Posterior Approach in Management of Phacomorphic Angle Closure

Abstract

This article presents a case of posterior lensectomy through 3-port pars plana vitrectomy for the management of phacomorphic angle closure. A 67-year-old man presented to the outpatient department with headache and decreased vision in his left eye for the past 3 days. Visual acuity 2/60, intraocular pressure (IOP) >60 mm Hg, and the anterior chamber (AC) depth Van Herick grade 1. A complete ophthalmologic examination revealed a phacomorphic angle closure. Serial management was performed consisting of mannitol 20% intravenously, laser peripheral iridotomy, and trabeculectomy. However, the depth of the AC became more shallow, and the IOP remained high. Lens extraction as definitive therapy could not be performed because of the adhesion of the iris and anterior lens capsule to the corneal endothelium; thus, posterior lensectomy using 3-port pars plana vitrectomy, and phacofragmatome was performed. Once the corneal thickness was returned to normal, and the AC depth was sufficient, the patient underwent secondary intraocular lens implantation. A significant improvement in visual acuity, normal IOP, and AC depth were achieved after the management of the posterior approach. Thus, this posterior approach should be considered a good option of management technique in cases with phacomorphic angle closure with very shallow AC depth and a fragile cornea.

Keywords: Anterior chamber depth; Phacomorphic angle closure; Posterior lensectomy.

Fig. 1

a AS-OCT in the left eye revealed a narrowed iridocorneal angle due to forward displacement of the lens and iris. b Anterior lens capsule adhered to the posterior iris. c A small hole connected to the posterior chamber to the AC, as indicated by a blue arrow. d Filtering bleb after trabeculectomy surgery as indicated by the red arrow. AS-OCT, anterior segment optical coherence tomography; AC, anterior chamber.

Fig. 2

One week after trabeculectomy, AS-OCT showed an extremely shallow AC depth with lenticulo-irido-endothelial adhesion. AC, anterior chamber.

Fig. 3

a Three-port pars plana vitrectomy was performed by a vitreoretinal surgeon (AMI). b Posterior lensectomy was performed once the AC depth has sufficient space to avoid friction between the lens and corneal endothelium. AC, anterior chamber.

Fig. 4

a On the first day after surgery, AS-OCT revealed thickened CCT to 814 μm. b After 3 weeks, AS-OCT showed normal AC depth after posterior lensectomy through 3-port pars plana vitrectomy, and the thickened CCT decreased to 600 μm. AC, anterior chamber; CCT, central corneal thickness.