We read with great interest the correspondence by Singh and associates regarding our recent article, in which we have shown the short-term results of glued intraocular lens (IOL) in pediatric eyes. Ectopia lentis (9 eyes) is one of the indications for which the procedure has been used. The authors reported retinal detachment in 2 out of 4 eyes after glued IOL procedure for ectopia lentis in Marfan syndrome in their short study. We would like to clarify that the study eyes of ectopia lentis in our report consist of ectopia lentis attributable to Weill-Marchesani syndrome (4 eyes), familial ectopia lentis (3 eyes), and Marfan syndrome (2 eyes). We agree that the retinal complications in Marfan syndrome are high. However, in our analysis of a small group (n = 2), there was no retinal detachment reported in the follow-up (mean 36 months). It is known that the incidence of retinal detachment in Marfan syndrome depends on preexisting high-risk retinal pathologies like lattice, retinal holes, vitreous liquefaction, and vitreous incarceration in the sclerotomy wound. Sclerotomy port–related retinal detachment after pars plana vitrectomy has been reported earlier. In a small study of glued IOL sclerotomy wounds with ultrasound biomicroscopy (UBM), we noted good scleral flap adhesion, and there was no vitreous incarceration. On imaging the haptic position with UBM, there was no significant vitreous incarceration or traction noted in the wound.
Externalization of the haptic is the important step in the glued IOL method, and in the learning curve of the technique this is the complication-limiting step. It is known that the vitreous incarceration in the scleral wound can produce undue traction on the peripheral retina, which can lead to retinal break and later detachment. Hence, complete removal of the vitreous in the sclerotomy site should be done before externalizing the haptic. The “handshake technique” should be used for externalizing the haptics. Use of foldable 3-piece IOL instead of rigid lenses and 23-gauge instruments can reduce complications. Properly sized forceps that pass through the sclerotomy without difficulty should be used. Too tight an entry site and repeated maneuvering should be avoided. Other maneuvers common to all vitrectomies, such as infusion position, positioning of port from limbus, and proper wound closure, should be followed. Examination of peripheral retina and port site is advisable during follow-up visits to rule out iatrogenic breaks or vitreous traction. Any preexisting retinal pathology, such as lattice or erosions, should be laser photocoagulated preoperatively.
We agree that the incarceration and traction of vitreous in the sclerotomy site can lead to peripheral retinal breaks and retinal detachment; nevertheless, proper vitreous removal from the surgical site and careful haptic externalization can prevent this. In our experience, the procedure has shown good results in the recent past. Moreover, as explained in our article, the follow-up in these eyes is too short to draw conclusions on the long-term effects on retina. A long-term prospective study is already underway in our institute to check the safety and efficacy of this technique.