Corneal vs. Scleral Incisions: Managing Lens luxation in homocystinuria

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Corneal vs. Scleral Incisions
Managing Lens luxation in homocystinuria

• Suqin Guo, MD, Tatyana Milman, MD, N Bhagat, MD,
  D Chu, MD and R Fechtner, MD
• The Institute of Ophthalmology and Visual Science
• UMDNJ-New Jersey Medical School

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Corresponding /Senior AuthorSuqin Guo, MD

• Assistant professor
• The Institute of Ophthalmology and Visual Science
• UMDNJ-New Jersey Medical School

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Purpose of the Study

• To compare the wound healing of clear corneal
  incision with scleral incision in surgically
  managing lens luxation in a child with
  homocystinuria

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Methods-Case Report

• A 10-year old child with a known history of
  homocystinuria
• Presented with bilateral complete luxation of the
  lens into the anterior chamber
• Recurrent angle-closure glaucoma from pupillary
  block of complete luxated lens into anterior
  chamber.

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Case Report

• Her Intraocular pressure was medically
  uncontrollable.
• Her left eye Underwent lensectomy and anterior
  vitrectomy via clear corneal incision by an
  anterior segment surgeon
• Her right eye Had pars plana lensectomy ( PPL)
  and vitrectomy (PPV) by a vitreoretinal
  specialist

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Results-surgical OutcomeLEFT eye- lens removal
via clear cornea

• Her left eye underwent Lensectomy via a clear
  corneal incision and healed well
• Intraocular pressure remained within normal limit
  without needing any medication over 7 years.
• 20/80 with aphakic correction

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Results-surgical OutcomeRIGHT eye post-PPVPPL

• Her right eye that underwent pars plana
  lensectomy (PPL) and vitrectomy (PPV) via
  sclerotomy incisions
• Developed scleral necrosis, scleromalacia over
  the sclerotomy sites
• Had poor controlled intraocular pressure (IOP)

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Results-surgical OutcomeRIGHT eye post-PPVPPL

• Her right eye needed multiple scleral patch graft
  surgeries

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Results-surgical Outcome RIGHT eye post-PPVPPL

• Her right eye, later, perforated over the
  sclerotomy sites. Additional multiple operations
  were needed, including scleral patch graft and
  retinal detachment repair surgeries.
• Visual acuity HM

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Discussion/Conclusion

• One of the main characteristics of homocystinuria
  is a high risk of arterial and venous
  thromboembolism.
• High risk of tissue necrosis secondary from
  ischemia
• High risk of general anesthesia

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Conclusion

• Sclera is vascular tissue whereas cornea is
  avascular. Arterial and venous thromboembolism
  could occur within scleral vessels due to minimal
  surgical trauma or ischemic changes from abnormal
  IOP, causing poor wound healing.

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Discussion/Conclusion

• Cornea is avascular and may be spared from
  thromboembolism. Clear corneal incision may
  provide better wound healing in patients with
  homocystinuria.