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Scleral-sutured IOL improves vision in ectopia lentis

A case report presents an alternative approach to this sometimes serious condition.

ByS. K. Gibran, FRCS, MMS

ByG. O’Connor, FRCS, FRCOphth

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Ectopia lentis is a therapeutic challenge for ophthalmologists. It may occur as an isolated condition following ocular trauma or in association with other ocular and systemic disorders. Minimal subluxation of the lens may be asymptomatic, but in more severe cases serious visual disturbances may arise. This is most important in children, when amblyopia (often bilateral) may be disastrous.

The technique we present here is an alternative approach that may achieve a satisfactory postoperative visual result in selected cases of simple ectopia lentis.

Case report

An eight-year-old boy was referred to our department with visually significant ectopia lentis. On examination, he had a visual acuity of 20/200 in both eyes. There was bilateral symmetrical temporal lens subluxation with the lens edge encroaching on the visual axis (Figure 1). Fundus examination was normal.

Bilateral symmetricatemporal lens subluxation with the lens edge encroaching on the visual axis.

Left eye 6 months postop.

A lensectomy, anterior vitrectomy and scleral-sutured posterior chamber IOL were surgically proposed. His left eye was operated on first.

The conjunctiva was retracted superiorly and at the 2 o’clock and 8 o’clock positions. Two triangular partial-thickness scleral flaps measuring 2 mm at the base were raised with apices pointing superiorly. The flaps were centered at the site where the needle with the suture was expected to exit the eye, 1.5 mm from the limbus. A partial-thickness shelved peripheral corneal limbal incision measuring 7 mm was prepared for the IOL at 12 o’clock.

Lensectomy was performed followed by a shallow anterior vitrectomy. An IOL was inserted in the usual manner. The scleral flaps were closed with 8-0 Vicryl and interrupted 10-0 nylon was applied to the corneal wound. Conjunctival continuity was achieved with 10-0 Vicryl.

The postop course was unremarkable. After 6 months the uncorrected visual acuity was 20/20.

In the absence of any refractive surprise, the right eye of the patient was operated on in a similar surgical manner. A visual acuity of 20/20 was also achieved. The desired IOL power was calculated by SRK-T formula.

In both eyes the IOL was centered with no pupillary complications (Figure 2).

Comment

This surgical intervention for simple ectopia lentis provides rapid visual improvement in younger patients.

Without surgery, amblyopia may have occurred in one or both eyes. In these cases it is frequently difficult to provide adequate visual rehabilitation with contact lenses or aphakic glasses.

Several surgical options for the centration for capsular bag and IOL insertion have been described. Many of them prove to be technically difficult and are associated with frequent intraoperative and postop complications.

We prefer a single-piece solid PMMA IOL (Alcon CZ70BD) with a larger optic in order to reduce the incidence of pupillary and centration problems.

Complications like IOL subluxation due to suture breakage have been described. In our technique we use a 10-0 polypropylene loop suture on a long curved needle (Alcon 307901 on PC 9 needle) to lock one haptic of the IOL. After suturing it to the sclera with multiple knots, each haptic is secured by two 10-0 polypropylene sutures, which act in a complementary mechanical fashion.

The careful closure of the superficial scleral flaps is aimed at preventing the external exposure and erosion of the suture ends and subsequent risk of postop endophthalmitis.

Retinal detachment remains a concern. Simple ectopia lentis has a lower incidence of retinal detachment than ectopia lentis associated with Marfan syndrome, homocystinuria and ocular trauma. Careful attention to the needle passage helps to avoid retinal perforation and minimizes the risk of retinal detachment. In cases of suspected retinal touch, preoperative cryotherapy/indirect diode laser posterior to the scleral flaps may be performed, but this is controversial.

For Your Information:

• S.K. Gibran, FRCS, MMS, can be reached at Cork University Hospital, Cork, Ireland; +(353) 21-454-6400; fax: +(353) 21-492-2646; e-mail: syedgibran@yahoo.com.
• G. O’Connor, FRCS, FRCOphth, can be reached at Cork University Hospital, Cork, Ireland; +(353) 21-454-6400; fax: +(353) 21-492-2646.

References:

• Mirza KA, Kinsella F. Technique creates scleral flaps in sulcus/scleral sutured IOLs. Ocular Surgery News. 2001;19(2):5.
• Kora Y, Kinohira Y, et al. Intraocular lens power calculation and refractive change in pediatric cases. Nippon Ganka Gakkai Zasshi. 2002;106:273-280.
• Lam DS, Young AL, et al. Scleral fixation of a capsule tension ring for severe ectopia lentis. J Cataract Refract Surg. 2000;26:609-612.
• Assia EL, Nemet A, Sachs D. Bilateral spontaneous sublaxation of scleral-fixated IOL. J Cataract Refract Surg. 2002;28:2214-2216.
• Noel LP, Bloom JN, et al. Retinal perforation in strabismus surgery. J Pediatr Ophthalmol Strabismus. 1997;34:115-117.