British Journal of Ophthalmology, 1979, 63, 771-778

Management of subluxated and dislocatedlenses with the vitrophageGHOLAM A. PEYMAN, MOTILAL RAICHAND, MORTON F. GOLDBERG,AND DANIEL RITACCAFrom the Department of Ophthalmology, University of Illinois Eye and Ear Infirmary, USA

SUMMARY Thirty-two eyes with subluxated and dislocated lenses were surgically managed bymeans of the vitrophage. The best results were obtained for those cases in which subluxation ordislocation of lenses into the vitreous was not associated with other complications such as glaucoma,perforating injuries, and retinal detachment. No major intraoperative or postoperative problemswere seen in uncomplicated cases during a follow-up period ranging from 5 to 45 months.

Management of subluxated and dislocated lenseshas remained controversial. The indications forsurgical intervention and the procedure of choiceare still debatable. Many indications for the removalof dislocated lenses have been described (Haik,1961; Chandler, 1964; Selleyer and Barraquer,1973). However, these vary among surgeons.Surgical techniques previously used for removingsubluxated or dislocated lenses have included dis-cission, aspiration, lens extraction with forceps orloop, and cryoextraction. Unfortunately these pro-cedures have been associated with a high incidenceof operative and postoperative complications(Jarrett, 1967; Barraquer, 1972; Liesman, 1972),such as vitreous loss, retinal detachment, and glau-coma. For this reason many ophthalmologists haveconsidered surgery for dislocated lenses to be veryrisky and have avoided operating on such eyes.The automated vitrectomy instruments such as

the vitrophage have greatly aided the surgery of theanterior segment. We have previously described theuse of this instrument for cataracts in adults andchildren, for anterior segment reconstruction (Pey-man and Sanders, 1975; Peyman, et al., 1975;Peyman et al., 1977; Peyman et al., 1978a, b) andfor removal of dislocated lenses through the parsplana route (Peyman and Sanders, 1975). In thisreport we describe various techniques we have usedto deal with dislocated lenses of different types.

Materials and methods

The surgical management of ectopia lentis dependson the dislocation site and the consistency of the

Correspondence to Dr G. A. Peyman, Eye and Ear Infirmary,1855 West Taylor Street, Chicago, IL 60612, USA.

lens. A total of 32 such eyes (27 patients) werereferred to the Vitreous Service of the University ofIllinois Eye and Ear Infirmary between 1974 and1978. These cases were divided into 6 categories,because the management and prognosis variedaccording to the clinical aspects of each group.

Group a-Subluxation of soft lens behind thepupil. This group was composed of 10 eyes (6patients). Two patients had Marfan's syndrome;in the rest the subluxation was of unknown aetio-logy. Except for 1 patient age 30 all were youngerthan 17 years (range 5-16). All eyes were uninflamedand normotensive. The indications for surgicalintervention were impaired vision in 8 eyes andannoying diplopia in 2.

Group b-Dislocation of soft lens into the vitreous.In 12 eyes (12 patients) there was total dislocationof the lens into the vitreous. All had a history oftrauma. One patient had diabetes mellitus, andanother had a positive serological test result forsyphilis. Five eyes had clear corneas and normalintraocular pressures. The other 7 patients hadraised intraocular pressures. Of these 7 patients 5had angle recession and 2 had phacolytic glaucoma.The indications for surgery were raised intraocularpressure in 7 eyes and vitreous opacities in 5 eyes.

Group c-Dislocation ofhard lens into the vitreous.Only 1 patient was in this category. An 80-year-oldpatient fell and dislocated a mature cataract in 1eye. The cornea showed 1+ oedema, intraocularpressure was high, and the vitreous had a markedreaction, possibly due to leakage of lens material.

Group d-Lens dislocation associated with per-forating ocular injuries and severe ocular trauma.Five eyes (5 patients) had lens dislocation due toperforating corneoscleral injuries. All had total

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detachment of the retina and vitreous haemorrhage.Because of the extensive nature of the oculartrauma these eyes were considered virtually lostpreoperatively.

Group e-Dislocation of soft lens into the anteriorchamber. Two eyes (2 patients) had a dislocation ofthe lens into the anterior chamber. Both patientshad aniridia, corneal oedema and dystrophy, andraised intraocular presure.

Group f-Dislocation of hard lens into theanterior chamber. One patient with tertiary syphilishad bilateral dislocation of hard lenses into theanterior chamber with comeal oedema and raisedintraocular pressure.

SURGICAL TECHNIQUESGroup a-Technique of pars plicata lensectomy andvitrectomy for soft subluxated lenses. Sutures arepassed through the lid margins for exposure.Then 4-0 silk traction sutures are placed beneaththe bellies of the four rectus muscles. A radialperitomy is made in the inferotemporal or supero-temporal quadrant and extended in a T-shapedmanner along the limbus toward the inferior andlateral recti. After cauterising the episcleral bleedingpoints, a 4-mm long sclerotomy bed 2-5 to 3 mmfrom the limbus is prepared with a No. 15 Bard.Parker blade. When the underlying ciliary body isexposed, it is gently cauterised. A mattress sutureis passed through the lips of the sclerotomy and aloose double-throw knot is applied. Either 4-0 or

Fig. 1 Schematic diagram ofpars plicata approachto remove subluxated lenses. A 52S Beaver knife isinserted through the ciliary body into the lens capsule

Fig. 2 Vitrectomy instrument is inserted through theknife tract and the soft subluxated lens is removed

5-0 polyglactin 910 (Vicryl) or Supramid suturematerial can be used for this purpose.A 52S Beaver blade is passed through the sclero-

tomy and through the pars plicata into the lensequator, and a track in the lens is made by meansof slow slicing motions of the blade. The blade isremoved and a wide angle cutter vitrophage (Figs.1 and 2) is introduced through the sclerotomy intothe lens. The mattress suture at the sclerotomy istightened.The lens material is cut and removed by the

cutting/aspirating tip of the vitrophage. It is essen-tial that the cutting tip is always visible in the pupil-lary axis. The lens material that is lying behind theiris or ciliary body is brought into the operator'sview by indenting the corresponding sclera with afinger tip or cotton-tipped applicator. With thesuction function of the vitrophage lens material isbrought into view and then cut. The cutting actionof the vitrophage is activated only when the cuttingport of the vitrophage is in view. This manoeuvreavoids cutting the iris or ciliary processes acci-dentally. After the lens is removed an anterior vitrec-tomy is done. At this point a self-infusing funduscontact lens is placed on the cornea. A deep vitrec-tomy to the optic disc is done. Any lens particlesthat may have fallen into the vitreous accidentallycan easily be retrieved. After completion of thevitrectomy the vitrophage is removed and thesclerotomy suture is tied. Conjunctiva is suturedwith 6-0 plain catgut. Atropine and Maxitrol(neomycin and dexamethasone) drops are instilled,and a patch and shield are applied to the eye.

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Management of subluxated and dislocated lenses with the vitrophage

(Figs. 5 and 6). The assistant also holds the vitro-phage in place while infusion is running to preventcollapse of the eye. Then the surgeon performs aclear corneal incision. The lens can be either ex-pressed transcorneally or removed by a cryoprobe.

Fig. 3 Schematic diagram of removal of a dislocatedsoft lens with the vitrophage

On a routine basis an iridectomy (either peri-pheral or sector) is not necessary. However, whenthe pupil does not dilate well, a small sector iridec- Fig. 4 Two-needle technique of removing lenses of

be performed with the cutting action o 1 to 2+ nuclear sclerosis. The needle stabilises the lenstomycanvberper while it is cut with the vitrectomy instrument. A. Afterthe vitrophage. vitrectomy a 25-gauge needle engages the dislocated

Group b-Management of dislocated soft lens lens. B. Lens in midvitreous supported by the needleinto the vitreouts. When a soft lens is dislocated into and vitrophage. C. Lensectomy performedthe vitreous or is lying on the surface of the retina,the initial steps of the technique are the same asfor group a.

After the vitrophage is inserted into the vitreous :cavity an anterior vitrectomy is performed, and thevitreous surrounding the lens is removed. By apply- Bing suction it is possible to lift the lens and bring itto the pupillary area, where it can be cut awayunder direct visualisation (Fig. 3).At times, in addition to the vitrophage tip, a

25-gauge needle (1 j inches long) (3 8 cm) is inserted ,through the pars plicata at the opposite side of theinitial sclerotomy incision (Peyman and Sanders, 0

1975) (Fig. 4). The lens can be lifted with the tip ofthe needle, brought into the pupillary area, andremoved by the vitrophage.

Group c-Management of hard dislocated lens in ------vitreous. When the nucleus of the subluxated ordislocated lens is very hard, as in older patients, itis inadvisable to attempt removal of the lens througha posterior approach. These lenses are best removedthrough a clear corneal incision. The techniqueinvolves lifting the dislocated lens with a needle and Fig. 5 Removal of dislocated hard lens. A. Afterbringing it into the anterior chamber. The assistant vitrectomy the lens is lifted with the tip of a 25-gaugeholds the lens pierced by the needle in this position needle. B. Lens is brought into the anterior chamber

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The vitrophage is kept in the eye while this occurs.By keeping the eye infused intraocular pressure canbe easily re-established. After closure of the cornealincision (with 9-0 nylon), a vitrectomy is performed(Fig. 7). If the lens is ruptured, lens fragments orcapsular remnants can be removed with the vitro-phage.

Group d-Lens dislocation associated with per-forating ocular injuries. The initial step in these casesis to repair the scleral and corneal perforations. Asclerotomy is made in a quadrant that is usually

I \\ Il} h.1

\ \'\Fig. 6 The vitrophage and the needle remain inside theeye while the dislocated hard lens is removed through a

clear corneal incision with a cryoprobe

Fig. 7 After closure of the corneal wound and removalof the 25-gauge needle the vitrectomy is completed

opposite the quadrant in which the perforation hasoccurred. Vitrectomy is performed to clear thevitreous haemorrhage and to remove the dislocatedlens. Once the media are clear, appropriate retinalsurgery is performed.

Group e-Dislocation of soft lens into the anteriorchamber. A standard sclerotomy is made in theinferotemporal or superotemporal quadrant, andthe vitrophage is inserted as described for group a.The pupil should be well dilated so that the vitro-phage tip has access to the anteriorly dislocatedlens. With the wide angle cutter vitrophage the lensis cut and removed. Then a vitrectomy is performedfrom the iris plane back to the optic disc.

Group f-Dislocation of a hard lens into theanterior chamber. When the crystalline lens is hardand dislocated into the anterior chamber, it isbetter to remove it through a corneal incision. Astandard sclerotomy is performed before the removalof the lens. This is a helpful step, because the eyemay collapse during extraction of the lens due tovitreous loss. To perform sclerotomy on a collapsedeye is difficult, and insertion of a vitrectomy instru-ment through such a sclerotomy can cause detach-ment of the ciliary body and choroid. After insertionof a 52S Beaver knife through the sclerotomy intothe vitreous the sclerotomy is closed temporarilyand a clear corneal incision or another type oflimbal incision is made. The lens is then removed.After suturing the corneal incision the sclerotomy isopened and a vitrectomy from the iris to the opticnerve is done.

Results

Group a-Subluxation of soft lens behind the pupil.Excellent surgical results were obtained in all 10eyes (Table la). There were minimal operative com-plications, namely, limited bleeding in 1 case. Thepostoperative period, except for transient cornealoedema in 2 eyes, was uneventful. Visual improvementwas seen in all cases. However, the visual improve-ment was minimal in 2 eyes due to amblyopia.

Group b-Dislocation of soft lens into the vitreous(Table lb). Operative results were excellent in the5 eyes that did not have preoperative glaucoma.

In the 2 eyes with phacolytic glaucoma the intra-ocular pressure returned to normal between 2 and3 weeks postoperatively. During that time the intra-ocular pressure was controlled by medical therapy.

In 5 eyes with angle recession glaucoma theintraocular pressure did not return to normal aftersurgery. In 2 of these eyes additional surgery wasrequired to control glaucoma; in the other 3 eyesprolonged medical therapy has been necessary.Visual acuity deteriorated in 2 eyes of this group.

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Management of subluxated and dislocated lenses with the vitrophage

Table 1 Details of cases

Case Age Preoperative Operative Postoperative Preoperative Postoperative Follow-upnumber (yr) diagnosis complication complication visual acuity visual acuity Comment (mo)

(a) Subluxation of soft lens

1 8 -

2

3

4

5

None None

8 -

12

12 -

16 Marfan's syndrome

6 7 -

7

8

9

10

20/300

,, ,,93'/200

,,9 ,,91 4'/200

,, ,,1) 20/400

,,9 Transient corneal 20/300oedema

,,0 None 20/200

,,

Minimalbleeding

None

(b) Dislocation of soft lens into the vitreous

1 42 Uncontrolled Transientglaucoma, traumatic cornealdislocated lens, oedemavitreous touch,angle recession

2 54 Traumatic dislocation,corneal oedema,raised intraocularpressure, anglerecession

3 60 Traumatic dislocation, Mildangle recession, bleedingraised intraocularpressure

4 76 Angle recession, Nonetraumatic dislocation,raised intraocularpressure, choroidalrupture

,,9 Hand motions

Transient corneal 20/200oedema

None 20/200

,, S'/200

Persistent raised Hand motionsintraocularpressure

Phthisis

20/60

20/40

20/50

20/60

20/100

20/80

Alternatingesotropia

7

,,91 7

II 5

II, 5

Amblyopia 8

Alternatingesotropia

20/70

20/50

8

9, 7

9,, 6

20/60

20/200

,, 6

Amblyopia 6

Light perception Trabeculectomy 45done

Hand motions No light Trabeculectomy 5

perception done

Raised intraocular Counting fingers 20/70pressure

Intraocularpressure con-trolled withacetazolamide

Transient corneal Hand motions 20/60oedema

5 35 Phacolytic glaucoma, ,,traumatic dislocation

6 78 Traumatic dislocation, Noneangle recession,uveitis, raisedintraocular pressure

7 54 Traumatic dislocation, ,,phacolytic glaucoma

8 11 Traumatic dislocation ,,

9

10

11

12

32

14

38

45

Trauma, uveitis

Trauma

Trauma

Trauma

Counting fingers 20/100

None Counting fingers 20/S0

20/100

Intraocularpressure con-trolled withacetazolamide

20/30

Counting fingers 20/25

Hand motions 20/80

Hand motions 20/25

Hand motions 20/70

Hand motions Counting fingers Maculardegeneration

775

7 -

5 -

5 -

30 Marfan's syndrome

11

29

8

5

5

5

8

16

Continued

1 9 9 9

9 0 9 9

9 9 9 9

99 99

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Table 1 continued

Case Age Preoperative Operative Postoperative Preoperative Postoperative Follow-upnumber (yr) diagnosis complication complication visual acuity visual acuity Comment (mo)

(c) Dislocated hard lens into the vitreous

None None Hand motions Counting fingers

1 32 Corneoscleral lacera-tion, retinaldetachment

2 13 Corneoscleral lacera-tion, retinaldetachment

None None Light perception 20/25

,,ll Phthisis No lightperception

3 10 Scleral laceration,dislocated lens,retinal detachment

4 27 Scleral laceration,dislocated lens,retinal detachment

5 59 Corneoscleral lacera-tion, retinaldetachment

(e) Dislocation of soft lens into the anterior chamber

1 61 Aniridia, cornealdystrophy, raisedintraocular pressure,cupped disc

2 28 ,,

None None Hand motions Light perception -

Counting fingers 2'1/200

(f) Dislocation of hard lens into the anterior chamber

1 48 Comeal oedema,tertiary syphilis,raised intraocularpressure

2 48 ,,

None None Counting fingers 5'/200

Light perception 10'/200

Group c-Dislocated hard crystalline lens into thevitreous (Table Ic). After surgery the intraocularpressure gradually returned to normal during a

period of 3 weeks. There were no complicationsduring surgery and the postoperative period. Finalvisual acuity was only counting fingers owing tosenile macular degeneration.

Group d-Lens dislocation associated with per-forating ocular injuries (Table Id). Because of theextensive nature of injuries only 1 eye of the 5 couldbe salvaged. Visual acuity was reduced to no lightperception in 4 eyes. Three of these eyes becamephthisical.

Group e-Dislocation of soft lens into the anteriorchamber (Table le). Both lenses were removedsuccessfully. Because of the decompensated state ofthe cornea, raised intraocular pressure, and opticatrophy, visual improvement was minimal in one

case and vision worsened in the other case. Therewere no complications during surgery.

Group f-Dislocation of hard lens into the anteriorchamber (Table If). Visual acuity improved, butimprovement was limited because of coexistentcomeal pathology and glaucoma. There were no

surgical complications.

Discussion

Management of ectopia lentis presents a perplexingproblem for many ophthalmologists. There is a

continuing debate between proponents of activesurgical intervention and advocates of conservativetreatment. The latter group cite cases in whichdislocated lenses have been tolerated well withmaintenance of good vision for many years.

Although this is true in many instances, other cases

1 80 -

(d) Lens dislocation with perforating injuries

Senile maculardegeneration

6

9

5

5

8

9

10

10

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require lens removal for optical purposes or forrelief of phacolytic glaucoma.With the availability of automated vitrectomy

instruments the much dreaded complication ofvitreous loss and its subsequent sequelae can beavoided. Through a small incision a vitrectomy can

be done at the time the lens is removed.In the past the major concern in management of

subluxated and dislocated lenses has been theoccurrence of operative and postoperative compli-cations, mainly those due to vitreous manipulation.In a large series reported by Jarrett (1967), forexample, there was an incidence of vitreous loss of41%, and one-third of these eyes became blind.Retinal detachments occurred in about 7% of thecases.

Jensen and Cross (1972) reported a 30% inci-dence of vitreous loss during surgery in patientswith Marfan's syndrome. Surgical techniques in-cluded discission, aspiration, and intra- or extra-capsular extraction. In one-fourth of these eyesretinal detachment subsequently developed. Similarcomplications were seen in patients with homo-cystinuria, and vitreous loss occurred in 30% ofthese cases. The surgical procedures includedaspiration, discission, and intracapsular extraction.Retinal detachment was noted in 11%. Othercomplications included corneal oedema and irisprolapse. In a large series reported by Selleyer andBarraquer (1973) vitreous loss occurred in 15 of 222eyes. The surgical techniques used were aspirationand intra- or extracapsular extraction.The technique of lens aspiration (Maumenee and

Ryan, 1969) has been associated with a lowerincidence of complications. However, in some casesa secondary discission of pupillary membranes isrequired. Realising the importance of the vitreous,other surgeons have advocated open-sky vitrectomybefore and after lens removal. Croll and Croll(1975), employing open-sky vitrectomy, reportedexcellent results with cryoextraction of 22 dislocatedlenses. Barraquer (1972) also used an open-skyvitrectomy technique to complement cryoextraction.To avoid confusion we use the term 'subluxation'

to imply partial dislocation and 'dislocation' tomean total displacement. In our series excellentsurgical results were obtained in all 10 cases ofsubluxated lenses. There were no significant opera-tive or postoperative complications. In most casesthe visual improvement was dramatic. In the eyeswhere final visual acuity was impaired due to thepresence of amblyopia annoying symptoms ofmonocular diplopia were eliminated.

In our series trauma caused 12 cases of totaldislocation of soft lenses into the vitreous. Goodsurgical results were obtained in 10 eyes. Except for

transient corneal oedema and minimal bleedingthere were no significant operative complications.Eyes with phacolytic glaucoma returned to normalintraocular pressure after lensectomy and vitrec-tomy. However, eyes with traumatic angle recessionglaucoma did not do so well. Rosenbaum andPodos (1967) reported on a series of 27 cases oftraumatic dislocation of lenses. Of these, 15 (56%)had raised intraocular pressure preoperatively. Oneof these was due to phacolytic glaucoma, andothers were due to angle recession and peripheralanterior synechiae. Intracapsular lens extractionwas attempted on 13 in this group. There wasvitreous loss in 11 cases (84%). Seven eyes (54%)had postoperative vision of counting fingers or less.In Jarrett's series (Jarrett, 1967) there were 31 casesof traumatically dislocated lenses associated withglaucoma. Removal of lenses in 24 eyes led tocontrol of glaucoma in only 6 eyes. The other 7cases were managed conservatively. Rodman (1963)studied histopathologically a series of eyes that hadbeen enucleated because of glaucoma and a dislo-cated lens. Postcontusion deformity of the chamberangle was seen in 95% of those eyes that had glau-coma and an open angle. The efficiency of lensremoval in the management of angle recessiondepends therefore upon the state of the angle.

Dislocation into the vitreous of a lens with ahard nucleus occurred in only 1 case in our series.This was successfully removed through a clearcorneal incision, while the vitrophage tip wasmaintained in the vitreous through a sclerotomy.Our visual results were poor when lens dislocation

was associated with perforating injuries, althoughvitrectomy and lensectomy helped to clear themedia and reform the globes. Because of damage tothe ciliary body and the retina (often with inoperableretinal detachment), the majority of the eyes couldnot be saved.

Anteriorly dislocated lenses can be managedthrough the pars plicata or pars plana if the lens issoft. If the lens is hard, it should be removed througha clear corneal incision. In our series the post-operative results depended on the preoperativestatus of the cornea and presence of glaucoma orretinal changes. There were no complications as aresult of surgery.We now have postoperative follow-up of sub-

luxated and dislocated lenses for a period rangingfrom 5 to 45 months. The early postoperativecomplications were directly related to pre-existingconditions of the eyes, such as corneoscleral lacera-tion, retinal detachment, or uncontrollable glau-coma. We have not observed significant adversechanges late in the follow-up period. Althoughlonger follow-up is desirable, the present results can

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be considered very encouraging. We believe that a1-stage pars plicata or pars plana lensectomy andvitrectomy is an ideal procedure for the managementof those subluxated or dislocated lenses that requireremoval.

This work was supported in part by core grant lP30EYO1792and training grant EY703802 from the National Institutesof Health, Bethesda, Maryland, and the Lions of IllinoisFoundation.

References

Barraquer, J. (1972). Surgery of the dislocated lens. Transac-tions of the American Academy of Ophthalmology andOtolaryngology, 1976, 44-59.

Chandler, P. A. (1964). Choice of treatment in dislocationof lens. Archives of Ophthalmology, 7, 765.

Croll, M., and Croll, L. J. (1975). Cryoextraction of dislo-cated lens. Annals of Ophthalmology, 12, 45-52.

Haik, G. M. (1961). Subluxation and luxation of the lens.Southern Medical Journal, 54, 642.

Jarrett, W. M. (1967). Dislocation of the lens. Archives ofOphthalmology, 78, 289.

Jensen, A. D., and Cross, H. E. (1972). Surgical treatment ofdislocated lenses in the Marfan syndrome and homo-cystinuria. Transactions of the American Academy ofOphthalmology and Otolaryngology, 76, 1491.

Liesman, N. (1972). Congenital cataract and ectopic lentis:an analysis of 152 patients treated in 1943-1967. ActaOphthalmologica, Suppl. 112, 13-79.

Maumenee, A. E., and Ryan, S. (1969). Aspiration tech-nique in the management of the dislocated lens. AmericanJournal of Ophthalmology, 68, 808-811.

Peyman, G. A., Huamonte, F. J., and Goldberg, M. F.(1975). Management of cataracts in patients undergoingvitrectomy. American Journal of Ophthalmology, 8, 30-36.

Peyman, G. A., Huamonte, F. U., Goldberg, M. F., Sanders,D. R., Nagpal, K. C., and Raichand, M. (1978a). Fourhundred consecutive .pars plana vitrectomies with thevitrophage. Archives of Ophthalmology, 96, 45-50.

Peyman, G. A., Raichand, M., and Goldberg, M. F. (1978b).Surgery of congenital and juvenile cataracts: a parsplicata approach with the vitrophage. British Journal ofOphthalmology, 62, 780-783.

Peyman, G. A., and Sanders, D. R. (1975). Advances inUveal Surgery, Vitreous Surgery and the Treatment ofEndophthalmitis, p. 113. Appleton-Century-Crofts: NewYork.

Peyman, G. A., Sanders, D. R., Rose, M,, and Korey, M.(1977). Vitrophage in the management of congenitalcataracts. Albrecht von Graefes Archiv fur klinische undexperimentelle Ophthalmologie, 202, 305.

Rodman, H. I. (1963). Chronic open angle glaucoma asso-ciated with traumatic dislocation of the lens: a newpathogenetic concept. Archives of Ophthalmology, 69,445-454.

Rosenbaum, L. J., and Podos, S. M. (1967). Traumaticectopia lentis: some relationships to syphilis and glaucoma.American Journal of Ophthalmology, 64, 1095-1098.

Selleyer, L. F., and Barraquer, J. (1973). Survey of etopiclens. Annals of Ophthalmology, 5, 1127-1135.

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