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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 30  |  Issue : 1  |  Page : 43-45

Double trouble: Bilateral spontaneous posterior dislocation of cataractous lens


Department of Cataract and Glaucoma, Giridhar Eye Institute, Kochi, Kerala, India

Date of Web Publication7-Jun-2018

Correspondence Address:
Seshadri J Saikumar
Department of Cataract and Glaucoma, Giridhar Eye Institute, Kadavanthra, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_1_18

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  Abstract 

Subluxation or dislocation of clear or cataractous lens occurs commonly following ocular trauma or in association with systemic or other ocular risk factors. Spontaneous dislocation of lens in the absence of any of these risk factors is very rare. We report a case of bilateral spontaneous posterior dislocation of cataractous lens in a 64-year-old man who was on long-term antipsychotic medications with no preceding history of trauma or other risk factors. Simultaneous bilateral pars plana vitrectomy with lensectomy and glued scleral fixated intraocular lens implantation was done under general anesthesia, following which he had a good visual recovery.

Keywords: Bilateral spontaneous dislocation of lens, ectopia lentis, glued scleral fixated intraocular lens


How to cite this article:
Saikumar SJ, Manju A, Leena M V, Lakshmi J. Double trouble: Bilateral spontaneous posterior dislocation of cataractous lens. Kerala J Ophthalmol 2018;30:43-5

How to cite this URL:
Saikumar SJ, Manju A, Leena M V, Lakshmi J. Double trouble: Bilateral spontaneous posterior dislocation of cataractous lens. Kerala J Ophthalmol [serial online] 2018 [cited 2018 Sep 19];30:43-5. Available from: http://www.kjophthal.com/text.asp?2018/30/1/43/233768


  Introduction Top


Ectopia lentis is defined as displacement or malposition of the crystalline lens of the eye. The lens is considered dislocated/luxated when it lies completely outside the patellar fossa of the lens. The lens is described as subluxated when it is partially displaced but contained within the fossa. In the absence of trauma, ectopia lentis should evoke suspicion for any hereditary systemic disease or associated ocular disorders.[1],[2]

Disruption or dysfunction of zonular fibers of the lens is the underlying pathophysiology of ectopia lentis. Lens subluxation may occur in many congenital or developmental conditions such as Marfan syndrome, homocystinuria, Ehlers–Danlos syndrome, simple primary ectopia lentis, and congenital aniridia syndrome.[3],[4] Subluxation may also occur following acquired conditions like blunt trauma or iatrogenic zonular dehiscence induced during complicated cataract surgery. Spontaneous luxations occur due to rupture of the zonular fibers in degenerative and inflammatory conditions such as long-standing glaucoma, high myopia, hypermature cataract, retinal detachment, and pseudoexfoliation syndrome (PXFS). Perhaps, the most common cause for adult-onset zonular weakness is PXFS, in which progressive zonular degradation can result in phacodonesis and crystalline lens subluxation.[5],[6]


  Case Report Top


A 64-year-old male presented with blurring of vision for 3 months. He gave no history of preceding trauma or pain or redness in his eyes. He was on oral antidepressants for the previous 6 months, which included clonazepam (1 mg) + escitalopram (20 mg) twice daily, olanzapine (5 mg) twice daily, and vilazodone hydrochloride (20 mg) at night. He was a known hypertensive on treatment with enalapril (2.5 mg) twice daily for the past 24 years. On examination, his best-corrected visual acuity (BCVA) in both eyes (BE) was 6/12 (logMAR 0.301) with +10.0 DS and N6 with add of +3.0DS in Both eyes. Anterior segment showed sluggishly reacting pupils with vitreous prolapse into the anterior chamber, aphakia, and iridodonesis. There was no clinical evidence of pseudoexfoliation in either eye. Dilated fundus examination revealed posteriorly dislocated crystalline lens seen in the inferior vitreous cavity, with rest of the fundus appearing normal. Intraocular pressure measured by Goldmann applanation tonometer was 18 mmHg in BE. The patient underwent evaluation by an internist, and no clinical evidence of Marfan syndrome was detected. His serum homocysteine level was 7.2 micromoles/L, which ruled out homocystinuria. A planned pars plana vitrectomy and lensectomy of the right eye under local anesthesia had to be deferred on table due to the patient's systemic morbidities. A week later, vitrectomy with lensectomy and glued scleral fixated intraocular lens (SFIOL) implantation was done simultaneously in BE under general anesthesia. Postoperatively, his BCVA improved to 6/9 (logMAR 0.176) and N6 in BE, and intraocular lenses were stable after multiple follow-ups.

Technique

Localized peritomy was done at the site of exit of the IOL haptics. An anterior chamber maintainer was introduced near 6 o'clock limbus for initial anterior vitrectomy which was later removed after pars plana infusion was put in place. Two partial-thickness limbal based scleral flaps (2.5 mm × 2.5 mm) were created 180° apart, aligned with limbal markings placed preoperatively [Figure 1].
Figure 1: Vitrectomy ports with scleral flaps

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Three-port pars plana vitrectomy and fragmatome removal of crystalline lens were performed [Figure 2].
Figure 2: Fragmatome removal of dislocated crystalline lens

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Two straight sclerotomies were made under the scleral flaps, 1 mm from the limbus. An intrascleral tunnel was made adjacent to the flap, aligned to the sclerotomy. A three-piece foldable IOL (Sensar AR40e, Abbott Medical Optics) was introduced into the eye through a clear corneal incision [Figure 3].
Figure 3: Implantation of glued scleral fixated intraocular lens

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The tip of the leading haptic was exteriorized through the sclerotomy following the curve of the haptic. The trailing haptic was externalized through the opposite sclerotomy under the scleral flap [Figure 4].
Figure 4: Externalization of intraocular lens haptics

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The haptic tips were tucked into the scleral tunnels on either side, and the scleral flaps were closed using reconstituted tissue glue (Tisseel Lyo, Baxter). The corneal wounds were hydrated. Conjunctiva was also closed with glue.


  Discussion Top


Bilateral spontaneous posterior dislocation of lens in the absence of any systemic associations and trauma is a very rare entity. Similar anterior dislocation of clear lens has been reported by Jovanović which was managed by lens removal followed by contact lens correction for aphakia.[7]

Posterior dislocation of the lens into the vitreous with excursions to the anterior chamber was observed by Schäfer et al. in two patients, one of whom had a history of a blunt ocular trauma and the other had Marfan syndrome, both of which are known risk factors for this condition.[8] In both cases, a YAG iridotomy and a surgical lens extraction were immediately performed.

Our patient was on antipsychotic medication, and an association between its use and zonular weakness was studied. Psychotropic medications on long-term use can cause numerous and diverse unwanted ocular effects on the eyelids, cornea and conjunctiva, uvea, accommodation interference, angle-closure glaucoma, cataract/pigmentary deposits in the lens, retinopathy, and other disorders such as ocular dystonias, decreased color vision, and contrast sensitivity.[9] None of the drugs have been known to cause simultaneous dislocation of lens even on long-term use.

Brown et al. reported a case of a 68–year-old woman on antipsychotic medications who presented with loss of vision in the right eye. She was found to have a dislocated lens possibly following repeated fist punches on that side of her face in an attempt to rid herself of her distressing auditory hallucinations.[10] Our patient denied a history of self-inflicted or other injuries.

Sutured scleral fixation of intraocular lens involves passing sutures through uveal tissue, which may lead to complications such as retinal detachment or intraocular hemorrhage, especially in high-risk patients such as myopes, hypertensives, or patients on anticoagulants. Externalized suture and knots can have increased risk for suture or tissue erosion and endophthalmitis. Sutures may become loose or may break to cause IOL dislocation or tilt.

Foldable-glued IOLs have the postoperative advantage of having fewer complications associated with larger wounds such as postoperative wound leak and shallow anterior chamber as well as decreased astigmatism and also a lesser chance of suture-related complications.

This is the first reported case of bilateral spontaneous posterior dislocation of lens in an elderly man on antipsychotic medications and with no preceding history of trauma or other risk factors managed by glued SFIOL implantation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Clark CC. Ectopialentis: A pathologic and clinical study. Arch Ophthalmol 1939;21:124-53.  Back to cited text no. 1
    
2.
Albert DM, Jakobiec FA. Pathology of the lens. Principles and Practice of Ophthalmology. WB Saunders Company; 2000. p. 2225-39.  Back to cited text no. 2
    
3.
Dureau P. Pathophysiology of zonular diseases. Curr Opin Ophthalmol 2008;19:27-30.  Back to cited text no. 3
[PUBMED]    
4.
Nelson LB, Maumenee IH. Ectopia lentis. Surv Ophthalmol 1982;27:143-60.  Back to cited text no. 4
[PUBMED]    
5.
Kohnen T. Pseudoexfoliation: Impact on cataract surgery and long-term intraocular lens position. J Cataract Refract Surg 2010;36:1247-8.  Back to cited text no. 5
[PUBMED]    
6.
Davis D, Brubaker J, Espandar L, Stringham J, Crandall A, Werner L, et al. Late in-the-bag spontaneous intraocular lens dislocation: Evaluation of 86 consecutive cases. Ophthalmology 2009;116:664-70.  Back to cited text no. 6
[PUBMED]    
7.
Jovanović M. Bilateral spontaneous crystalline lens dislocation to the anterior chamber: A case report. Srp Arh Celok Lek 2013;141:800-2.  Back to cited text no. 7
    
8.
Schäfer S, Spraul CW, Lang GK. Spontaneous dislocation to the anterior chamber of a lens luxated in the vitreous body: Two cases. Klin Monbl Augenheilkd 2003;220:411-3.  Back to cited text no. 8
    
9.
Richa S, Yazbek JC. Ocular adverse effects of common psychotropic agents: A review. CNS Drugs 2010;24:501-26.  Back to cited text no. 9
[PUBMED]    
10.
Brown R, Al-Bachari MA, Kambhampati KK. Self-inflicted eye injuries. Br J Ophthalmol 1991;75:496-8.  Back to cited text no. 10
[PUBMED]    


    Figures

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



 

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