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ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 43-45

Pars plana vitrectomy for dislocated crystalline/artificial intraocular lens: Factors predicting the visual outcome


Department of Ophthalmology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication17-Nov-2017

Correspondence Address:
Siddhartha Bose
Department of Ophthalmology, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/erj.erj_16_16

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  Abstract 


Aims: This study aims to study the factors predicting the visual outcome of pars plana vitrectomy (PPV) done for dislocated crystalline or artificial intraocular lens (IOL). Settings and Design: This was a retrospective observational study. Subjects and Methods: The records of patients who underwent PPV with lens retrieval and IOL exchange or repositioning for traumatic or iatrogenic dislocation of crystalline or artificial IOL were reviewed. Pre- and post-operative visual acuity and complications were recorded. Six-month patient follow-up data were reviewed. Statistical Analysis Used: Chi-square test. Results: Final best-corrected visual acuity (BCVA) 6/60 or better was found in the majority of patients who underwent PPV within 1 year of dislocation, but for patients who were delayed for over a year, the final BCVA was <6/60 (P = 0.001). Significant correlations were found between delayed PPV and postoperative retinal detachment (RD) (P = 0.001); between PPV for dislocated nuclear fragment(s) due to complicated cataract surgery and preoperative uveitis (P = 0.007) as well as postoperative cystoid macular edema (CME) (P = 0.001); between preoperative corneal edema and postoperative corneal decompensation (P = 0.03). Finally, the final BCVA <6/60 had significant correlations with preoperative corneal edema (P = 0.001) and uveitis (P = 0.039) and with postoperative corneal decompensation (P = 0.013), CME (P = 0.001), and RD (P = 0.001). Conclusions: In cases of dislocated lens, factors such as delayed intervention, dislocated nuclear fragment(s), preoperative uveitis, and corneal edema were related to increased postoperative sight-threatening complications resulting in poorer visual outcome.

Keywords: Dislocated crystalline lens, dislocated intraocular lens, pars plana vitrectomy


How to cite this article:
Bose S, Gupta SK, Kishore P, Agrawal S, Katiyar V, Kumar P. Pars plana vitrectomy for dislocated crystalline/artificial intraocular lens: Factors predicting the visual outcome. Egypt Retina J 2017;4:43-5

How to cite this URL:
Bose S, Gupta SK, Kishore P, Agrawal S, Katiyar V, Kumar P. Pars plana vitrectomy for dislocated crystalline/artificial intraocular lens: Factors predicting the visual outcome. Egypt Retina J [serial online] 2017 [cited 2017 Dec 11];4:43-5. Available from: http://www.egyptretinaj.com/text.asp?2017/4/2/43/218585




  Introduction Top


Dislocation of crystalline or artificial intraocular lens (IOL) is a known complication of phacoemulsification and blunt trauma.[1],[2] This may lead to elevated intraocular pressure (IOP), corneal edema, uveitis, cystoid macular edema (CME), or retinal detachment (RD) resulting in profound visual loss.[3],[4],[5] Various studies support pars plana vitrectomy (PPV) for favorable visual outcome in such cases.[4],[6],[7] However, the associated postoperative complications may be raised IOP, RD, corneal decompensation, and CME.[8] The aim of our study was to evaluate the pre- and post-operative factors determining the visual outcome in patients undergoing PPV for dislocated lens.


  Subjects and Methods Top


The study was performed in accordance with the ethical standards of the Institutional Committee on human experimentation and with the Helsinki Declaration of 1975 as revised in 2000.

A retrospective review was performed of the records of all patients who underwent PPV and retrieval of dislocated crystalline lens/IOL during 3 years from August 2012 to July 2015. Patients having ocular conditions which independently affect the visual outcome (including irreversible corneal disorders, advanced proliferative vitreoretinopathies, macular degenerations, glaucoma, uveitis, or optic neuropathies) and patients with <6-month follow-up were excluded from the study.

Preoperative information included demographics, preexisting eye diseases, systemic associations, details of the primary surgery or traumatic event, best-corrected visual acuity (BCVA) using Snellen's chart, anterior and posterior segment findings at presentation, and complications such as raised IOP, corneal edema, uveitis, vitreous hemorrhage (VH), RD, and CME. Operative details included the duration between dislocation and surgery, surgical method of management and type of IOL implanted. Postoperative follow-up information included BCVA using Snellen's chart and complications such as raised IOP, corneal decompensation, RD, CME, uveitis, and secondary IOL dislocation.

The surgical technique consisted of making a 6–7 mm sclera-corneal tunnel, followed by standard 20-gauge three-port PPV, and complete removal of vitreous strands adherent to the dropped crystalline lens or IOL. The lens was brought into the anterior chamber using vacuum aspiration in cases of dropped crystalline lens and intravitreal forceps in cases of dropped IOL, which was then delivered out through the sclera-corneal tunnel. If there was more than 180° of capsular remnant, a three-piece posterior chamber IOL was placed in the sulcus, and if there was no capsular remnant, an anterior chamber IOL was implanted.

Data were analyzed using SPSS software (SPSS 21.0, IBM Corp.) employing Chi-square test.[9]P < 0.05 were considered as statistically significant.


  Results Top


Fifty-eight eyes of 58 patients including 42 male and 16 female patients were studied. The surgery was performed for ten patients with dislocated nuclear fragment(s) due to cataract surgery, 26 patients with dislocated IOL due to cataract surgery, twenty patients with traumatic dislocation of crystalline lens, and two patients with traumatic dislocation of IOL. Out of the 36 patients who had iatrogenic dislocation related to cataract surgery, 26 patients (72.2%) underwent phacoemulsification, and ten patients (27.8%) underwent small-incision cataract surgery (SICS). The odds of phacoemulsification causing dislocation are 6.8 times higher as compared to SICS (P = 0.001). Out of the 22 cases of trauma, two (9.1%) patients had suffered penetrating trauma, and the rest of them sustained blunt trauma. The odds of blunt trauma causing dislocation are 100 times higher as compared to penetrating trauma (P = 0.001).

The distribution of the latency between dislocation and surgery of the patients is shown in [Table 1], and the distribution of the final visual outcomes at 6-month follow-up is shown in [Table 2].
Table 1: Distribution of time duration between dislocation and surgery (n=58)

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Table 2: Distribution of final visual acuity at the final follow-up (n=58)

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Final BCVA of 6/60 or better was found in the majority of patients who underwent PPV within 1 year of dislocation, but for all patients who were delayed for over a year, the final BCVA was <6/60 (P = 0.001).

The preoperative complications were raised IOP in six (10.3%) patients, corneal edema in four (6.9%), uveitis in two (3.4%), and VH in four (6.9%) patients. Preoperative uveitis had a significant correlation with dislocated nuclear fragment(s) following cataract surgery (P = 0.007) when compared to iatrogenic dislocation of IOL and traumatic dislocation. In addition, the final BCVA had significant correlations with preoperative corneal edema (P = 0.001) and uveitis (P = 0.039). All patients with preoperative corneal edema and uveitis had final BCVA <6/60.

The postoperative complications seen in this study are raised IOP in twelve (20.7%), corneal decompensation in eight (13.8%), uveitis in eight (13.8%), CME in four (6.9%), RD in four (6.9%), and foveal thinning in two (3.4%) patients. The final BCVA had significant correlations with postoperative corneal decompensation (P = 0.013), CME (P = 0.001), and RD (P = 0.001). All patients with postoperative CME and RD had final BCVA <6/60, whereas 50% patients with postoperative corneal decompensation had final BCVA between 6/12 and 6/60, and the rest 50% had final BCVA <6/60 despite adequate treatment. Furthermore, RD was seen in patients whose PPV was delayed over a month, which was statistically significant (P = 0.001). CME had significant correlations with iatrogenic dislocation of nuclear fragment(s) (P = 0.001) and preoperative uveitis (P = 0.001). In addition, postoperative corneal decompensation had a significant correlation with preoperative corneal edema (P = 0.03).


  Discussion Top


PPV for retrieval of dislocated crystalline lens or artificial IOL is a necessary intervention for visual rehabilitation and to prevent several sight-threatening complications.[3],[4],[5] However, there are certain factors that predict the visual outcome and future complications. Our study has shown that postoperative complications such as corneal decompensation, CME, and RD have resulted in poor visual outcomes with majority of the patients having BCVA <6/60. In our study, we managed to evaluate the risk factors for such sight-threatening complications. We found that patients having preoperative corneal edema are likely to develop corneal decompensation following the procedure due to endothelial injury. In our study, dislocated nuclear fragment(s) as a result of complicated cataract surgery increases the risk of CME. This can be supported by a previous study done by Jaffe et al.[10] and explainable as the presence of lens matter in vitreous is likely to induce uveitis. Excessive manipulation during the primary surgery (in this case, cataract surgery) may also induce uveitis which later increases the chances of CME. We have also found that delayed presentation and intervention are likely to result in a poor visual outcome due to increased risk of RD. This is in agreement with the previous studies that state that RD is a well-documented complication of lenticular dislocation if vitrectomy is delayed.[8],[11]


  Conclusions Top


The risk factors for poor visual outcomes associated with the procedure should be assessed, explained to the patients, and kept on close watch in their postoperative follow-up visits.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Emery JM, Wilhelmus KA, Rosenberg S. Complications of phacoemulsification. Ophthalmology 1978;85:141-50.  Back to cited text no. 1
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2.
Hoffman RS, Snyder ME, Devgan U, Allen QB, Yeoh R, Braga-Mele R; ASCRS Cataract Clinical Committee; Challenging/Complicated Cataract Surgery Subcommittee. Management of the subluxated crystalline lens. J Cataract Refract Surg 2013;39:1904-15.  Back to cited text no. 2
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3.
Lambrou FH Jr., Stewart MW. Management of dislocated lens fragments during phacoemulsification. Ophthalmology1992;99:1260-2.  Back to cited text no. 3
    
4.
Rossetti A, Doro D. Retained intravitreal lens fragments after phacoemulsification: Complications and visual outcome in vitrectomized and nonvitrectomized eyes. J Cataract Refract Surg 2002;28:310-5.  Back to cited text no. 4
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Gilliland GD, Hutton WL, Fuller DG. Retained intravitreal lens fragments after cataract surgery. Ophthalmology 1992;99:1263-7.  Back to cited text no. 5
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6.
Gurunadh VS, Banarji A, Ahluwalia TS, Upadhyay AK, Patyal S. Management of Nucleus and IOL Drop. Med J Armed Forces India 2008;64:315-6.  Back to cited text no. 6
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7.
Huang HM, Kao ML, Kuo HK, Tsai SH, Chen YJ, Liu CC. Visual results and complications after trans pars plana vitrectomy and lensectomy for lens dislocation. Chang Gung Med J 2004;27:429-35.  Back to cited text no. 7
    
8.
Vanner EA, Stewart MW. Meta-analysis comparing same-day versus delayed vitrectomy clinical outcomes for intravitreal retained lens fragments after age-related cataract surgery. Clin Ophthalmol 2014;8:2261-76.  Back to cited text no. 8
    
9.
Nayak BK, Hazra A. How to choose the right statistical test? Indian J Ophthalmol 2011;59:85-6.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Jaffe NS, Clayman HM, Jaffe MS. Cystoid macular edema after intracapsular and extracapsular cataract extraction with and without an intraocular lens. Ophthalmology 1982;89:25-9.  Back to cited text no. 10
    
11.
Salam GA, Greene JM, Deramo VA, Tibrewala RK, Ferrone PJ, Fastenberg DM. Retinal tears and retinal detachment as factors affecting visual outcome after cataract extraction complicated by posteriorly dislocated lens material. Retina 2005;25:570-5.  Back to cited text no. 11
    



 
 
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Abstract
Introduction
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