Effective treatment for secondary angle-closure glaucoma caused by traumatic lens subluxation:phacoemulsification with capsular-tension-ring implantation combined with ophthalmic endoscope-controlled goniosynechialysis

AIM:To investigate the safety and efficacy of phacoemulsification with capsular-tension-ring implantation and posterior chamber intraocular lens implantation combined with ophthalmic endoscope-controlled goniosynechialysis(Phaco-CTR-IOL-OE-GSL)for treating secondary angle-closure glaucoma induced by traumatic lens subluxation.METHODS:A retrospective and descriptive study was performed on patients with lens subluxation,angle closure,goniosynechia,and evaluated intraocular pressure(IOP)that cannot be controlled with medication,who underwent Phaco-CTR-IOL-OE-GSL.The postoperative best-corrected visual acuity(BCVA),IOP,range of goniosynechia and complications were retrospectively observed.RESULTS:Nine patients with secondary angle-closure glaucoma induced by traumatic lens subluxation were included.The follow-up period was 51.1±8.6 mo.The preoperative range of zonule rupture was 158.2°±33.0°,and the range of goniosynechia was 220.0°±92.5°.The baseline BCVA was 0.9±1.0 logMAR,IOP was 30.7±17.3 mm Hg and number of anti-glaucoma medication was 3.2±1.1.Mild intraoperative hyphaemia with 8 eyes(88.8%)in the anterior chamber,and was absorbed two days postoperatively.One eye(11.1%)had postoperative ciliary body detachment and was recovered after five days of topical drug treatment.BCVA was 0.2±0.2 logMAR at 3 mo postoperatively.The average IOP at the last follow-up was 16.7±2.0 mm Hg,and no anti-glaucoma medications were used.The average range of recurrent goniosynechia was 54.9°±33°at the final postoperative gonioscopic examination.CONCLUSION:Phaco-CTR-IOL-OE-GSL is safe and effective in the treatment of secondary angle-closure glaucoma induced by traumatic lens subluxation.The use of an endoscope provides a more direct and clear examination for GSL,and 360°dissection is easily achieved.

Sutured scleral fixation of existing subluxated/dislocated acrylic one-piece intraocular lenses

AIM:To evaluate the visual and refractive outcomes in cases after sutured scleral fixation of existing subluxated or dislocated acrylic one-piece intraocular lenses(IOLs).METHODS:This study retrospectively enrolled a consecutive series of patients who underwent a surgery of sutured existing subluxated or dislocated IOLs from October 2018 to June 2020.All patients underwent comprehensive preoperative and postoperative ophthalmologic examination,and data were collected including age,sex,surgical indications,best-corrected visual acuity,refractive error,intraocular pressure.Presence of intraoperative and postoperative surgical complications was documented.RESULTS:A total of 20 consecutive cases were enrolled for analysis with mean final follow-up period 9.8±5.3mo.Visual acuity improved from a mean of 0.35(0.46±0.32 logMAR)preoperatively to 0.61(0.21±0.18 logMAR)at the 3-month follow-up(P=0.002).The mean amount of preoperative keratometric astigmatism and total postoperative refractive astigmatism was-1.24±0.80 diopters(D)and-1.42±0.97 D,respectively.There was no statistically significant difference between preoperative and postoperative astigmatism(P=0.156).The mean IOL-induced astigmatism was-0.23±0.53 D.The mean spherical equivalent at the 3-month follow-up was-0.1±0.94 D.No major complications were noted during the follow-up period.CONCLUSION:Surgical techniques using sutured scleral fixation of existing subluxated or dislocated acrylic one-piece IOLs result in favorable visual and refractive outcomes without major complications.

Intraocular lens exchange or explantation post cataract surgery

AIM:To report incidence,indications,and visual outcomes of intraocular lens(IOL)exchange/explantation surgery.METHODS:Retrospective analysis of 60 eyes requiring IOL exchange/explantation surgery between 1^(st) January 2017 and 31^(st) December 2022.The overall outcomes as well as comparison between the trainee versus experienced surgeons were analyzed.RESULTS:Out of 39778 cataract surgeries(with no preexisting ocular co-morbidities)during a six-year period(2017-2022),60(0.15%)needed IOL exchange/explantation.Surgeons-under-training performed 36/60 cases(60%)while 24/60(40%)were by experienced surgeons.The commonest indication was subluxated IOL in 26(43.3%),followed by dislocated IOL in 20(33.3%),postoperative refractive surprise in 7(11.6%),IOL induced uveitis in five and broken haptic in two eyes.Twenty-four(40%)eyes had intraoperative complications during primary surgery.Posterior chamber IOL(PCIOL)was the commonest secondary IOL in 21(35%)eyes,scleral fixated in 20(31.6%),anterior chamber IOL(ACIOL)in 13(21.6%),iris fixated IOL in three(5%)and three eyes(5%)were left aphakic.The mean time between primary and secondary surgery was 168d(168±338.8).Best corrected visual acuity(BCVA)of>20/60 was obtained in 43 eyes(71.66%),20/80-20/200 in 14(23.33%),20/250 in two and hand movements in one.No statistically significant difference in visual outcome was noted at post-op one month between trainees versus experienced surgeons(UCVA 0.45±0.29 vs 0.53±0.32,P=0.20,BCVA 0.34±0.25 vs 0.37±0.26,P=0.69).CONCLUSION:IOL subluxation as the commonest indication and posterior capsular rupture is the commonest intraoperative risk factor.This complication can be effectively addressed with selection of the appropriate secondary IOL achieving good visual outcomes in over 70% of patients.

Evaluation of functional outcome and stability of sutureless scleral tunnel fixated IOLs in children with ectopia lentis

AIM:To evaluate functional outcome of sutureless scleral tunnel intraocular lens(SSTIOL)in children with crystalline lens subluxation of more than 7 clock hours.METHODS:A prospective interventional study was conducted consisting of 45 eyes of 44 children in age group 6-18 y having>7 clock hours of lens subluxation who underwent lensectomy-vitrectomy followed by SSTIOL implantation.Primary outcome was improvement in best corrected visual acuity(BCVA)and secondary outcomes were assessment of intraocular lens(IOL)tilt using ultrasound biomicroscopy(UBM),mean change in astigmatism at last follow-up of 1 y and associated complications.RESULTS:The mean preoperative and postoperative BCVA was 1.05±0.28 and 0.64±0.45(log MAR)respectively(P=0.001)at last follow-up.The mean astigmatism preoperatively and postoperatively was-4.17±2.69 D and-1.86±1.25 D respectively(P=0.011).Significant IOL tilt(>5 degrees)was present in 5 cases.The mean percentage endothelial loss was 3.65%±1.92%.The most serious complication encountered was retinal detachment seen in 2 cases.CONCLUSION:SSTIOL implantation provides efficient visual rehabilitation in children provided there is stringent case selection.We recommend caution in children having white-to-white distance>12 mm and presence of peripheral retinal degenerations.