Intracapsular Lens Extraction for the Treatment of Pupillary Block Glaucoma Associated with Anterior Subluxation of the Crystalline Lens
A healthy 34-year-old man presented with ocular pain and decreased vision in his left eye. Two years previously, he had been diagnosed with crystalline lens dislocation in his right eye. Lensectomy and intraocular lens scleral fixation had been performed at that time. Initial best-corrected visual acuity was 20/20 in his right eye and hand motion in his left eye. The intraocular pressure in his left eye was 42 mm Hg when measured with an applanation tonometer. Inspection revealed an edematous cornea and Descemet's membrane folds. The left pupil was irregular and anteriorly displaced, touching the endothelium of the cornea (fig. ). There was no zonule around the anteriorly subluxated crystalline lens. Anterior segment optical coherence tomography revealed the partially subluxated lens, which was incarcerated in the pupil, and touching the endothelium of the cornea (fig. ). The fundus displayed no significant finding.\nA physical examination and laboratory test were performed to evaluate the comorbidity. His height was 182 cm, weight 75 kg and arm-span 175 cm. Blood pressure was 110/70 mm Hg and pulse rate 80 bpm. There was no gross craniofacial abnormality or any skeletal abnormality on his spine and extremities (fig. ). No valvular disease or aortic abnormality was found on electrocardiogram and echocardiogram. Complete blood count, renal function test, liver function test and routine urine analysis were within normal limits.\nMannitol was given intravenously to lower intraocular pressure. Pharmacological pupil dilatation was performed, and the patient lay on his back for repositioning of the lens. With the medical treatments not having any effect, we proceeded with a surgical intervention which consisted of partial pars plana dry vitrectomy, intracapsular lens extraction and intraocular lens scleral fixation. Corneal puncture was made at 3 o'clock and 10 o'clock, and viscoelastic materials (DisCoVisc, Alcon, Fort Worth, Tex., USA) were gently injected between the cornea and iris. Sclerotomy was performed with a 23-gauge microvitreoretinal blade 3 mm away from the limbus at the 11 o’ clock site; the vitreous cutter probe was inserted here, and the trocar was left. Partial pars plana dry vitrectomy was performed (fig. ). Viscoelastic materials were simultaneously injected into the anterior chamber. After getting enough space, a 6-mm corneoscleral incision was made. The whole lens was extracted with a lens spoon, without difficulty (fig. ). Herniated vitreous was removed with a vitreous cutter. After deepening of the anterior chamber, intraocular lens scleral fixation was performed with an ab externo approach.\nOn the first postoperative day, severe stromal edema was found, and intraocular pressure was 18 mm Hg. For resolving the corneal edema, treatment with 5% sodium chloride solution was continued 4 times a day. Two months after the surgery, we observed a well-fixed intraocular lens and intraocular pressure was stable. The postoperative corneal astigmatism was −3.5 dtp and best-corrected visual acuity was 20/25. As a postoperative complication, decreased endothelial cell count was observed and sector iris paralysis was found near the incision site.