Commentary: Innovation is the key to manage complications in rare ocular conditions like spherophakia
Spherophakia is a rare diagnosis that is characterized by weak zonules encircling a more spherical, smaller, and thicker anteroposterior crystalline lens.[1] The eye is usually severely myopic. The lens zonules are abnormally weak and hypoplastic during development. It frequently coexists with lenticular myopia, lens subluxation, angle-closure glaucoma, and a shallow anterior chamber.[1] The crystalline lens in this situation has an increased anterior–posterior diameter and a smaller equatorial diameter.[2] Lens subluxation can cause pupillary block glaucoma[3] and can happen anteriorly, inferiorly, or posteriorly.[4] The indication of undergoing a lensectomy has already been mentioned for treating a displaced lens.[5] The surgeon and the patient's characteristics play a significant role in the intraocular lens (IOL) selection. Both iris-fixated lenses[6] and angle-supported anterior chamber lenses (ACIOLs) are frequently used. Numerous case studies have also discussed posterior chamber IOLs (PCIOLs) and scleral-fixated IOLs (SFIOLs) – glued or sutured with/without capsule tension rings (CTR).[7,8] In 2008, Agarwal et al.[9] introduced the glued IOL technique, which was glued intrascleral haptic fixation of a PCIOL. Zonular weakness is frequently linked to ectopia lentis, congenital cataract with luxation, or traumatic cataract. A PCIOL (foldable or nonfoldable) is implanted in the eyes with a defective posterior capsule using a quick-acting surgical fibrin sealant. Glued IOL in various indications has shown very promising results. In nearly half of the cases of spherophakia, it is accompanied with subsequent glaucoma.[10] When the intraocular pressure (IOP) is uncontrolled, there is disagreement over the treatment to manage these eyes. Based on our previous experience and various studies, lens removal alone appears to help with IOP management in around 50% of the eyes, with the remainder perhaps handled with additional drugs. Glaucoma surgery is seldom required for IOP management.[11] Lensectomy, vitrectomy, and glued IOL have been done in eyes with spherophakia and secondary glaucoma in the current investigation. The findings of these procedures seem to be favorable in terms of the procedure's safety and effectiveness. In one-third of the eyes, the IOP was managed without the use of Anti-Glaucoma Medications (AGM); the remaining eyes required AGM for IOP management. Lensectomy with glued IOL resulted in significant improvement in visual acuity and correction of refractive error to almost emmetropia in a majority of the eyes. Other factors associated with poor glaucoma control were also evaluated. Preoperative AGM, male gender, and low preoperative visual acuity were shown to be related to poor glaucoma management and the requirement for AGM or surgery to reduce IOP. Rao et al.[11] previously showed that younger age at presentation, higher IOP, and more disk injury at presentation were all substantially linked with increased failure after lensectomy. Muralidhar et al.[5] did report that lensectomy did not have any impact on IOP. Lensectomy was performed in 16 eyes in their study, but only four eyes had raised IOP before lensectomy. Hence, from four eyes, one cannot interpret that lensectomy is not effective in controlling IOP. In a study by Rao et al.,[11] following lensectomy, close to half of the patients had IOP control without AGM, while only one-third of the patients in this glued IOL cohort could achieve the same. The percentage of eyes needing surgical intervention for IOP control was similar (16%) either with lensectomy or with lensectomy with glued IOL surgery in eyes with spherophakia and secondary glaucoma. To the best of our knowledge, this was the first study to report on the results of lensectomy with glued IOL in spherophakia and glaucoma eyes.[12] Overall, IOP was managed well in 30% of the eyes after lensectomy and glued IOL without the need for AGM, 65% of the eyes required AGM for IOP management, and only 5% of the eyes required glaucoma surgery. The study's shortcomings include a small sample size and a short postoperative follow-up period. The benefits of conducting lensectomy with glued IOL in eyes with spherophakia include not only improved IOP management, but also improved uncorrected and corrected visual acuity. There were no intraoperative or postoperative complications in this sample, indicating that the technique is safe. The authors would like to advocate lensectomy with glued IOL in spherophakic eyes with subluxated crystalline lens and increased IOP in the absence of syndromic disease due to these benefits and the shorter learning curve.[12] However, these individuals require regular monitoring of IOP; one-third of the eyes had well-controlled IOP, and almost two thirds required further antiglaucoma drugs or surgery for IOP management. Because this is a recent surgery, long-term results and complications must be investigated to determine the technique's long-term effectiveness and safety.
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