中川 卓

BACKGROUND: This study aimed to report and recall a simple method to remove the lens capsule ab externo when performing intrascleral fixation of an intracapsular intraocular lens (IOL) dislocation with reuse of the IOL. CASE PRESENTATION: A 43-year-old Japanese male patient underwent pars plana vitrectomy, phacoemulsification, and IOL fixation for rhegmatogenous retinal detachment in the right eye 10 years prior. A 3-piece IOL was intraocularly fixed during the initial procedure. In December 2023, the patient presented with intracapsular IOL dislocation in his right eye, causing the IOL to descend into the vitreous cavity enveloped by its entire capsule. During surgery, an intravitreal dislocated IOL was placed over the iris with the entire capsule. The haptics on 1 side of the IOL were placed outside the eye through the corneoscleral wound. Subsequently, the lens capsule and Soemmerring's ring surrounding the haptics were removed. After the haptics were placed back over the iris, the same extraction procedure was performed for the remaining haptics. The IOL was intrasclerally fixed using a flange technique through the intrascleral tunnel at the 4 and 10 o'clock positions. One week postsurgery, the best-corrected visual acuity of the right eye was 20/16, and the corneal endothelial cell density was recorded as 2923 cells/mm2 (preoperative: 1650 cells/mm2). DISCUSSION AND CONCLUSIONS: In cases of 3-piece IOL dislocation, employing the ab externo technique for lens capsule extraction has been proven to be a straightforward and efficient method. This approach facilitates the removal of the lens capsule around the IOL. If subsequent damage to the IOL is identified, it allows for easy conversion to replacement.

BACKGROUND: Posterior synechiae of the iris rarely cause secondary angle-closure glaucoma after pars plana vitrectomy, mainly reported in cases with high postoperative inflammation. The face-down position with gas tamponade can cause acute angle-closure glaucoma in phakic eyes owing to relative pupillary block. This report presents a rare case of pseudophakic eye with secondary acute angle-closure glaucoma after 25-gauge pars plana vitrectomy and long-term vitreous gas tamponade for a macular hole. CASE PRESENTATION: A 61-year-old Japanese female patient presented with a chief complaint of right-sided visual impairment that had persisted for several months. Slit-lamp examination revealed deep anterior chamber and moderate nuclear sclerotic cataracts in both eyes. The axial length of the eye was 23.53 mm right eye and 24.05 mm left eye, and the fundus examination revealed a full-thickness macular hole (stage 3) in the right eye. The patient underwent simultaneous cataract surgery and pars plana vitrectomy with 7-mm diameter 3-piece monofocal intraocular lens implantation, internal limiting membrane peeling, and air tamponade. There were no complications during surgery. Due to non-closure of the macular hole, a second pars plana vitrectomy with internal limiting membrane inverted flap and SF6 gas tamponade was performed 13 days later. The patient maintained face-down position after both surgeries, and 6 days after the second surgery, intraocular pressure was elevated to 53 mmHg, and acute angle-closure glaucoma with iris bombe was diagnosed in the right eye. A laser peripheral iridotomy was performed, resulting in a deepened anterior chamber, normalized intraocular pressure, and a closed macular hole. CONCLUSIONS: This case presents a rare occurrence of secondary acute angle-closure glaucoma in a pseudophakic eye after 25-gauge minimally invasive pars plana vitrectomy and SF6 gas tamponade for macular hole. The cause was presumed to be posterior synechiae of the iris or relative pupillary block due to forward pushing of the intracapsular intraocular lens by vitreous gas. In cases where surgery is repeated without achieving macular hole closure, necessitating long-term face-down position, where vitreous gas is retained for an extended period, or when a large-diameter intraocular lens is implanted, secondary acute angle-closure glaucoma should be considered. This applies even when the 25-gauge pars plana vitrectomy is performed not for a highly invasive proliferative diabetic retinopathy but for macular hole repair, especially if the patient has a pseudophakic eye.

We describe a case of serous retinal detachment (SRD) with ciliochoroidal detachment (CCD) that persisted for 2 years and 7 months after minimally invasive glaucoma surgery (MIGS). A 71-year-old woman with primary open-angle glaucoma and cataracts had a central corneal thickness of 489 μm/492 μm and an ocular axis length of 24.05 mm/24.30 mm. She underwent phacoemulsification and intraocular lens implantation in the right eye (OD), along with goniosynechialysis and microhook ab interno trabeculotomy. Postoperative intraocular pressure was 4-6 mmHg in the OD. Five months later, SRD was observed temporally and inferiorly to the macula, with increased choroidal thickness. Best-corrected visual acuity at 5 months was (1.2)/(1.2) (right eye [OD]/left eye [OS]), and intraocular pressure was 6 mmHg/13 mmHg. CCD in the OD was accompanied by choroidal vessel dilation and choroidal vascular hyperpermeability. Two years and 7 months post-surgery, intraocular pressure spiked to 50-54 mmHg but settled at 12 mmHg 1 week later. CCD resolved, and choroidal folds and SRD disappeared, with decreased choroid thickness. Two years and 10 months postoperatively, there was no SRD recurrence at 10 mmHg on two antiglaucoma eye drops, and best-corrected visual acuity remained stable at (1.0)/(1.0). This case suggests that SRD may result from increased choroidal vessel permeability and retinal pigment epithelium dysfunction secondary to prolonged CCD/low IOP after MIGS. The prolonged disease course may be attributed to the balance between aqueous humor excretion and absorption, influenced by the limited size of the cyclodialysis cleft caused by MIGS.