Refixation of subluxated capsular tension ring–intraocular lens complex In their report of a patient with complete subluxation of a capsular tension ring–intraocular lens (CTR–IOL) complex, Monterio et al.1 performed 20gauge vitrectomy using perfluorocarbon to retrieve the complex from the retinal surface, removing it through an enlarged limbal incision and inserting an anterior chamber IOL. We recently managed a similar case in which the CTR–IOL complex was also almost completely subluxated inferiorly, although not quite so posteriorly. Cataract surgery had been done elsewhere 4 years previously. Visual acuity was counting fingers. Through the undilated pupil, the edge of a fibrosed capsular bag was seen protruding above the inferior pupil margin (Figure 1). After dilation, part of the CTR with a 3-piece IOL could be seen (Figure 2). On the operating table, the CTR–IOL complex, which was dangling vertically by a few zonules at the 6 o’clock position, could not be seen. However, indenting the sclera inferiorly brought it into view and we were able to retrieve the complex via an anterior segment approach; ie, grasping the anterior capsular rim with a micrograsper forceps, bringing it forward, then passing a 10-0 polypropylene (Prolene) suture behind and in front of each adjacent CTR loop and IOL haptic and suturing it to the sclera. Postoperatively, the corrected distance visual acuity was 20/30 and the CTR–IOL complex was well-centered (Figure 3). The main difference between our case and that of Monterio et al. is the position of the subluxated complex. While ours was hinged posteriorly, suspended by a few zonules, theirs was lying on the retina. The approach we advocate allows refixation of the CTR– IOL complex in the preferred posterior chamber
Figure 2. Overlapping ends of CTR seen with the pupil dilated.
Figure 3. Centered CTR–IOL complex following scleral fixation.
position without large limbal incisions regardless of how the complex is retrieved. Ronald Yeoh, FRCS(Ed), FRCSG, FRCOphth Soon Phaik Chee, FRCS(Ed), FRCSG Singapore REFERENCE 1. Monterio TP, Silva SEE, Domingues M, Fernandes AV, Falca˜oReis F. Complete spontaneous posterior luxation of capsular bag-intraocular lens-capsular tension ring complex. J Cataract Refract Surg 2009; 35:2154–2156
Figure 1. Upper edge of capsular bag visible in the pupil in the upright position.
Q 2010 ASCRS and ESCRS Published by Elsevier Inc.
REPLY: We agree that both cases share clinical features concerning etiology and the complex decision process, but the surgical management should be, and was, quite different. In our case, we had complete posterior luxation of the capsular bag–CTR–IOL complex. The surgical approach had to include vitreoretinal 0886-3350/$dsee front matter doi:10.1016/j.jcrs.2010.03.036