Overcoming challenges of cataract surgery in Marfans syndrome

Take Home

Pathology in eyes with Marfans syndrome makes cataract surgery challenging and can limit implantation of a toric IOL. Jonathan D. Solomon, MD, describes a Marfans syndrome patient who underwent bilateral surgery with a very successful outcome thanks to the use of a femtosecond laser.

Dr. Solomon

By Cheryl Guttman Krader; Reviewed by Jonathan D. Solomon, MD

Bowie, MD-Use of a femtosecond laser can minimize the challenges of cataract surgery in patients with Marfans syndrome, reduce the potential for complications, and enable a successful outcome, according to Jonathan D. Solomon, MD.

Dr. Solomon detailed his positive experience using a proprietary femtosecond laser (LensAR Laser System, LensAR) to perform sequential bilateral cataract surgery with a single-piece acrylic toric IOL (AcrySof IQ Toric, Alcon) implantation to correct pre-existing astigmatism in a 55-year old patient with significant ectopia lentis due to Marfans syndrome.

The laser was used to make the clear corneal cataract incisions, capsulotomy, and to divide the cataract into eight pie-shaped fragments. A capsular tension ring was placed in both eyes and was supplemented with an Ahmed capsular tension segment in one eye to center the capsular bag. Toric IOL alignment was guided using intraoperative aberrometry (ORA, WaveTec Vision Systems) and an image overlay/registration system (Callisto Eye, Carl Zeiss Meditec).

No complications were encountered intraoperatively, and the second eye surgery was performed 1 week after the first procedure. At 1 month, the patient had excellent UCVA in both eyes (20/20-2) and minimal residual astigmatism (+0.25 −0.50 x 145 OD, plano −0.25 x 12 OS).

“This case truly highlights the benefits of femtosecond laser-assisted cataract surgery in complex cases,” said Dr. Solomon, director of refractive surgery, Solomon Eye Physicians & Surgeons, Bowie, MD. “Certainly, making the clear corneal incision, performing capsulorhexis, and removing the lens can all be more challenging in eyes of patients with Marfans associated zonulopathy, and implantation of a toric IOL would likely only be considered intraoperatively after establishing the presence of a centered and stable capsular bag with an appropriately sized and centered capsulorhexis.

“However, this case was undertaken with toric IOL implantation part of the primary plan based on the idea that use of the laser would control the variables that could interfere with its completion,” he continued. “Furthermore, had the procedure been done manually, a decision about toric IOL implantation in the second eye would likely have been significantly delayed until we could assess the outcome following a protracted recovery period. In this laser-assisted case, the patient was comfortable with his vision in the first eye after just 1 week and was confident about proceeding with the second eye.”

Diving deeper

Dr. Solomon noted that with the need to apply counter-traction, there is a significant risk of causing a capsular tear during manual capsulorhexis in eyes with Marfans syndrome.

“As long as the pupil can be sufficiently dilated to allow for laser-assisted capsulotomy, creating an intact opening of the anterior capsule in these difficult eyes is as easy as pushing a button,” Dr. Solomon said.

He also highlighted the unique imaging system of the laser platform he used as being an asset for guiding creation of a 4.95 mm anterior capsulotomy that was centered on the vertex of the subluxated crystalline lens. The laser’s technology couples high resolution Scheimpflug imaging, structured illumination, variable scan rates to create a precise, and 3-demensional reconstruction of the anterior segment, and therefore allowed determination of the thickest part of the cataractous lens.

Using the laser to fragment the lens also simplified nuclear disassembly and removal, Dr. Solomon said.

“The intralenticular gas bubbles generated by the laser treatment essentially caused a pneumatic dissection of the lens material that enabled a relative delineation of the nuclear portion of the cataract and then allowed for a straightforward viscodissection of the residual epinuclear and cortical material,” he said. “Whereas zonular instability in eyes with Marfans syndrome can make removal of the nucleus, epinucleus, and cortex challenging, these steps were done safely and predictably following laser lens fragmentation.”

Jonathan D. Solomon, MD

E: jdsolomon@hotmail.com

Dr. Solomon is a consultant to LensAR and WaveTec Vision Systems.