Scleral-Fixated Capsular Tension Rings and Segments for Ectopia Lentis in Children ERIC J. KIM, JAMES P. BERG, MITCHELL P. WEIKERT, LINGKUN KONG, MARSHALL B. HAMILL, DOUGLAS D. KOCH, AND KIMBERLY G. YEN
PURPOSE:

To report the short-term outcomes and complications of implantation of scleral-fixated capsular tension rings and/or capsular tension segments with intraocular lenses (IOL) in pediatric patients with ectopia lentis.
DESIGN: Retrospective, observational case series.
METHODS: Thirteen consecutive pediatric patients (19 eyes) underwent placement of in-the-bag IOL with either a Cionni modified capsular tension ring or a capsular tension segment in conjunction with a conventional capsular tension ring between January 1, 2009 and March 30, 2013 by 3 anterior segment surgeons at a single academic center. The scleral fixation suture was 9-0 polypropylene in 16 eyes and CV-8 Gore-Tex (expanded polytetrafluoroethylene) in 3 eyes. Outcome measures included change in corrected distance visual acuity (CDVA) and complications.
RESULTS: The mean age was 10.2 years ± 4.8 (SD) and the median follow-up, 23.4 months. A Cionni modified capsular tension ring was implanted in 5 eyes and a capsular tension segment with an unsutured capsular tension ring was implanted in 12 eyes. In 2 eyes, capsular tension segment alone was placed. The mean CDVA at the final follow-up (0.10 ± 0.11 logMAR, 18 eyes) was significantly better than preoperatively (0.58 ± 0.26 logMAR, 15 eyes) (P < .001). The CDVA at the final follow-up was 20/40 or better in 18 eyes (94.7%). All IOLs were well centered. Posterior capsule opacification developed in 11 eyes (57.9%), 9 eyes (47.4%) required neodymium–yttrium-aluminum-garnet capsulotomy, and 3 eyes (15.8%) required pars plana vitrectomy and posterior capsulotomy. Other complications included broken suture (5.3%) (9-0 polypropylene at CTR eyelet, repaired with CV-8 Gore-Tex), conjunctival dehiscence (5.3%), suture exposure (5.3%) (trans-scleral 9-0 polypropylene), and vitreous strand at inferior paracentesis (5.3%).
CONCLUSIONS: Implantation of in-the-bag IOL with either a Cionni modified capsular tension ring or a capsular tension segment in conjunction with a conventional Accepted for publication Aug 1, 2014. From the Department of Ophthalmology, Texas Children’s Hospital (E.J.K., J.P.B., L.K., K.G.Y.), and Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine (E.J.K., J.P.B., M.P.W., L.K., M.B.H., D.D.K., K.G.Y.), Houston, Texas. Inquiries to Kimberly G. Yen, Department of Ophthalmology, Texas Children’s Hospital, 6621 Fannin MC-CCC 640.00, Houston, TX 77030; e-mail: [email protected] 0002-9394/$36.00 http://dx.doi.org/10.1016/j.ajo.2014.08.002

Ó

2014 BY

capsular tension ring appears to be a safe and effective technique for visual rehabilitation in pediatric ectopia lentis. (Am J Ophthalmol 2014;158:899–904. Ó 2014 by Elsevier Inc. All rights reserved.)

C

RYSTALLINE LENS SUBLUXATION IN CHILDREN HAS

been associated with hereditary metabolic disorders such as Marfan syndrome, homocystinuria, and Weill-Marchesani syndrome, as well as trauma and idiopathic ectopia lentis.1–4 When the lens loses significant zonular support, a large refractive error, a partially phakic visual axis, and anisometropia can result; untreated, these conditions place children at risk for dense amblyopia. Loss of significant zonular support also increases the difficulty of cataract extraction with intraocular lens (IOL) implantation in children, which is already complicated by a high incidence of posterior capsule opacification (PCO), the likelihood of progressive zonular weakness, and a proclivity for inflammation.5–8 Additionally, surgical treatment for ectopia lentis carries a risk for serious complications such as glaucoma or retinal detachment.9 Previously, investigators have reported achieving good visual outcomes with no serious complications in children by performing limbal lensectomy with both anterior and posterior capsulotomies or pars plana lensectomy.10,11 However, these methods leave patients aphakic postoperatively, thus necessitating correction with spectacles or contact lenses. Lens-induced aniseikonia and social issues can lead to noncompliance with spectacles, while contact lenses for a child may be difficult to fit or poorly tolerated and predispose to complications such as keratitis. The capsular tension ring has been used to effectively manage localized zonular weakness.12,13 However, it cannot provide adequate support or correct decentration of the capsular bag in the presence of extensive zonular dialysis.14 In 1998, the Cionni modified capsular tension ring (Morcher) was introduced to help manage profound zonular weakness.15 The Cionni modified capsular tension ring can be fixated to the sclera without compromising capsular bag integrity via 1 or 2 sutures; advantages are stabilization of the lens capsule and reduced risk of future IOL dislocation. Implantation of the Cionni ring with in-the-bag IOL placement in children with ectopia lentis has been reported to be safe with few short-term significant complications.16,17 In 2002, Ahmed designed the capsular tension segment (Morcher), which is also intended for patients with

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significant zonular insufficiency. The capsular tension segment is a partial ring segment of 120 degrees; like the Cionni modified capsular tension ring, it has an anteriorly positioned eyelet, which enables scleral suture fixation. Compared to the Cionni modified capsular tension ring, the capsular tension segment can be inserted into the capsule bag with greater ease and less trauma because a dialing technique is not necessary.18 The capsular tension segment can be used alone or in combination with other endocapsular support devices such as the capsular tension ring to help manage extensive zonular loss.19 A case report has also reported the use of a capsular tension segment in conjunction with a capsular tension ring in a pediatric patient with microspherophakia.20 However, there is limited information in the literature regarding the outcome of the capsular tension segment in children with ectopia lentis. We present the short-term outcomes of 19 pediatric eyes after implantation of scleral-fixated capsular tension ring and/or capsular tension segment with IOL in pediatric patients with ectopia lentis.

METHODS A COMPUTER SEARCH OF OUR PATIENT DATABASE IDENTIFIED

the records of all patients 18 years old or younger with ectopia lentis who received a capsular tension ring and/or a capsular tension segment between January 1, 2009 and March 30, 2013. One patient was excluded because of incomplete follow-up. Patients received either a scleral-fixated Cionni modified capsular tension ring (Morcher, FCI Ophthalmics, Marshfield Hills, Massachusetts, USA; type 1L or 2C) or a scleral-fixated capsular tension segment (Morcher, FCI Ophthalmics, Marshfield Hills, Massachusetts, USA; type 6D or 6E) in conjunction with a conventional unsutured capsular tension ring (Morcher, FCI Ophthalmics, Marshfield Hills, Massachusetts, USA; type 14, 14A, 14C). The Institutional Review Board of the Baylor College of Medicine approved this retrospective observational study. In patients who were not able to be cooperative for awake measurements, IOL calculations were performed in the operating room using immersion A-scan ultrasonography for axial length measurements and keratometry was performed using a hand-held keratometer. All surgeries were performed under general anesthesia by 1 of 3 surgeons (D.D.K., M.P.W., M.B.H.). Patients were dilated preoperatively with topical cyclopentolate 1%, phenylephrine 2.5%, and tropicamide 1% or with lidocaine gel mixed with gatifloxacin, ketorolac, tropicamide, and phenylephrine drops. Paracenteses were created at 11 o’clock and 5 o’clock for the left eye, and at 1 o’clock and 7 o’clock for the right eye. In some patients, preservative-free 1% lidocaine was injected into the anterior chamber, followed by injection of sodium hyaluronate 3.0%– chondroitin sulfate 4.0% (Viscoat, Alcon, Fort Worth, Texas, USA) or a combination of Viscoat and sodium hyaluronate 900

1.4% (Healon GV, Abott/AMO, Abbott Park, Illinois, USA). A temporal clear corneal incision was made using a 2.4-mm blade; if necessary, iris hooks (Grieshaber, Alcon, Fort Worth, Texas, USA) were used to stabilize the capsular bag. A continuous curvilinear capsulorrhexis was created using a 27 gauge cystotome and a Utrata forceps. Hydrodissection and hydrodelineation were then performed with balanced salt solution. The cortical lens material was aspirated using bimanual irrigation/aspiration (I/A) with low aspiration parameters, and the posterior capsule was left intact. The capsular bag and anterior chamber were expanded with Healon and a capsular tension device was then inserted through the main incision into the capsular bag. Several combinations of capsular tension rings and/or segments were used: scleral-fixated Cionni modified capsular tension ring, scleralfixated capsular tension segment with unsutured capsular tension ring, or scleral-fixated capsular tension segment alone. The choice of capsular tension device was determined intraoperatively by the surgeon’s assessment of the degree of zonular weakness. The Cionni modified capsular tension ring and capsular tension segment were positioned with the fixation eyelet anterior to the capsulorrhexis and in the area of maximum zonular weakness. Two scleral stab incisions or scleral flaps were made 2 mm posterior to the limbus in order to suture the eyelet of the capsular tension device to the sclera, with 9-0 polypropylene in 17 eyes and CV-8 Gore-Tex (expanded polytetrafluoroethylene) in 3 eyes. The capsular bag was reinflated with Healon (Abbott/ AMO, Abbott Park, Illinois, USA), and an acrylic IOL was injected into the capsular bag. Patients received an acrylic 3-piece foldable IOL (Tecnis: ZA9003), an acrylic 1-piece foldable IOL (Tecnis: ZCB00; Alcon: AcrySofSN60WF or SN60AT), or an acrylic toric foldable IOL (Alcon: AcrySofSN6AT5 or SN6AT4); selection of lens was the surgeon’s preference. Residual Healon was aspirated using the I/A handpiece, and the lens was centered. The paracentesis and main incisions and the overlying conjunctiva were closed with 10-0 nylon suture. Postoperatively, all eyes were treated with gatifloxacin and prednisolone acetate 1% 4 times daily for the first week, followed by a taper of the topical prednisolone acetate 1% by 1 drop each week for 4 weeks. All patients received complete preoperative and postoperative ophthalmic evaluations, including age-appropriate assessment of corrected distance visual acuity (CDVA) (Snellen, Allen pictures, HOTV, Alternates), refraction (cycloplegic refraction if not aphakic), slit-lamp examination, intraocular pressure (IOP) measurement (if cooperative in clinic), and dilated funduscopy. All patients underwent examination under anesthesia (EUA), including IOP measurement, prior to the surgical procedure if this information could not be obtained accurately in the clinic. Preoperative and postoperative IOL centration was assessed by the examiner on dilated slit-lamp examination. Subject parameters reviewed included sex; age; diagnosis; relevant medical history; preoperative, postoperative, and most recent CDVAs; length of follow-up; capsular tension ring

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TABLE 1. Preoperative and Intraoperative Characteristics of Pediatric Eyes With Scleral-Fixated Capsular Tension Rings and Segments for Ectopia Lentis

Patient

1 2 3 4 5 6 7 8 9 10 11 12 13

Age (Y)/Sex

15.8/M 7.0/F 6.6/F 11.8/M 11.9/M 14.2/M 13.9/M 15.3/M 6.6/F 8.8/M 8.8/M 11.1/M 2.9/M 2.8/M 17.9/M 18.3/M 3.6/F 11.9/M 5.3/M

Eye

L R L R L R L L R R L R R L R L R L L

Diagnosis

Associated Ocular Condition

Surgical Procedure

IOL Model

Suture

Traumatic subluxed IOLa Marfan syndrome Marfan syndrome Familial ectopia lentis Familial ectopia lentis Marfan syndrome Marfan syndrome Idiopathic Marfan syndrome Marfan syndrome Marfan syndrome Marfan syndrome Familial ectopia lentis Familial ectopia lentis Marfan syndrome Marfan syndrome Idiopathic Idiopathic Idiopathic

— — — — — — — — — — — — Amblyopia, glaucoma, X(T) Amblyopia, glaucoma, X(T) — — Amblyopia — Amblyopia, E(T)

CTS PE/IOL/CTSþCTR PE/IOL/CTSþCTR PE/IOL/MCTR PE/IOL/MCTR PE/IOL/CTRþCTSx2 PE/IOL/CTRþCTSx2 PE/IOL/CTSþCTR PE/IOL/CTSþCTR PE/IOL/MCTR PE/IOL/MCTR PE/IOL/CTSþCTR PE/IOL/CTSþCTR PE/IOL/CTS PE/IOL/CTSþCTR PE/IOL/CTSþCTR PE/IOL/MCTR PE/IOL/CTSþCTR PE/IOL/CTSþCTR

ZA9003 SN60WF SN60WF SN6AT5 SN68C5 ZCB00 ZCB00 SN60WF ZCB00 SN60WF SN60WF SN60WF SN60WF SN60WF ZCB00 ZCB00 SN60AT ZCB00 SN60AT

P P P P Pb P P G P P P P P P P P G P P

MCTR Type

CTR Type

CTS Type

— — — 1L 1L — — — — 2C 1L — — — — — 1L — —

— 14 14 — — 14 14 14A 14 — — 14A 14 — 14A 14A — 14C 14

6E 6E 6E — — 6D 6D 6E 6D — — 6E 6D 6D 6E 6E — 6D 6D

CTR ¼ capsular tension ring; CTS ¼ capsular tension segment; E(T) ¼ intermittent esotropia; G ¼ CV-8 Gore-Tex; IOL ¼ intraocular lens; L ¼ left; MCTR ¼ Cionni modified CTR; P ¼ 9-0 polypropylene; PE ¼ phacoemulsification; R ¼ right; X(T) ¼ intermittent exotropia. a See text for details. b Suture tear; replaced with CV-8 Gore-Tex.

and/or capsular tension segment model; IOL model; suture material and gauge; presence of amblyopia; intraoperative or postoperative complications; and need for reintervention. Snellen CDVAs were converted to logarithm of minimal angle of resolution (logMAR) values for statistical analysis. Descriptive statistics and, when possible, the Wilcoxon signed rank test were used to support our findings and to compare subgroups. Significance was defined by a P value of less than .05.

RESULTS NINETEEN EYES OF 13 PATIENTS (3 FEMALE) MET CRITERIA

for inclusion. Ten eyes had Marfan-associated ectopia lentis, 8 eyes had non-Marfan-associated ectopia lentis (either hereditary or idiopathic), and 1 patient suffered traumatic dislocation of a previously implanted IOL. Detailed individual patient data are given in Table 1. Mean age at the time of original IOL placement was 10.2 years (median, 11.1 years; range, 2.8–18.3 years), and the average length of follow-up was 19.3 months (range, 0.7– 46.6 months). Six patients had bilateral surgery and 7 had unilateral surgery. Two patients underwent patching treatment for amblyopia. VOL. 158, NO. 5

All eyes received in-the-bag implantation of a posterior chamber IOL with a scleral-fixated capsular tension ring and/or capsular tension segment. A Cionni modified capsular tension ring was implanted in 5 eyes (26.3%), and a capsular tension segment with an unsutured capsular tension ring was implanted in 12 eyes (63.2%). In 2 eyes (10.5%), capsular tension segment alone was placed. In 1 eye, there was a peripheral extension of the continuous curvilinear capsulorrhexis; owing to the increased risk of capsular tension ring slippage, capsular tension segment alone was placed. In 1 eye, traumatic dislocation of a previously implanted IOL occurred; capsular tension segment alone was placed to minimize unnecessary manipulation of the IOL/capsule complex. Both eyes that received capsular tension segment alone did well during the follow-up period with IOLs remaining centered; both developed PCO, which were successful treated by neodymium–yttrium-aluminum-garnet (Nd:YAG) capsulotomy or pars plana vitrectomy and posterior capsulotomy. All IOLs were well centered. Of the 19 eyes, 11 eyes developed secondary cataract (57.9%), 9 eyes (47.4%) required Nd:YAG capsulotomy, and 3 eyes (15.8%) required pars plana vitrectomy and posterior capsulotomy. Mean time to PCO development from the time of surgery was 1.40 6 0.38 years. One eye had a recurrence of PCO following Nd:YAG capsulotomy and thus received pars plana vitrectomy and

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TABLE 2. Postoperative Visual Acuity and Complications in Pediatric Eyes With Scleral-Fixated Capsular Tension Rings and Segments for Ectopia Lentis Postoperative CDVA Patient

Eye

1 2

L R L R L

39.4 27.6 32.7 37.7 37.0

R L L R R L R R L R L R L L

0.8 3.2 0.7 3.9 22.5 24.1 46.6 23.4 25.3 2.8 0.9 27.5 0.7 9.7

3

4 5 6 7 8 9 10 11 12 13

F/U (M)

Preoperative CDVA

1M

3M

1Y

20/40 20/200 20/200 20/60 20/40

20/40 20/30 20/60 20/40 20/25

20/20 20/25 20/30 20/40 20/20

20/40 20/60 20/30 20/25

20/100 20/60 20/150 20/80 20/100 20/160 20/40 F&F F&F 20/50 20/60 F&F 20/30 F&F

20/25 20/30 20/25

20/20

2Y

20/20 20/20 20/20 20/30 20/20

20/40 20/40 20/60 20/25 20/150a 5/300b 20/30 20/32 20/125 20/25 CUSMc

20/20 20/25

20/40 20/20 20/100a 20/20 20/125b

20/60b 20/100b

20/40b 20/40b

20/50b

20/30

CUSMc

Final F/U

20/20 20/20 20/20 20/20 20/20 20/25 20/20 20/25 20/40 20/20 20/25 20/30 20/40b 20/40b 20/20 20/32 20/25b 20/25 F&F

Complications/Comments

PCO-Nd:YAG capsulotomy, prior PE/IOL PCO-Nd:YAG capsulotomy PCO-Nd:YAG capsulotomy PCO-Nd:YAG capsulotomy IOL subluxation, resuturing of IOL, PCO-Nd:YAG capsulotomy Transcleral suture exposure Conjunctival dehiscence Vitreous strand at inferior paracentesis PCO-Nd:YAG capsulotomy PCO-Nd:YAG capsulotomy PCO-Nd:YAG capsulotomy PCO-PPV PCO-PPV, extended capsulorrhexis

PCO-Nd:YAG capsulotomy, PCO-PPV

CDVA ¼ corrected distance visual acuity; CUSM ¼ central, unsteady, maintained; F&F ¼ fix-and-follow; F/U ¼ follow-up; IOL ¼ intraocular lens; L ¼ left; M ¼ months; Nd:YAG ¼ neodymium-doped yttrium-aluminum-garnet laser; PCO ¼ posterior capsule opacification; PE ¼ phacoemulsification; PPV ¼ pars plana vitrectomy; R ¼ right; Y ¼ years. a Allen Pictures. b HOTV. c Alternates.

TABLE 3. Refractive Outcomes of Pediatric Eyes With Scleral-Fixated Capsular Tension Rings and Segments for Ectopia Lentis

Refractive Outcomes

Preoperative (D)

Postoperative Week 3 (D)

Mean SE 6 SD Range Mean astigmatism 6 SD Range

9.56 6 6.34 22.00 to 0.50 4.15 6 3.73 0.00–11.00

1.22 6 2.34 7.50 to 1.50 0.88 6 0.51 0.00–2.00

D ¼ diopters; SD ¼ standard deviation; SE ¼ spherical equivalent.

posterior capsulotomy as well. One patient with a Cionni modified capsular tension ring suffered breakage of a 90 polypropylene suture after sports-related trauma; the IOL was noted to be slightly subluxated nasally at the time of the examination. The suture was replaced with CV-8 Gore-Tex; the patient has done well since the subsequent surgery, and the IOL has remained centered. There was 1 case each of conjunctival dehiscence, suture exposure (trans-scleral 9-0 polypropylene), and vitreous strand at inferior paracentesis. 902

Mean CDVA significantly improved from preoperatively (0.58 6 0.26 logMAR, 15 eyes) to the most recent postoperative follow-up (0.10 6 0.11 logMAR, 18 eyes) (P < .001) (Table 2). The CDVA at the final follow-up was 20/40 or better in 18 eyes (94.7%). Four eyes were fix-and-follow prior to surgery, and 3 of the 4 had measurable vision at the most recent follow-up, with 2 eyes measured at 20/40 and 1 eye measured at 20/25. The final patient maintained fix-andfollow at the most recent visit and had no noted complications. Mean preoperative spherical equivalent and astigmatism were 9.56 6 6.34 diopters (D) (range 22.00 to 0.50 D) and 4.15 6 3.73 D (range 0.00–11.00 D), respectively (Table 3). Mean spherical equivalent and astigmatism at postoperative week 3 were 1.22 6 2.34 D (range 7.50 to 1.50 D) and 0.88 6 0.51 D (range 0.00–2.00 D), respectively.

DISCUSSION IN THIS STUDY, 2 MAIN COMBINATIONS OF CAPSULAR

tension rings and/or segments were used: scleral-fixated Cionni modified capsular tension ring or scleral-fixated capsular tension segment with unsutured capsular tension

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ring. In 2 eyes, scleral-fixated capsular tension segment alone was placed. All capsular tension devices were successfully implanted in the capsular bag of all eyes. The choice of capsular tension device used was based on availability and surgeon preference. First introduced in 2002, the capsular tension segment is a newer device compared to the Cionni modified capsular tension ring, which was designed in 1998.15 Our surgeons gradually transitioned from the Cionni modified capsular tension ring to the capsular tension segment based on their perception that it was easier and less traumatic to position the capsular tension segment in the desired meridian compared to the Cionni ring because a dialing technique is not required by the segment.18 Additionally, they noted that the Cionni ring was stiffer compared to the capsular tension segment, which further increased its relative degree of difficulty to insert into the capsular bag. Among our study group, 94.7% of eyes showed an improvement in CDVA. The CDVA at the final follow-up was 20/40 or better in 18 eyes (94.7%). In contrast, Vasavada and associates reported 45.7% of eyes achieving a visual acuity of 20/40 or better.17 However, our study investigated the use of the capsular tension segment as well as the Cionni modified capsular tension ring, while Vasavada and associates used only the Cionni ring. Cionni and associates previously reported a postoperative CDVA of 20/40 or better in 88.9% eyes, but their study included both adult and pediatric eyes.21 When cataract surgery is performed in young children without posterior capsulorrhexis and anterior vitrectomy, there is a very high incidence of visual axis opacification.5 However, surgeons generally opt not to perform a posterior capsulorrhexis in the initial operation because of the technical challenge of opening the posterior capsule in the same procedure as implantation of a capsular tension device. Previous studies report rates of visual axis opacification of 60%–84% following capsular tension ring and in-the-bag IOL implantation in children with ectopia lentis.16,17 In our study, posterior capsular opacification developed in 11 eyes (57.9%), of which 9 eyes (47.4%) required Nd:YAG capsulotomy and 3 eyes (15.8%) required pars plana vitrectomy and posterior capsulotomy. In 1 of our patients, sports-related trauma led to suture breakage and postoperative IOL subluxation 26 months after surgery; this was subsequently repaired with CV-8 Gore-Tex and the patient has afterwards done well. Suture failure through degradation or breakage over time can lead to dislocation of the IOL and is a serious potential complication. This is of particular concern in children, given their longer life expectancy compared to adult patients, their continued globe enlargement with age, and their increased likelihood of eye trauma owing to their more active lifestyle. In a case study of 5 subluxed IOLs, late subluxation of the IOL was found to be correlated with

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microscopic degradation of the 10-0 polypropylene suture, with all cases occurring after 7–14 years.22 Asadi and associates reported spontaneous breakage of the 10-0 polypropylene suture in pediatric trans-sclerally fixated IOLs in 24% of cases 7–10 years after IOL implantation.23 Vote and associates observed late breakage of polypropylene sutures in 26.2% of mostly adult patients about 50 6 28 months post IOL fixation.24 The 9-0 polypropylene suture is believed to possess greater tensile strength and resistance to trauma and biodegradation compared to the 10-0 gauge22; therefore, our study exclusively used the 9-0 gauge of polypropylene suture, as well as CV-8 Gore-Tex suture. Although our study observed only 1 case of IOL dislocation postoperatively, our median follow-up period of 23.4 months was relatively short compared to the studies that observed spontaneous suture breakage and late IOL dislocation. A longer follow-up period would be useful in elucidating the probability of late IOL dislocation when using 9-0 polypropylene and CV-8 GoreTex sutures. The patients in our study were relatively older children, with a mean age of 10.2 6 4.8 years, and only 2 received patching treatment for amblyopia. One patient had ametropic amblyopia. Nevertheless, early detection and treatment is critical in maximizing visual potential, especially in a higher-risk population as children with ectopia lentis. The power of this study is limited by the fixed sample size. Other limitations include the retrospective design, the relatively short and variable follow-up, the inability to document CDVAs in preverbal patients, and the lack of a control group for comparison. In conclusion, 94.7% of eyes in our study showed in improvement in CDVA, which compares favorably to results previously achieved using the Cionni modified capsular tension ring, scleral-fixated IOLs, and sulcusfixated IOLs in children.16,17,25,26 Iris-fixated IOLs are another viable alternative in children,27,28 with reported visual outcomes comparable to those of optically corrected aphakia29; however, rates of IOL dislocation have been reported to be as high as 33%.29 We had 1 case (5.3%) of IOL subluxation postoperatively, but this was attributable to suture breakage from accidental sports-related trauma, and the IOL has subsequently remained centered following replacement of the broken suture. PCO was the most common complication and developed in 57.9% of eyes, which is comparable to the rate found in similar studies.16,17 Our results suggest that implantation of in-the-bag IOL with either a Cionni modified capsular tension ring or a capsular tension segment in conjunction with a conventional unsutured capsular tension ring can be safe and effective for visual rehabilitation in children with ectopia lentis. A larger prospective study with longer follow-up would be ideal to further delineate the outcomes and complications of this technique in the pediatric population.

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ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST and the following were reported: D.D.K.: Alcon Laboratories, Inc (Consultant), Abbott Medical Optics (Consultant); E.J.K., J.P.B., M.P.W., L.K., M.B.H., K.G.Y.: no financial disclosures. This study was supported in part by a grant from Research to Prevent Blindness Inc, New York, New York. Contributions of authors: Involved in design and conduct of the study (K.G.Y., E.J.K., J.P.B.); collection, management, analysis, interpretation of the data (E.J.K., J.P.B., L.K., K.G.Y.); and preparation, review, and approval of manuscript (E.J.K., J.P.B., D.D.K., M.B.H., M.P.W., K.G.Y.).

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AMERICAN JOURNAL OF OPHTHALMOLOGY

NOVEMBER 2014

Biosketch Eric J. Kim, BS, is currently a medical student at Baylor College of Medicine in Houston, Texas. He received his BS in bioengineering from Rice University in Houston, Texas.

VOL. 158, NO. 5

CAPSULAR TENSION RINGS AND SEGMENTS IN CHILDREN

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