Lensectomy and Anterior Vitrectomy When an Intraocular Lens Is Not Being Implanted
M. Edward Wilson
Suresh K. Pandey
Intraocular lens (IOL) implantation at the time of cataract surgery is commonplace in older children. However, infants are often left aphakic. Optical rehabilitation is accomplished with contact lenses or aphakic glasses during the rapid years of eye growth. Later in childhood, secondary IOL implantation is usually performed. For infants, there are some significant advantages to the lensectomy and vitrectomy procedure compared to the lensectomy, vitrectomy, and IOL implantation procedure.
Lensectomy and vitrectomy can be performed through two small corneal stab incisions, ≤20 gauge. This causes less surgical trauma for the infant eye compared to when an IOL is inserted. The avoidance of a larger incision makes a patch and shield unnecessary. We usually place a contact lens on the eye at the conclusion of surgery and leave the eye unpatched. Postoperative drops can be started immediately instead of waiting until the patch and shield are removed the day after surgery. Having the baby return after surgery with no eye bandage is a great psychological boost for the parents. The baby can “start seeing” right away.
The risk of recurrent visual axis opacification after infant surgery is much lower when an IOL is not placed primarily. The anterior and posterior capsule remnants seal to each other more securely when an IOL is not placed between them. If a Soemmering ring forms, it is more likely to remain peripheral to the visual axis. In contrast, infants with an IOL placed primarily are at higher risk of visual axis opacification from cortex that escapes the Soemmering ring and reaches the visual axis.
Aphakic contact lenses can be changed whenever the eye grows, allowing precise optical rehabilitation. When an IOL is placed in infancy, glasses must be worn for the residual hyperopia. Later in childhood, myopic glasses are often needed. Some parents find that contact lens wear (especially with the easy-to-handle extended-wear silicone contact lenses designed especially for infants) is easier to manage than glasses, at least in infancy. Later, if contact lens wear becomes more difficult, the eye has grown enough that the glasses (as an adjunct to an IOL) are less thick and less necessary for prevention or treatment of amblyopia.
The disadvantages of aphakia in infancy with optical replacement using contact lenses include worsening amblyopia whenever a contact lens is lost and the risk of corneal ulcers owing to the extended wear of the lenses during the day and night. These issues are also covered in other chapters in this book.
SURGICAL APPROACHES FOR LENSECTOMY AND ANTERIOR VITRECTOMY
Two main approaches exist for lensectomy and anterior vitrectomy in children: the pars plana/pars plicata approach and the limbal/corneal approach.1,2,3,4,5,6,7,8
The Pars Plana Approach for Lensectomy and Anterior Vitrectomy
The pars plana/pars plicata approach is not commonly used today for primary removal of a congenital cataract unless vitreoretinal pathology is also being addressed. When retina surgeons perform a lensectomy combined with a posterior vitrectomy and retinal repair in an infant, a pars plana approach is often preferred. Pediatric anterior segment surgeons are more likely to prefer a limbal approach. Pars plana posterior capsulectomy after limbal-approach lensectomy and IOL placement is covered elsewhere in this book.
Surgical Technique
Pars plana/pars plicata lensectomy requires a guillotine-type vitrectome. Epinephrine (adrenaline), 1:500,000, is mixed in balanced salt solution (BSS; Alcon Laboratories, Fort Worth, TX) to avoid intraoperative miosis and to avoid occurrence of pediatric intraoperative floppy-iris syndrome.9
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