Treatment of severe crystalline lens subluxation
We would like to congratulate Hoffman et al.1 for the thought-provoking and interesting case reports and make the following comments. The course of events in the left eye of Case 1 highlights the importance of not putting a posterior chamber intraocular lens (PC IOL) in the ciliary sulcus in the absence of adequate zonule support. It is almost impossible to stabilize and center the PC IOL over the anterior capsule without fixation in cases with zonular weakness or loss, especially in the inferior quadrants as in this case.
In Case 2, the patient achieved an uncorrected distance visual acuity of 20/30 one day after anterior chamber IOL implantation followed by neodymium:YAG (Nd:YAG) iridotomy. This indicates that the patient was using the aphakic portion of the pupil. What was the indication for Nd:YAG laser zonulysis if the patient was already functionally aphakic? It might facilitate posterior dislocation. This is likely to go unnoticed by the patient, as in this case he had no symptoms related to the lens edge. Posterior dislocation may lead to potentially sight-threatening complications such as glaucoma, localized retinal detachment, chronic uveitis, or cystoid macular edema, in which presentation may initially be asymptomatic. Hoping that the lens will not dislocate after zonulysis and that pars plana vitrectomy may be necessary is similar to the proverbial ostrich burying its head in the sand. The follow-up in this case is very short, and it would be interesting to know the long-term outcome to see whether this patient needed subsequent vitreoretinal intervention.
© 2010 by Lippincott Williams & Wilkins, Inc.
1. Hoffman RS, Fine IH, Packer M. Primary anterior chamber intraocular lens for the treatment of severe crystalline lens subluxation. J Cataract Refract Surg. 2009;35:1821-1825.