Mastering lensectomy: Surgical nuances in pediatric ectopia lentis

Purpose: Aim is to give an overview of  different lensectomy techniques which can be utilized in various scenarios of subluxated lenses in children.
Method: We present  various lensectomy techniques with or without  intraocular lens implantation in five pediatric cases of subluxated crystalline lenses  utilising anterior approach and a close chamber in a descriptive case series manner at Al-Shifa Trust Eye Hospital Rawalpindi, Pakistan.
Results: Case #1: Anterior approach; 02 limbal ports uni-manual technique: A 02 year old marfan’s syndrome child with unstable microspeherophakic lens in pupillary plane had undergone lensectomy via limbal approach. Two 20 guage limbal ports were fashioned at 3 and 9 o’clock using 20 guage MVR blade. A unimanual technique with 20G vitrectomy cutter was used for complete removal of subluxated lens keeping AC (anterior chamber) maintainer in the other port to ensure formed AC. Anterior vitrectomy was done to clear off any vitreous in AC and pupillary plane.
Case #2: 03 limbal ports bimanual “Surgeon’s 3rd hand” technique: In a microspeherophakic lens, subluxated in anterior chamber with <1 quadrant zonular support causing a pupillary block glaucoma, limbal approach 3 ports bimanual lensectomy using AC maintainer in 20G  port at 3 o’clock and a 9 o’clock port was used for vitrectomy cutter. Another port at 70 degree to the 3 o’clock port was made to hold the subluxated lens from falling posteriorly using a sinskey hook .
Case #3: Pharmacologically assisted- 02 ports uni-manual limbal approach: A microspherophakic lens subluxated in anterior chamber with <1 quadrant  zonular support.  Acetylcholine chloride in irrigating fluid assisted 02 port uni-manual lensectomy was performed similar to case No. 1.
Case #4: 03 ports bimanual technique in a subluxated traumatic cataract: 6 clock hours subluxation of traumatic cataract  was dealt with anterior approach lensectomy  using two 20G horizontal limbal ports and a superior 2.7mm partial thickness scleral port. Capsular tension ring was inserted to address the bag subluxation after anterior capsulorrhexis. Posterior capsulectomy and shallow anterior vitrectomy was performed after lens matter aspiration. A multipiece piece IOL was unloaded in the sulcus with optic capture behind the capsular bag.
Case #5: 03 ports bimanual technique in a traumatic iridodialysis and subluxation of  traumatic cataract: Traumatic superior 3 clock hour subluxation of cataract was dealt with the 03 port bimanual technique as described in case No. 4 except for an anterior vitrectorrhexis using high cutting rate with 20G vitrector and an endocapsular single piece foldable IOL. Iris root dialysis was repaired with double armed straight needle 9-0 polypropylene suture after fashioning partial thickness scleral flaps utilising cobbler’s technique.
Conclusion: Various lensectomy techniques are tailored to address different scenarios of ectopia lentis depending upon the specific cause and nature of zonular weakness.

5 key words: Ectopia lentis, traumatic subluxation,  lensectomy, bimanual technique, anterior vitrectomy