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Holly B. Hindman, MD; Heather Casparis, MD; Julia A. Haller, MD; Walter J. Stark, MD

Arch Ophthalmol. 2008;126(11):1567-1570.

ABSTRACT
Endocapsular intraocular lens (IOL) dislocation can be a challenge for the anterior segment surgeon. We describe a novel surgical strategy for repositioning an anteriorly dislocated endocapsular IOL by suturing it to the ciliary sulcus using an anterior segment approach in a patient with retinitis pigmentosa (RP).

INTRODUCTION

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Although the true incidence of late in-the-bag IOL dislocation is not known, 20% of cataract surgeons reported encountering this complication in a poll performed in 2001.¹ In case series, RP has been identified as a predisposing factor in 4% to 10.5% of cases of in-the-bag IOL dislocation.^2-3 Cataracts in patients with RP are typically posterior subcapsular in nature and occur earlier than age-related cataracts.⁴ In 1 study, cataract surgery was performed at a mean age of 47.5 years in patients with RP and resulted in improved visual acuity in 77% of eyes.⁵ However, a case-control study demonstrated that RP eyes have more capsular contraction and greater decentration length and tilt angles than controls, contributing to the dislocation risk.⁶ We report a case of a patient with RP and late spontaneous endocapsular posterior chamber IOL (PCIOL) dislocation into the anterior chamber and a novel technique to accurately suture fixate the lens to the ciliary sulcus via a small-incision anterior segment approach.

REPORT OF A CASE

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A 65-year-old man with a history of RP and previous uncomplicated cataract surgery was referred to the Wilmer Eye Institute for an investigational implant in the right eye to treat his RP. On examination, the best-corrected visual acuity in this eye was 20/40. The pupil was oval and the PCIOL was found to be subluxed into the anterior chamber. The posterior capsule had been previously opened with an Nd:YAG capsulotomy and the remaining capsule had contracted, causing the haptics of the 6.8-mm polymethyl methacrylate lens to crimp within the bag. The haptics and edge of the lens capsule could be seen nasally where the zonules were absent. There were posterior synechiae to the anterior lens capsule.

In the operating room, synechiolysis was performed, the conjunctiva was recessed, and 2 triangular partial-thickness scleral flaps were made at the limbus at the 3- and 9-o’clock positions. One flap was lifted and 1 side of a double-armed 10-0 polypropylene suture on a CIF4 needle (14-mm) was passed under the scleral flap, posterior to the iris and capsular bag, up through the capsular bag lateral to the haptic, and out through the peripheral cornea (Figure 1). The other arm of the 10-0 polypropylene suture was then passed under the scleral flap, posterior to the iris and capsular bag, up through the capsular bag medial to the haptic, and out the cornea (Figure 2). The needles were then cut off the sutures. A Sinskey hook was used to externalize the sutures through a paracentesis. A knot was placed in the 2 externalized sutures, creating a loop around the haptic within the capsular bag (Figure 3). The knot was reposited into the anterior chamber. The suture loop underneath the scleral flap was then lifted, cut, and pulled taut to recenter the IOL and capsular bag (Figure 4). The knot was then tied and the scleral flap was closed with 10-0 nylon suture. Attention was then turned to the opposite side where the procedure was repeated. At the conclusion of the case, the posterior chamber lens was scleral fixated at the ciliary sulcus and the lens and capsular bag were in good position. At the most recent visit, 6 months after surgery, the best-corrected visual acuity remained 20/40, the cornea was clear, and the lens remained well centered.

View larger version (51K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 1. One end of a double-armed 10-0 polypropylene suture on a CIF4 needle is passed under a partial-thickness scleral flap, posterior to the iris, through the capsular bag lateral to the haptic, through the pupil, and out the peripheral cornea.

View larger version (58K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 2. The other arm of the suture is passed in a similar fashion except the needle passes through the capsular bag medial to the haptic before exiting through the cornea. The needles are cut off the sutures and a limbal paracentesis is created.

View larger version (38K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 3. A, A Sinskey hook is placed into the anterior chamber through the limbal paracentesis and is used to externalize both ends of the suture. These ends are tied together creating a loop of suture that encircles the haptic. B, The previously created knot is reposited through the paracentesis back into the anterior chamber. The loop of suture located under the scleral flap is pulled taut.

View larger version (39K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 4. A, Tension on the loop of suture located under the scleral flap secures the suture tightly around the haptic and causes the lens and capsular bag to center within the sulcus. B, The loop of suture under the scleral flap is cut, and the 2 ends are tied securely together. The scleral flap is closed over the knot. An identical procedure is performed 180° away.

COMMENT

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Anterior endocapsular IOL dislocation can be a surgical challenge for the anterior segment surgeon. Proposed mechanisms for endocapsular IOL dislocation in RP include surgical trauma, capsular contraction, zonular weakness, and Nd:YAG laser capsulotomy.¹ Following continuous curvilinear capsulorrhexis, the area of the capsular opening decreases more significantly in RP as compared with controls over time, with a 43.4% reduction in the area of the capsular opening in RP eyes at 1 year compared with a 3.6% reduction in controls.⁶ Phimosis of the capsulorrhexis is secondary to fibrous metaplasia of lens epithelial cells,⁷ which are activated by cytokines that may be more abundant in RP eyes, which are known to have disruptions in the blood-aqueous and blood-retinal barriers.^8-9 A similar mechanism may be implicated in the high rates of posterior capsular opacification (PCO), with significant PCO developing in 70.7% of operated-on eyes at 3 years¹⁰ and the reproliferation following Nd:YAG capsulotomy seen in patients with RP.¹¹ This cellular proliferation increases the weight of the capsular bag–IOL complex, which may further contribute to subluxation and dislocation. Furthermore, because patients with RP have denser PCO, they require more Nd:YAG laser energy than controls.¹⁰ The contraction of the capsular bag triggered by Nd:YAG capsulotomy¹² and high energy from the Nd:YAG capsulotomy may also contribute to zonular weakness and instability.¹³

The increased decentration and IOL tilt identified in patients with RP is felt to be secondary to zonular weakness and fragility.⁶ In 1 case with preoperative zonular loss and laxity, bilateral spontaneous dislocation of endocapsular IOLs occurred postoperatively. Zonular remnants clumped on the equator of the capsule identified by scanning electron microscopy confirmed that zonular fragility was implicated in the IOL dislocation.¹⁴ Weak zonules may allow the anterior capsule contraction to worsen, and as the aperture becomes smaller, the capsular bag shrinks in diameter, which may lead to further strain on the zonules.¹⁵ The centripetal forces induced by chronic capsular contraction can lead to progressive zonular weakening and their eventual rupture. Furthermore, as the capsule shrinks, the haptics become crimped, reducing the centrifugal forces of the haptic on the capsular bag equator, resulting in a progressive cycle of capsular contraction and zonular rupture.

Anterior dislocation of PCIOLs is far less common than posterior dislocation. Pressure gradients between the aqueous and the vitreous induced by ciliary muscle contraction in accommodation may cause the IOL to move forward through the dilated pupil. Increases in vitreous pressure caused by exertion or external pressure may also be implicated.¹⁶ In 1 case of blunt trauma to the eye, wound dehiscence did not occur. Instead, the traumatic pressure applied posterior to the iris increased vitreous cavity pressure and resulted in anterior movement of the IOL.¹⁷ Another case of a 41-year-old patient with gyrate atrophy describes anterior PCIOL dislocation following physical activity.¹⁸ These younger patients are likely to have a more formed vitreous, which may increase tendencies for the IOL to dislocate into the anterior chamber.

Techniques for surgical management of IOL dislocations include IOL removal, exchange, or repositioning. Benefits of repositioning include less corneal endothelial injury and smaller wounds with less postoperative astigmatism. Repositioning can also reduce the risks of vitreous prolapse and choroidal bleeding from IOL removal.² Most repositioning techniques have been derived primarily for the vitreoretinal subspecialist; however, few techniques have been described using an anterior segment approach. A modified McCannel suture can be used to fixate the IOL to the iris,^19-21 but anterior approaches for scleral fixation are limited. Stark et al²² advocated a technique for scleral fixation of PCIOLs in the setting of IOL exchange or secondary IOL placement in the absence of capsular support. Oshika²³ described a technique for sulcus fixating an endocapsular IOL via a corneal stab incision. In this technique, the sutures are passed first through a clear cornea stab incision and then passed out underneath the iris near the ciliary sulcus where visualization is impaired and maneuvering becomes more difficult. This may result in less accurate placement of the IOL, which should ideally be placed in the ciliary sulcus. Gimbel et al¹ described another method for scleral fixating a subluxed endocapsular IOL using nesting needles; however, the precise alignment required for nesting needles is challenging, making this technique difficult.

We present an unusual case of a patient with RP with anterior dislocation of an endocapsular IOL. The combination of zonular laxity, capsular contraction, and Nd:YAG capsulotomy may have contributed to the zonular rupture. The dislocation of the IOL into the anterior chamber may have been a result of increased posterior pressure in the setting of a formed vitreous. Similar factors may be implicated in endocapsular IOL dislocations in patients with pseudoexfoliation syndrome.²⁴ We describe an accurate and rapid method for fixating the IOL to the ciliary sulcus via a small-incision anterior segment approach, avoiding the potential difficulties associated with lens replacement.

AUTHOR INFORMATION

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Correspondence: Holly B. Hindman, MD, University of Rochester Eye Institute, 601 Elmwood Ave, Box 659, Rochester, NY 14642 (holly_hindman{at}urmc.rochester.edu).

Submitted for Publication: March 6, 2008; final revision received June 2, 2008; accepted June 4, 2008.

Financial Disclosure: None reported.

Author Affiliations: University of Rochester Eye Institute, Rochester, New York (Dr Hindman); Hôpital Ophtalmique Jules Gonin, Lausanne, Switzerland (Dr Casparis); Wills Eye, Philadelphia, Pennsylvania (Dr Haller); and Wilmer Eye Institute, The Johns Hopkins Hospital, Baltimore, Maryland (Dr Stark).

REFERENCES

Jump to Section  • Top  • Introduction  • Report of a case  • Comment  • Author information  • References

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