Modified Capsular Tension Ring Scleral Fixation and Toric Intraocular Lens Implantation in a Patient with Homocystinuria

Dae Hyun Park; Jin Kwon Chung

doi:10.7469/JKOS.2015.56.04.614

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Park and Chung: Modified Capsular Tension Ring Scleral Fixation and Toric Intraocular Lens Implantation in a Patient with Homocystinuria

Original Article

J Korean Ophthalmol Soc 2015;56(4):614-619.

Published online: 7 September 2015

DOI: https://doi.org/10.7469/JKOS.2015.56.04.614

Modified Capsular Tension Ring Scleral Fixation and Toric Intraocular Lens Implantation in a Patient with Homocystinuria

Dae Hyun Park, MD, Jin Kwon Chung, MD

Department of Ophthalmology, Soonchunhyang University College of Medicine, Cheonan, Korea

￭ Address reprint requests to Jin Kwon Chung, MD Department of Ophthalmology, Soonchunhyang University Hospital, #59 Daesagwan-ro, Yongsan-gu, Seoul 140-743, Korea Tel: 82-2-709-9354, Fax: 82-2-710-3196 E-mail: schcornea@schmc.ac.kr

Received 21 November 201413 January 2015 Accepted 24 March 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

초록

Purpose:

To report a case of modified capsular tension ring scleral fixation and in-the-bag toric intraocular lens (IOL) implantation in a pediatric patient with severe crystalline lens subluxation due to homocystinuria.

Case summary:

A 9-year-old male diagnosed with homocystinuria and crystalline lens subluxation presented with progressive decrease of visual acuity. Uncorrected distant visual acuity (UDVA) and corrected distant visual acuity were 0.03 and 0.6 in the right eye and 0.01 and 0.5 in the left eye, respectively. Slit-lamp examination showed severe crystalline lens subluxation toward the inferiomedial side in both eyes. Corneal astigmatism in the right eye and left eye was 2.75 diopters (D) and 3.00 D, respectively based on keratometry. A combination of subluxated crystalline lens aspiration, scleral-fixated modified capsular tension ring insertion and in-the-bag toric IOL implantation were performed in both eyes. After continuous curvilinear capsulorhexis, nucleus and cortex of the crystalline lens were removed by irrigation and aspiration. A modified capsular tension ring with 2 fixation hooks (Model 2-L) was inserted into the capsular bag and fixed at the scleral wall. Next, toric IOL was inserted into the capsular bag. UDVA was 0.8 in the right eye and 0.9 in the left eye and 3 months postoperatively, the IOL rotation was less than 3 degrees from intended axis in both eyes.

Conclusions:

In a patient with severe congenital crystalline lens subluxation and moderate to severe corneal astigmatism, scleral fixation of modified capsular tension ring and in-the-bag toric IOL implantation is a possible surgical option.

Keywords: Crystalline lens subluxation, Homocystinuria, Modified capsular tension ring, Toric intraocular lens

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Figure 1.

Slit-lamp photographs showing bilateral inferomedial crystalline lens subluxation through the dilated pupil. (A) Inferomedial crystalline lens subluxation in the right eye. (B) Inferomedial crystalline lens subluxation in the left eye. OD = oculus dexter; OS = oculus sinister.

Figure 2.

Intraoperative photographs. (A) Making anterior capsule tear using two 26-gauge needles. (B) Supporting anterior capsule using 3 microhook iris retractors. (C) Fixation of modified capsular tension ring (MCTR) to the sclera. Note that two hooks are not perpendicular. The meridian of second hook is determined by the diameters of MCTR and sulcus, individually. (D) A complex of toric intraocular lens and scleral fixated MCTR is well centered along the intended axis.

Figure 3.

Postoperative photohgraphs. (A, B) External photographs shows clear cornea, conjunctiva and round pupil 3 months after operation. (C) Three degrees counterclockwise axis rotation is found in a postoperative 3 months slit-lamp photograph in the right eye. (D) Two degrees clockwise axis rotation is found in a postoperative 3 months slit-lamp photograph in the left eye. OD = oculus dexter; OS = oculus sinister.

Table 1.

Postoperative clinical results

	POD # 1 day					POD # 1 week
	UDVA	CDVA	MR	SE	IOP	UDVA	CDVA	MR	SE	IOP
OD	0.5	-	-	-	19	0.6	0.9	+1.00, -1.50 × 60º	+0.25	15
OS	0.2	-	-	-	15	0.6	0.8	+0.50, -1.50 ×20º	- 0.25	17

	POD # 1 month					POD # 3 months
	UDVA	CDVA	MR	SE	IOP	UDVA	CDVA	MR	SE	IOP
OD	0.6	0.8	+1.25, -1.75 × 50º	+0.25	15	0.8	0.9	+0.50, -1.25 × 60º	- 0.25	14
OS	0.6	0.8	+0.75, -1.75 × 20º	-0.25	16	0.9	0.9	+0.50, -1.25 × 10º	- 0.25	13

POD = postoperative day; UDVA = uncorrected distant visual acuity; CDVA = corrected distant visual acuity; MR = manifest refraction; SE = spherical equivalent; IOP = intraocular pressure.

Table 2.

The distribution of manifest refractive errors and Fourier transformed J₀ and J₄₅ values before and after surgery (spectacle plane)

	Before surgery				After surgery (POD # 3 months)
	M	J₀	J₄₅	B	M	J₀	J₄₅	B
OD	-15.25	2.11	1.77	15.50	-0.13	-0.31	0.54	0.64
OS	-17.00	2.50	0	17.18	-0.13	0.59	0.21	0.64

POD = postoperative day; M = S + C/2; J₀ = (-C/2)cos(2α); J₄₅ = (-C/2)sin(2α); B = $\sqrt{M^{2} + J_{0}^{2} + J_{45}^{2}}$ (S = spherical diopter; C = cylindrical diopter; α = cylindrical axis; B = blurring strength).

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