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Intraocular lens dislocation and tube shunt in the posterior chamber: a case report
© Moreno-Montañés et al. 2015
Received: 13 January 2015
Accepted: 26 May 2015
Published: 21 June 2015
To describe management of a case of intraocular lens (IOL) and capsular bag (CB) dislocation in an eye with an Ahmed glaucoma valve in the posterior chamber.
A 75-year-old pseudophakic man with open-angle glaucoma and diabetic retinopathy developed neovascular glaucoma. After two intravitreous injections of bevacizumab and panretinal photocoagulation were administered, the new vessels regressed. However, goniosynechiae were observed over 360° of the angle. An Ahmed glaucoma valve model FP7 was implanted with the tube in the posterior chamber with adequate intraocular pressure control. Nineteen years after cataract surgery, when the IOL-CB complex became dislocated, they were sutured transclerally to the sulcus without Ahmed glaucoma valve modification. After a coughing episode, the vitreous pushed the IOL-CB complex forward and the tube was behind the IOL-CB complex. A 25-gauge posterior vitrectomy was performed, and the tube was returned to in front of the optic of the IOL using a forceps tip through a sclerotomy.
This case suggested that management of IOL-CB dislocation can modify glaucoma shunt function. A complete pars plana vitrectomy may be required in order to reposition the dislocated IOL-CB complex in the presence of a posterior chamber drainage tube implant.
KeywordsNeovascular glaucoma Ahmed glaucoma valve Intraocular lens dislocation Posterior vitrectomy
Late intraocular lens (IOL)-capsular bag (CB) dislocation is a rare complication after uneventful cataract surgery that results from progressive zonular dehiscence in cases with pseudoexfoliation, retinitis pigmentosa, high myopia, vitreoretinal surgery, connective tissue disorders, and zonular trauma [1–5]. Little is known about the effect of IOL-CB dislocation on glaucoma in eyes that underwent trabeculectomy or have glaucoma valve shunts. We present a case of IOL-CB subluxation in an eye in which an Ahmed Glaucoma Valve (New World Medical, Inc., Rancho Cucamonga, CA) was implanted in an elderly patient with angle-closure glaucoma secondary to neovascular glaucoma. The tube was in the posterior chamber, and repositioning of the IOL altered glaucoma management. To our knowledge, no previous cases of IOL-CB complex subluxation in an eye with a glaucoma drainage valve have been reported.
Intraocular injections of bevacizumab result in resolution of new vessels and panretinal photocoagulation causes ablation of the hypoxia in eyes with neovascular glaucoma. In cases with angle-closure glaucoma exceeding 330°, implantation of a drainage valve is recommended . In the current case, 2 years after Ahmed tube implantation, the IOL-CB complex became dislocated, after which the IOL haptics were secured with transscleral Prolene sutures at the 3 and 9 o’clock positions using our previously described surgical technique . Nevertheless, the superior CB was folded over the optic IOL (Fig. 2). No changes in shunt function and vitreous incarceration were seen in the tube. However, after an episode of coughing, the tube was placed behind the optic IOL. We hypothesized that during the Valsalva maneuver, the vitreous pushed the IOL forward and the optic IOL moved forward because only two stitches sutured the IOL haptics. This case suggested that management of IOL-CB complex dislocation can modify glaucoma shunt function.
Several surgical therapeutic options are available in cases of IOL-CB complex subluxation, including IOL repositioning or replacement [1, 2, 7–10]. The surgical approach depends on surgeon preferences and the degree of dislocation. The preferred approach for most surgeons is repositioning of the IOL-CB complex if it is not completely luxated into the vitreous, because surgical trauma to the corneal endothelium is reduced and the technique is performed easily [2, 7, 8]. A posterior pars plana vitrectomy is recommended when necessary, and in some cases it can be performed to remove vitreous strands from the haptics and capsular remnants, thus reducing the risk of peripheral retinal breaks . In the current case, the IOL-CB complex was dislocated inferiorly without vitreous prolapse into the anterior chamber or vitreous strands, and the IOL-CB complex was repositioned without a posterior vitrectomy. However, the vitreous pushed the IOL forward and the tube was behind the IOL. The vitreous was removed completely during a 25-gauge sutureless posterior vitrectomy. In addition, the tube was repositioned in front of the optic using the tip of a forceps through one of the sutureless sclerotomies.
We described a new complication after IOL-CB complex dislocation and sulcus transscleral suture in an eye with an Ahmed glaucoma implant. This case suggested that a posterior vitrectomy should be recommended as a one-stage surgery to suture the haptics transsclerally and the sulcus in cases with a tube in the posterior chamber. This combined procedure is especially necessary if the vitreous cavity is communicating with the anterior and posterior chambers, although the vitreous did not prolapse into the anterior chamber in the current case.
A relative of the patient provided signed consent for publication of this case, which we can provide if requested.
The consent was obtained from the patients relative because the patient was died.
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