands and vitrectomy was performed above the IOL plane to remove all vitreous and ensure a circular pupil [Figure 1]i and [Figure 1]j. The corneal wounds were hydrated at the end of surgery.

On postoperative day 1, the pupil was circular, a well-centered PCIOL was present in the bag, and there was no vitreous in AC. The UDVA was 20/25 with an endothelial cell count of 2711 cells/mm2 and IOP of 17 mmHg. The corrected distance visual acuity was 20/20. At 3 months, the UDVA was 20/20 and the IOL was stable.


  Discussion Top


Femtosecond laser technology is increasingly being used in the management of complicated cases such as posterior polar cataract, intumescent cataract as well as subluxated cataract.[2],[3],[4]

Femtosecond laser pretreatment offers the unique advantage of a closed-chamber creation of corneal incisions, capsulotomy, and lens fragmentation. The sudden upward lens-diaphragm movements that may occur in conventional phacoemulsification due to aqueous egress are minimized. The integrated imaging systems allow a customization of the size and position of capsulotomy as well as the extent of nuclear fragmentation, based on the extent and site of subluxation. The prefragmented nucleus is easily emulsified during subsequent phacoemulsification, safeguarding against further zonular damage.

Only a few studies have described FLACS in subluxated lenses, and the management of vitreous in AC in such cases has not been adequately described.[2],[3] The presence of vitreous in AC did not hamper effective femtosecond laser application in our case, though the cavitation bubbles adhered to the vitreous gel. Simplified vitreous management is possible without the risk of damaging the anterior capsule, as the capsulotomy is already complete. Triamcinolone-assisted vitrectomy should be performed both before and after phacoemulsification to prevent continual vitreous traction during surgery and ensure complete vitreous removal from AC.

A capsular tension ring may suffice in moderate degrees of subluxation as in our case; however, bag fixation should be considered in cases with severe subluxation.[2] We did not observe any anterior capsular microadhesions or rips, and the capsular rim had enough strength to withstand the application of nylon hooks.


  Conclusion Top


Femtosecond laser pretreatment simplifies management and ensures optimal outcomes in subluxated cataractous lens with vitreous in AC.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chee SP, Jap A. Management of traumatic severely subluxated cataracts. Am J Ophthalmol 2011;151:866-710.  Back to cited text no. 1
    
2.
Chee SP, Wong MH, Jap A. Management of severely subluxated cataracts using femtosecond laser-assisted cataract surgery. Am J Ophthalmol 2017;173:7-15.  Back to cited text no. 2
    
3.
Crema AS, Walsh A, Yamane IS, Ventura BV, Santhiago MR. Femtosecond laser-assisted cataract surgery in patients with Marfan syndrome and subluxated lens. J Refract Surg 2015;31:338-41.  Back to cited text no. 3
    
4.
Titiyal JS, Kaur M, Sharma N. Femtosecond laser-assisted cataract surgery technique to enhance safety in posterior polar cataract. J Refract Surg 2015;31:826-8.  Back to cited text no. 4
    


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