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COMMENTARY
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 675-676

Commentary: Cataract surgery in lenticonus


Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Savleen Kaur
Assistant Professor, Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1302_22

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How to cite this article:
Kaur S, Sukhija J, Chatla V. Commentary: Cataract surgery in lenticonus. Indian J Ophthalmol Case Rep 2022;2:675-6

How to cite this URL:
Kaur S, Sukhija J, Chatla V. Commentary: Cataract surgery in lenticonus. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:675-6. Available from: https://www.ijoreports.in/text.asp?2022/2/3/675/351121



Lenticonus is an abnormal transparent projection of the lens, most commonly seen in the axial plane. Lenticonus can occur as an isolated entity or as a part of other systemic diseases such as Alport syndrome, Waardenburg syndrome, and Lowe syndrome. Detection of lenticonus is necessary, particularly in young individuals with decreased vision, to avoid the risk of ocular problems such as amblyopia as well as systemic complications.

Lenticonus can be divided into anterior and posterior lenticonus. Though the actual prevalence of lenticonus is not clear, bilateral lenticonus is more commonly associated with systemic syndromes as compared to unilateral disease. Lenticonus causes decreased vision due to myopia and astigmatism, which is often uncorrectable with spectacles. If left untreated, it causes progressive lens opacification, leading to further deterioration of vision. Often, the lenticonus is observed intraoperatively only as the presentation is that of a total cataract. Hence surgical removal of the cataract is more than often needed in these patients.[1],[2] Some authors have also advocated clear lens extraction in these cases because of the risk of impending cataracts.[3],[4]

A study published in the current issue of the journal describes lens extraction in 15 eyes with lenticonus.[5] The authors elaborate on the surgical management in individual cases. Out of 10 patients, 8 of them were diagnosed with bilateral lenticonus. Two of the patients presented initially with lenticonus, hearing loss, and proteinuria (all features suggestive of Alport syndrome) and were diagnosed with the disease after the diagnosis of lenticonus, thus helping the physician diagnose the disease early and prevent further damage to the kidneys. Alport syndrome presents with anterior lenticonus, though, posterior lenticonus is not uncommon.

The lens extraction in patients with lenticonus comes with its risks such as the fragility of the anterior capsule, an inadvertent posterior extension of the capsule during capsulorhexis, and posterior capsule rupture, vitreous prolapse, and/or traction. Syndromic associations, particularly Alport syndrome, in which the defective collagen IV fibers weaken the lens capsule further, increase the rate of complications during surgery. Therefore, the type of surgery and precautions during crucial steps of surgery improve the surgical outcome.[1],[2]

Continuous curvilinear capsulorhexis (CCC) can be particularly difficult and as the authors suggest, can be started from mid-periphery instead of the center of the capsule to avoid inadvertent spontaneous rupture. Small paracentesis to decrease the nuclear bulk can also be performed. A high molecular weight viscoelastic agent should be used to deepen the anterior chamber and flatten the anterior capsule. Hydrodissection should be performed in multiple strokes. Gentle cleaning of the peripheral portion of the cataract should be done circumferentially first to avoid tension on the zonules, followed by the central nucleus. The posterior capsular defect can be converted to a primary posterior capsulorhexis and supplemented with anterior vitrectomy in small children. Posterior capsular defect and white dots in the anterior vitreous can be seen intraoperatively known as the “fishtail sign.” Imaging tools such as the ASOCT or Scheimpflug imaging can be used to detect posterior capsular rupture preoperatively, especially in denser cataracts, and in that case, hydrodelineation within the epinucleus can be done instead of dissection. There is a paucity of Femtosecond-Laser-Assisted Cataract Surgery (FLACS) treated anterior lenticonus cases in the scientific literature.[6] Nevertheless, the advantages of achieving a cantered and round capsulorhexis with FLACS or precision pulse capsulotomy[2] cannot be denied. A foldable, hydrophobic, acrylic intraocular lens (IOL) should be inserted into the capsular bag wherever possible. If the IOL cannot be implanted in the bag, other techniques of sulcus implantation,[2] or posterior optic capture can be performed.[7] Even after a well-done surgery, astigmatism, amblyopia, and strabismus need to be tackled in the post-operative period.

Dense lenticular opacities can be imaged preoperatively to detect an underlying lenticonus with/without posterior capsular defect. Genetic analysis in cases of bilateral and familial posterior lenticonus should be done. IOL implantation can be successfully done in most cases if caution is taken before and during surgery; however, the visual outcome might be moderate due to co-existing amblyopia. The article stresses an important clinical tip that early diagnosis of systemic syndrome can be made by diagnosing lenticonus and thereby preventing further systemic complications. Though the sample size is less with both adult and pediatric cases described concurrently, the present article provides a well-grounded reference for cataract surgery in patients with lenticonus.



 
  References Top

1.
Mavrikakis I, Zeilmaker C, Wearne MJ. Surgical management of anterior lenticonus in Alport's syndrome. Eye (Lond) 2002;16:798-800.  Back to cited text no. 1
    
2.
Kekunnaya R, Deshmukh AV, Kulkarni S. Newer insights into the clinical profile of posterior lenticonus in children and its surgical, visual, refractive outcomes. Eye (Lond) 2022;36:985-93.  Back to cited text no. 2
    
3.
Gupta A, Ramesh Babu K, Srinivasan R, Mohanty D. Clear lens extraction in Alport syndrome with combined anterior and posterior lenticonus or ruptured anterior lens capsule. J Cataract Refract Surg2011;37:2075–8.  Back to cited text no. 3
    
4.
Bayar SA, Pinarci EY, Karabay G, Akman A, Oto S, Yilmaz G. Clear lens phacoemulsification in Alport syndrome: Refractive results and electron microscopic analysis of the anterior lens capsule. Eur J Ophthalmol2014;24:345–51.  Back to cited text no. 4
    
5.
Rashme VL, Prasad RS, Nagu K, Shekhar M. Cataract surgery outcomes in patients with lenticonus: A case series. Indian J Ophthalmol Case Rep 2022;3:673-5.  Back to cited text no. 5
    
6.
Barnes AC, Roth AS. Femtosecond laser-assisted cataract surgery in anterior lenticonus due to Alport syndrome. Am J Ophthalmol Case Rep2017;6:64-6.  Back to cited text no. 6
    
7.
Sukhija J, Kaur S, Korla S. Posterior optic capture of intraocular lens in difficult cases of pediatric cataract. Indian J Ophthalmol 2022;70:293-5.  Back to cited text no. 7
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