Corneal vs. Scleral Incisions: Corneal vs. Scleral Incisions: Managing Lens luxation in Managing Lens luxation in

homocystinuriahomocystinuria

Suqin Guo, MD,* Tatyana Milman, MD, N Bhagat, Suqin Guo, MD,* Tatyana Milman, MD, N Bhagat, MD, D Chu, MD and R Fechtner, MDMD, D Chu, MD and R Fechtner, MDThe Institute of Ophthalmology and Visual The Institute of Ophthalmology and Visual ScienceScienceUMDNJ-New Jersey Medical SchoolUMDNJ-New Jersey Medical School

Corresponding /Senior AuthorCorresponding /Senior AuthorSuqin Guo, MDSuqin Guo, MD

Assistant professorAssistant professor The Institute of The Institute of

Ophthalmology and Ophthalmology and Visual ScienceVisual Science

UMDNJ-New Jersey UMDNJ-New Jersey Medical SchoolMedical School

Purpose of the StudyPurpose of the Study

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

Methods-Case ReportMethods-Case Report

A 10-year old child with a known A 10-year old child with a known history of homocystinuria history of homocystinuria

Presented with bilateral complete Presented with bilateral complete luxation of the lens into the anterior luxation of the lens into the anterior chamberchamber

Recurrent angle-closure glaucoma Recurrent angle-closure glaucoma from pupillary block of complete from pupillary block of complete luxated lens into anterior chamber. luxated lens into anterior chamber.

Case ReportCase Report

Her Intraocular pressure was Her Intraocular pressure was medically uncontrollable.medically uncontrollable.

Her left eye: Underwent lensectomy Her left eye: Underwent lensectomy and anterior vitrectomy via clear and anterior vitrectomy via clear corneal incision by an anterior corneal incision by an anterior segment surgeon segment surgeon

Her right eye: Had pars plana Her right eye: Had pars plana lensectomy ( PPL) and vitrectomy lensectomy ( PPL) and vitrectomy (PPV) by a vitreoretinal specialist(PPV) by a vitreoretinal specialist

Results-surgical OutcomeResults-surgical OutcomeLEFT eye- lens removal via clear corneaLEFT eye- lens removal via clear cornea

Her left eye underwent Lensectomy Her left eye underwent Lensectomy via a clear corneal incision and via a clear corneal incision and healed well healed well

Intraocular pressure remained within Intraocular pressure remained within normal limit without needing any normal limit without needing any medication over 7 years. medication over 7 years.

20/80 with aphakic correction 20/80 with aphakic correction

Results-surgical OutcomeResults-surgical OutcomeRIGHT eye – post-PPV+PPLRIGHT eye – post-PPV+PPL

Her right eye that underwent pars Her right eye that underwent pars plana lensectomy (PPL) and plana lensectomy (PPL) and vitrectomy (PPV) via sclerotomy vitrectomy (PPV) via sclerotomy incisions incisions

Developed scleral necrosis, Developed scleral necrosis, scleromalacia over the sclerotomy scleromalacia over the sclerotomy sitessites

Had poor controlled intraocular Had poor controlled intraocular pressure (IOP)pressure (IOP)

Results-surgical OutcomeResults-surgical OutcomeRIGHT eye – post-PPV+PPLRIGHT eye – post-PPV+PPL

Her right eye needed multiple scleral Her right eye needed multiple scleral patch graft surgeriespatch graft surgeries

Results-surgical OutcomeResults-surgical Outcome RIGHT eye – post-PPV+PPLRIGHT eye – post-PPV+PPL

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

Visual acuity= HMVisual acuity= HM

Discussion/ConclusionDiscussion/Conclusion

One of the main characteristics of One of the main characteristics of homocystinuria is a high risk of arterial homocystinuria is a high risk of arterial and venous thromboembolism. and venous thromboembolism.

High risk of tissue necrosis secondary High risk of tissue necrosis secondary from ischemiafrom ischemia

High risk of general anesthesiaHigh risk of general anesthesia

ConclusionConclusion

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

Discussion/ConclusionDiscussion/Conclusion

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