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   Table of Contents      
BRIEF REPORT
Year : 2006  |  Volume : 54  |  Issue : 4  |  Page : 267-269

Phacoemulsification using iris-hooks for capsular support in high myopic patient with subluxated lens and secondary angle closure glaucoma


Cardiff Eye Unit, University Hospital of Wales, Cardiff, CF14 4XW, United Kingdom

Correspondence Address:
Rizwan A Cheema
University Hopsital of Wales, Cardiff, CF14 4XW
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0301-4738.27953

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  Abstract 

We report an unusual case of angle closure glaucoma in a 78-year-old highly myopic female patient. The patient did not show any preoperative signs of subluxation of lens. However, the capsular bag was noted to be unstable during surgery. The patient was managed with phacoemulsification of lens using a novel method of iris hooks for stabilization of capsular bag during surgery.

Keywords: Angle closure glaucoma, high myopia, iris hooks, phacoemulsification, subluxated lens


How to cite this article:
Morris B, Cheema RA. Phacoemulsification using iris-hooks for capsular support in high myopic patient with subluxated lens and secondary angle closure glaucoma. Indian J Ophthalmol 2006;54:267-9

How to cite this URL:
Morris B, Cheema RA. Phacoemulsification using iris-hooks for capsular support in high myopic patient with subluxated lens and secondary angle closure glaucoma. Indian J Ophthalmol [serial online] 2006 [cited 2020 Dec 5];54:267-9. Available from: https://www.ijo.in/text.asp?2006/54/4/267/27953

Myopia is associated with anatomical factors that offer considerable protection from angle closure. We treated an unusual case of high myopia patient with secondary angle closure glaucoma due to subluxation of lens. The patient was managed with phacoemulsification of lens using a novel method of iris hooks for stabilization of capsular bag during surgery.


  Case Report Top


A 78-year-old female presented with a three-week history of her right pupil being enlarged and oval in shape. This was on a background of intermittent pain and inflammation in the same eye over the last year. The patient was a high myope in the right eye (-14.0 Dioptre) and emmetropic in the left eye, with longstanding poor vision in the affected eye due to anisometropic amblyopia and myopic macular degeneration. There was no history of trauma or uveitis in the past.

On examination, the visual acuity was hand movement (HM) in the right eye and 20/30 in the left eye. There was circumciliary injection and clear cornea. The anterior chamber was quiet and shallow (central depth 1.71 mm / Von Herrick Grade 1), compared to the fellow eye (central depth 2.83 mm / Von Herrick Grade 4) [Figure - 1] A,B and C and [Figure - 2] A, B and C. The axial length of the right eye was 29 mm and 21 mm in the left eye. The intraocular pressure (IOP) was 36 mmHg in the affected right eye and 15 mmHg in the left eye on applanation tonometry. There was no iridodonesis or phacodonesis. The affected right eye showed a brunescent cataract and the limited fundal view did not reveal any abnormality. Gonioscopy revealed 360 narrow angles. B-scan ultrasonography confirmed absence of ciliary body mass, choroidal effusion or obvious aqueous misdirection. A clinical diagnosis of phacomorphic glaucoma in the right eye was made.

Following treatment with oral acetazolamide 250 mg and topical ocular anti-hypertensives (timolol 0.5% and dorzolamide 2%) twice daily, the IOP reduced to 18 mmHg. Phacoemulsification was done the next day. During capsulorrhexis, the capsular bag was noted to be unstable due to zonular weakness. In order to facilitate an anterior approach of lens removal, the capsular bag was stabilized using four iris hooks applied to the capsulorrhexis edge prior to hydro dissection [Figure - 3]. This enabled safe phacoemulsification of the patient's subluxated lens. No intraocular lens was inserted. Postoperatively, the patient was treated with topical steroid-antibiotic drops (prednesolone 1% and 0.5% chloramphenicol) for four weeks and was doing well at follow-up of six months with an open angle and normal IOP [Figure - 4] a and b, achieving an uncorrected vision of 20/200.


  Discussion Top


It has long been recognized that highly myopic eyes are somewhat immune to angle closure glaucoma. This patient's raised IOP was due to a subluxated lens causing secondary angle closure. However, in retrospect this should have been considered as a probable diagnosis as there was central shallowing of anterior chamber. Preoperative gonioscopy and conventional B-scan ultrasonography did not demonstrate any mass around ciliary body, which is a recognized cause of secondary angle closure,[1] and no abnormality was detected in the ciliary body and fundus on postoperative examination. However, ultrasound biomicroscopy which is the tool of choice to aid diagnosis in such patients[2] was not done.

There are a number of surgical approaches available for the removal of subluxated lenses. Inatani et al. have observed that lens extraction is effective in controlling intraocular pressure in eyes with secondary glaucoma associated with lens subluxation.[3] These include intra and extra-capsular cataract extraction, endocapsular lensectomy with vitrector,[4] fragmatome removal via the pars plana,[5] anterior phacoemulsification with the use of a capsular tension ring to provide stability for phacoemulsification[6] or as we have demonstrated, the use of iris hooks to provide support to the capsular bag. This new approach was originally described for use in patients with lens instability due to pseudoexfoliation syndrome.[7] We favor this approach as most surgeons are familiar with and frequently use iris hooks; however, care needs to be taken as iris hooks can occasionally tear the margins of the capsulorrhexis. We feel that it is technically easier to stabilize the capsular bag this way rather than insert a capsular tension ring before phacoemulsification. At this stage the capsular bag is subjected to radial stress forces which can cause the zonular dehiscence to extend. The above described technique of capsular support during cataract surgery can also be utilized in other clinical conditions associated with subluxated lens such as trauma and Marfan's syndrome.



 
  References Top

1.
Demirci H, Shields CL, Shields JA, Honavar SG, Eagle RC Jr. Ring melanoma of the ciliary body: Report on twenty-three patients. Retina 2002;22:698-706.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.
Pavlin CJ, McWhae JA, McGowan HD, Foster FS. Ultrasound biomicroscopy of anterior segment tumors. Ophthalmology 1992;99:1220-8.  Back to cited text no. 2
[PUBMED]    
3.
Inatani M, Tanihara H, Honjo M, Kido N, Honda Y. Secondary glaucoma associated with crystalline lens subluxation. J Cataract Refract Surg 2000;26:1533-6.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.
Friedman Z, Feiner M. A simplified technique for extraction of subluxated lenses in young patients. Ophthalmic Surg Lasers 1998;29:949-50.  Back to cited text no. 4
[PUBMED]    
5.
Girard LJ. Pars plana lensectomy for subluxated and dislocated lenses. Ophthalmic Surg 1981;12:491-5.  Back to cited text no. 5
[PUBMED]    
6.
Cionni RJ, Osher RH. Endocapsular ring approach to the subluxed cataractous lens. J Cataract Refract Surg 1995;21:245-9.  Back to cited text no. 6
[PUBMED]    
7.
Lee V, Bloom P. Microhook capsule stabilization for phacoemulsification in eyes with pseudoexfoliation-syndrome-induced lens instability. J Cataract Refract Surg 1999;25:1567-70.  Back to cited text no. 7
[PUBMED]    


    Figures

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



 

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