A Challenging Cataract Surgery: Preventing The Escape Of A Subluxated Cataractous Lens Into Vitreous Cavity And Using The Modified Four-Flanged Intrascleral Iol Fixation Technique

-To determine the importance of stabilizing the capsular bag intraoperatively in order to confidently remove the crystalline by phacoemulsification as a safer method to proceed with scleral fixation afterwards.

-To emphasize the efficacy of avoiding complications of dropped lens fragments into the vitreous cavity and avoid damaging the retina from the attempts to remove those fragments.

Albanian Eyes Center, Tirana, Albania

This report (video included) describes a challenging case of a patient with subluxated cataractous lens that underwent the surgery of scleral fixation.

A 70-year-old woman was admitted into our clinic due to gradual vision loss, referred for a routine cataract surgery. Visual acuity Hand Motion. IOP 26 mmHg. Biomicroscope examination: Subluxated nuclear cataract, major zonular weakness. Fundus examination normal. No history of accompanying diseases.  Surgery was proposed and planned on the next day.

Surgery was performed under sub Tenon block. 25G Infusion cannula was placed. Since zonular instability was evident in more than 270 degrees, the capsular bag was almost hanging downwards due to the supine position. We used an intraocular micro-forceps to levitate the inferior surface and hold it anteriorly in order to proceed with the capsulorhexis. Straight after this step, five 0.9 mm corneal incisions around the cornea were used to stabilize the capsular bag. Fragmentation, phacoemulsification followed. A single piece hydrophilic IOL (Akreos AO60) was implanted into the bag. Appropriate measurements were made and using a 30 gauge needle and 6-0 prolene suture, IOL was intrascleral fixated by modified four flanged technique. After the fixation, core vitrectomy followed to cut vitreous strands. Ten days following surgery, after corneal sutures removal, BCVA was 0.6. No conjuctival injection, transparent cornea, very few Descemet folds, IOL well centered, light vitreous haze.

Stabilizing the capsular bag was a risky, but crucial step to avoid major intra and postoperative complications, as retained posterior nucleus fragments would require more surgical maneuvers for their removal and risk damage the retina.  It is an advantage particularly valuable for surgeons who may not be specialized under VitreoRetinal surgery. Moreover using a smaller needle to penetrate the sclera minimizes the risk for wound leakage and postoperative hypotony ensuring a more secure and stable surgical outcome.

In conclusion this method may be seen as an effective option for managing dislocated cataractous lens in eyes lacking sufficient capsular support to achieve favorable long term visual outcomes with low complication rate.