Lens-Related Emergencies: Not Always So Clear.

Emergencies involving the crystalline lens are not common; however, their clinical signs must be recognized quickly to begin treatment or referred immediately to improve the chances of retaining sight. The lens is a unique structure because of its immunologically privileged status and its imperative clarity for vision. Any insult to the lens capsule's integrity, its position within the globe, or to its clarity may result in undesirable sequelae.

Canine Secondary Glaucomas.

Secondary glaucomas are common in dogs, and occur due to obstruction of aqueous humor flow at the pupil, iridocorneal angle, or trabecular meshwork by numerous mechanisms. Secondary glaucoma is suspected based on examination findings, or presence of elevated IOP in an animal with a signalment inconsistent with primary glaucoma. Animals with secondary glaucoma require more diagnostic testing than animals with primary glaucoma. Management is challenging, and treatments used for primary glaucoma may be ineffective or even detrimental. Prognosis for vision and/or globe retention may be better than for primary glaucoma, particularly if underlying causes can be found and addressed promptly.

Management of subluxated lens in young patients.

OBJECTIVES: To evaluate visual outcomes in patients treated for lens subluxation. Secondary objectives are to report best corrected visual acuity (BCVA) in LogMAR and compare the outcomes of patients managed conservatively with those treated surgically. METHODS: Retrospective comparison of BCVA in patients under 50 years-old with lens subluxation, managed conservatively or surgically. RESULTS: A total of 49 eyes of 28 patients were included. Demographic characteristics were similar in both groups. Twenty eyes were treated surgically (40.8%) compared to 29 with medical treatment (59.2%). Marfan syndrome (79.6%) was diagnosed in 39 eyes. LogMAR BCVA post intervention was 0.35±0.31 for medical treatment and 0.39±0.32 for the surgical group, with no significant differences (P=.63). Improvements in LogMAR lines were 2.7±4.2 and 4.11±4.2 (P=.35), respectively. Two eyes in the surgery group developed ocular hypertension (0.04%), none with retinal detachment. CONCLUSIONS: The final BCVA showed no significant differences in this group of patients. BCVA depends on the visual potential of the rehabilitated eye rather than a specific type of intervention.

Minimally invasive relocation of subluxated single piece AcrySof intraocular lens.

We describe an ab externo technique for scleral fixation of a subluxated single piece AcrySof (Alcon, Texas, USA) intraocular lens (IOL). A 10-0 polypropylene transcleral suture brought out of a paracentesis and traced back to form a loop is used to tie a cow hitch knot around a temporarily externalised haptic. The one piece design of the IOL, with flexible haptics, allows temporary externalisation through a 1.2 mm paracentesis. The tacky nature of the haptic material, square edges and the knob at the tip prevent slippage of the knot. The advantage of this technique is that the same one piece AcrySof IOL is retained and secured, while the risks and manipulations associated with explantation and exchange are avoided. While mere sulcus placement of a single piece AcrySof IOL may be associated with complications, scleral fixation is a viable solution.

Anterior dislocation of a sulcus fixated posterior chamber intraocular lens in a high myope.

A 31-year-old man with high axial myopia and strabismus fixus convergens underwent bilateral refractive lens exchange followed by a squint surgery (bilateral superior partial Jensen's procedure and medial rectus recession). After one year he presented with traumatic anterior dislocation of the sulcus fixated posterior chamber polymethyl methacrylate lens. The lens was dialed back into the ciliary sulcus without any complications. This case highlights the importance of implanting an intraocular lens (IOL) in-the-bag. If the IOL needs to be implanted in the sulcus, a larger diameter of the IOL with larger optic size and overall length is desirable, especially in highly myopic eyes.

Marfan syndrome-diagnosis and management.

Marfan syndrome (MFS) is the most common inherited disorder of connective tissue that affects multiple organ systems. This autosomal-dominant condition has an incidence of 2-3 per 10,000 individuals. Although genetic testing is available, the diagnosis is still primarily made using the Ghent criteria. Early identification and appropriate management is critical for patients with MFS who are prone to the life-threatening cardiovascular complications of aortic dissection and rupture. Advances in the understanding of the cause of MFS, early recognition of the disorder, and subsequent institution of medical and surgical therapy has resulted in dramatic improvement in the prognosis of this patient population over the past few decades. Beta-blockers have been demonstrated to slow aortic growth and thus delay the time to aortic surgery. Operative intervention has markedly changed the prognosis of patients with MFS and can be safely performed on an elective basis. Identification of presymptomatic patients is critical to reduce the frequency of catastrophic aortic events.

Ocular axial length in homocystinuria patients with and without ocular changes: effects of early treatment and biochemical control.

PURPOSE: To establish whether myopia in homocystinuria could be due to increased ocular axial length. METHODS: Measurement of ocular axial length by A-scan ultrasound in eyes of homocystinuria patients. RESULTS: Patients were divided into three groups. Group I, with no ocular pathology (28 eyes), had mean refractive error of -0.25 D (spherical equivalent) and mean axial length of 23.4 mm +/- 0.9 (+/-1 standard deviation) mm. Group II, with phacodonesis or lens subluxation (12 eyes), had mean refractive error of -10.7 D and mean axial length of 23.8 mm +/-1.9 mm. Patients with phacodonesis had simple myopia whereas those with lens subluxation had marked myopic astigmatism. Group III included patients with complete lens dislocation in at least one eye (12 eyes) and were optically aphakic with a mean refractive error of +12.9 D and mean axial length of 24.9 mm +/- 0.9 mm. All Group I patients had good long-term metabolic control while those in Groups II and III did not. Group III eyes had significantly longer mean axial length than Group I (P =.0018) or normal eyes (P =.0163). There was no statistical difference in mean axial length between Group I and normal eyes. CONCLUSIONS: Ocular axial length is significantly increased in individuals with homocystinuria and lens dislocation. Increased axial length is a complication that has not been previously described in homocystinuria and may be preventable with early treatment and good biochemical control.

The impact of echography on evaluation and management of posterior segment disorders.

PURPOSE: To investigate the impact on patient management of posterior segment echographic evaluation at an academic institution. DESIGN: Retrospective, noncomparative, consecutive case series. METHODS: Records were reviewed of all patients evaluated for the first time with ocular echography for posterior segment evaluation at Bascom Palmer Eye Institute between September 2000 and August 2001. Patients with prior posterior segment echography, intraocular tumors, or suspected optic nerve or orbital disease were excluded. An "impactful" echographic evaluation was defined as an evaluation that confirmed the diagnosis and management plan. A "pivotal" evaluation was defined as an evaluation that either (1) made or subclassified the diagnosis or (2) established or changed the management plan or both. Main outcome measures include proportions of impactful and pivotal echographic evaluations and factors associated with pivotal evaluations. RESULTS: The study included 154 eyes of 143 patients. The requesting physician was a retina fellowship-trained faculty member in 55 cases (36%), a nonretina faculty member in 22 (14%), a fellow in 9 (6%), and a resident in 68 (44%). Reasons for obtaining echography included evaluation for retinal tear or detachment in 83 eyes (54%), evaluation for posterior segment disease (for example, before cataract extraction) in 40 (26%), evaluation for endophthalmitis in 10 (7%), evaluation for intraocular foreign body in 8 (5%), characterization of choroidal detachment in 4 (2%), and other in 9 (6%). Echography confirmed the suspected diagnosis and pre-echography management plan in 128 eyes (83%). Echography made or subclassified the diagnosis in 20 eyes (13%) and established or changed the management plan in 12 eyes (8%). Accounting for definitional overlaps, echography was pivotal in 22 eyes (14%). Significant predictors of a pivotal evaluation or an evaluation that affected the management plan include a retina faculty member as the requesting physician (P =.003), lack of a management plan before echography (P <.001), and certain reasons for obtaining echography (for example, to rule out retinal tear or detachment and to rule out intraocular foreign body; P =.032). The final clinical or pathologic diagnosis confirmed the echographic diagnosis in 148 eyes (96%). CONCLUSIONS: Posterior segment echography may be a very useful diagnostic tool. Its value may be optimized in certain subsets of patients. Considerations such as these may contribute to more cost-effective allocation of resources.

Indirect trauma causing dislocation of the crystalline lens--a case report.

PURPOSE: To report a case of indirect trauma causing dislocation of the crystalline lens in a patient with no underlying risk factors. METHODS: Case report. RESULTS: A 76-year-old woman fell injuring her right temple area. She complained of blurring of vision in her right eye. Her vision was reduced to 6/60. Ocular examination revealed right aphakia associated with complete posterior dislocation of the crystalline lens into the vitreous cavity. No predisposing factors as pigment dispersion or pseudoexfoliation material was found on gonioscopy. CONCLUSIONS: Dislocation of the crystalline lens has been reported following direct trauma. It is known to occur spontaneously in mature and hypermature cataracts and in cases of weak zonules. Our case shows that indirect trauma can cause complete dislocation of the crystalline lens in the absence of any predisposing factors.

[Vitrectomy and perfluorocarbons in the management of luxated lenses]. / Vitrectomía y perfluorocarbonos en el tratamiento de la luxación del cristalino.

PURPOSE: To evaluate the use of vitrectomy with perfluorocarbon liquids (Perfluoro-DK-line) (PFCL) to refloat the luxated lenses of surgical etiology. Follow-up complications are considered. METHODS: The cases with vitreous posteriorly luxated lenses were reviewed between 1989 and 1999. 8 cases were found, all had similar surgery with vitrectomy and PFCL performed by the same surgeon. In two cases an anterior chamber IOL and in 6 cases a posterior chamber IOL sulcus fixated were used. RESULTS: The average age of the 8 cases with unilateral vitreous luxated lenses of no surgical etiology was 64.5 years. 3 of them were myopic with a history of spontaneous luxation with a duration of 5.9 and 10 years respectively. The other 5 cases reported a history of ocular trauma with a shorter time of luxation (between 1 week and 3 years). 7 cases (87.5%) had ocular hypertension, 6 cases (75%) showed epithelial corneal edema and one case retinal detachment preoperatively. Vitrectomy with PFCL normalized IOP and corneal edema. The complications related with decreased final VA were cystoid macular edema (1 case), macular atrophy (1 case) and retinal detachment (1 case). Only in one case a postsurgical retinal detachment was found likely to be iatrogenic. CONCLUSION: As vitrectomy with PFCL simplifies surgical technique with good results and modern sulcus fixated IOL may be used during the same surgery offering visual restoration, we believe this combined technique must be recommended always after posterior lens dislocation, to prevent complications and to preserve visual acuity.

[Good practices in traumatic glaucoma]. / Les bonnes pratiques des glaucomes traumatiques.

We review different aspects of trauma induced glaucoma and hypertonia, discussing pathophysiology, patient management, and the main clinical presentations. One can distinguish schematically first acute hypertonia related to changes in the position of the crystalline lens or to a hyphema which requires emergency medical or surgical care and second, chronic situations generally related to definitive angle lesions. We also discuss particular presentations such as phantom cell glaucoma and glaucoma by chemical burn or siderosis.

[A distance ring for stabilization of the lens capsule (a multicenter clinical study)]. / Distancní krouzek urcený k stabilizaci pouzdra cocky (multicentrická klinická studie).

Cataract extraction in eyes with a loose suspension apparatus implies always an unconventional method of surgery. An important contribution towards the stabilization of the capsule during surgery and during the postoperative period is implantation of a polymethyl methacrylate (PMMA) ring into the capsular bag during phacoemulsification and implantation of the lens in patients with dialysis of the zonula. Erilens Co. produced three types of distance rings which were tested in 1997 within the framework of a multicentre clinical trial in seven departments in the Czech Republic: the most frequent indication for implantation of a distance ring was subluxation of the lens in 16 eyes, instability of the capsule in patients with myopia in nine eyes, traumatic cataract after contusion in five eyes and after a perforating injury in five eyes. In two patients the ring was used during normal cataract extraction when during aspiration of the lenticular mass the zonula loosened. From the total number of 47 distance rings it proved possible to implant primarily into the capsule only 42, two further rings were implanted primarily into the sulcus and left there. In patients with ectopia of the lens the ring was fixed into the sulcus ciliaris. In two instances the ring was explanted during the operation on account of instability of its position, in one instance the ring was damaged during implantation. The type and frequency of complications during and after surgery corresponded to the patient's pathology before the operation. More than three quarters of the operated eyes had after operation corrected vision better than 6/18. Poorer vision after surgery in nine patients was due to age-related or post-traumatic changes on the fundus. The results of the multicentre clinical trial evaluating the implantation of the distance ring of Erilens Co. conducted in seven departments of the Czech Republic in 1997 provided evidence that the quality of these rings is comparable with types produced abroad and used in complicated surgery of the anterior segmental of the eye.

[Phacotopic glaucoma]. / Glaucomul fakotopic.

Phacotopic glaucomas or hypertonias due to lens movements are not rarely in ophthalmology. They are often due to a traumatic pathology. They are seldom due to a congenital or acquired zonular disease. It is very important to recognize the pathogenic mechanism for a proper treatment: pupillary block and/or angular block or phacolytic glaucoma. Lens displacement is possible in three different places, that may lead to different causes of hypertonia, that need different treatments. Laser iridotomy, improvement of lens and vitreous surgery changed the prognosis of this diseases.

Contact lens correction of patients with Marfan syndrome.

BACKGROUND: Marfan syndrome, a genetic connective tissue disorder, manifests many problems: high myopia, astigmatism, crystalline lens subluxation, and cataracts. No published studies have described the contact lens corrections that can be used with Marfan syndrome patients. This report describes the variety of contact lens modalities used for a subpopulation of patients with Marfan syndrome. METHODS: The clinical records of eight patients with Marfan syndrome (16 eyes) from two hospital-based contact lens practices were retrospectively reviewed. Seven different contact lens modalities were used for this subpopulation. RESULTS: Mean unaided visual acuities were 20/296, while mean best-corrected optimal spectacle refraction visual acuities were 20/33. Contact lenses improved the mean visual acuity to 20/27. Patients wore the contact lenses for an average of 12 hours per day. Complications of contact lens wear occurred in approximately 70% of eyes and included neovascularization, giant papillary conjunctivitis, 3 and 9 o'clock staining, and central superficial punctate staining. Additionally, ocular non-contact lens-related complications occurred in 50% of patients. CONCLUSIONS: A variety of contact lens designs may be used during the care of patients with Marfan syndrome. However, patients may experience an increased rate of complications associated with contact lens wear or unrelated to lens wear, and thus they deserve more intensive follow-up care than non-Marfan syndrome patients.

Ultrasound biomicroscopy in anterior ocular trauma.

BACKGROUND AND OBJECTIVE: The authors investigated the role of ultrasound biomicroscopy after ocular trauma. PATIENTS AND METHODS: Ultrasound biomicroscopy was performed in six eyes of six patients at the New York Eye and Ear Infirmary after a variety of traumatic ocular injuries. RESULTS: Eyes with angle recession, iridodialysis, cyclodialysis, hyphema, an intraocular foreign body, scleral laceration, and subluxed crystalline lens were imaged without complication. Ultrasound biomicroscopy aided in the diagnosis when visualization was limited by media opacities or distorted anterior segment anatomy. CONCLUSION: Ultrasound biomicroscopy is a safe and effective adjunctive tool for the clinical assessment and management of ocular trauma, especially when visualization is limited and multiple traumatic injuries are involved.

Incidence of lens matter dislocation during phacoemulsification.

PURPOSE: To assess the incidence and visual morbidity of lens matter dislocation during phacoemulsification and the relationship between this complication and surgical experience. SETTING: Teaching and district general hospitals. METHODS: A multiple-choice questionnaire was sent to members of the Northern and Midlands Ophthalmological Societies. They were asked about the incidence of lens matter dislocation, the visual outcome of the cases, and their surgical experience. RESULTS: Forty-seven of the 177 survey respondents (26.5%) were using phacoemulsification. The incidence of lens matter dislocation was 1.1%; 49.0% of the surgeons had experienced at least one case. The incidence increased significantly when surgeons assessed their expertise with phacoemulsification toward the expert end of the scale. Final visual acuity was worse than 6/12 in 35.0% of cases. CONCLUSIONS: The incidence of lens matter dislocation with phacoemulsification is significant and related to an incorrect assessment of expertise by the surgeons. The considerable visual morbidity associated with this complication can be minimized using the management strategy discussed.