Management of Subluxated Lenses - KSOS

June 2009 S R John et al. - Management of Subluxated Lenses 163 

Management of Subluxated Lenses 

Dr. Sonia Rani John DNB, Dr. Meena Chakrabarti MS DO DNB, Dr. Arup Chakrabarti MS 

Introduction 

Subluxation of lens signifies partial displacement of 

crystalline lens or cataractous lens from its central 

position in the pupillary area. 

Fig. 1. A subluxated clear lens 

Etiology 

Subluxation of lens may be congenital or acquired. 

Congenital subluxation of lens can occur as an isolated 

anomaly or associated with heritable disorders. The 

acquired subluxation of lens may occur due to 

hypermaturity of cataract, trauma, stretching, pull and 

degeneration of the zonule 1,2,3,4 . 

Signs of Zonular damage should be sought in every 

patient especially if there is history of ocular trauma 

or pseudo-exfoliation (PXF). 

- Systemic abnormalities associated with zonular 

weakness (Marfan’s, Weil Marchesani, 

Homocysteinuria) may not always be present. 

Hense a loose cataract may be overlooked with 

severe surgical consequences. Waneela MV 

Margress et al 5 describe 5 subtle signs of zonular 

Chakrabarti Eye Care Centre, Kochulloor, Trivandrum 695 011 

E-mail: tvm_meenarup@sancharnet.in 

damage that should be looked for as a warning 

sign. These includes 

1. Visibility of the lens equator during eccentric gaze. 

2. Decentered nucleus in primary position 

3. Iridolenticular gap. 

4. Changes in contour of lens periphery. 

5. Focal iridodonesis. 

OPHTHALMIC 

SURGERY 

Obvious signs of subluxation are less easy to miss and 

includes phacodonesis,vitreous prolapse, iridodonesis, 

and lens subluxation. 

Fig. 2. Anterior segment images demonstrating various 

degrees of subluxation of the crystalline lens 

Even without development of cataract, subluxation of 

the crystalline lenses can induce significant visual 

symptoms such as large refractive errors, 

anisometropia, or amlyopia in a child undergoing visual 

development.. Historically surgical treatment for 

sublaxated lens was undertaken with great caution

164 Kerala Journal of Ophthalmology Vol. XXI, No. 2 

because of attendant complications and poor visual 

outcome. 

Surgical management was limited to Surgical 

iridectomies, Laser iridectomy, discission, or ICCE 

Patients who underwent ICCE were either left aphakic 

or prescribed aphakic correction ,or CL or were advised 

Epikeratophakia. An ACIOL in an older patient was 

another option that was considered.These patients 

ended up with graft rejection, retinal detachment, 

glaucoma and gross visual loss. 

Advances that have been made in the surgical 

management of patients with weak / missing zonules 

are SICS, Pars plana lensectomy and aphakic CL wear 

or 2 0 ACIOL implantation, suturing PCIOL to ciliary 

sulcus / posterior aspect of iris 6,7 , introduction of 

CTR(capsular tension rings), MCTRs (modified capsular 

tension rings), CTSs (capsular tension segments) 8,9,10,11 

and the possibility of small incision phacoemulsification 

with in the bag IOL implantation. 

Management 

Timing of surgery is critical and is governed by the 

amount of subluxation. Children who are in their 

visually formative years, need early surgery if they have 

a large amount of subluxation. Early surgery and visual 

rehabilitation prevents development of amblyopia or 

permits early initation of amblyopia therapy. In children 

with minimal amounts of subluxation that is compatible 

with normal visual development can be followed up 

without surgical intervention. 

An initial assessment of the BCVA for distance and near 

should be performed. Several attempts at refracting the 

child is necessary before deciding whether he is seeing 

best with the phakic or aphakic correction. If the 

subluxation is not large and there is no eminent danger 

of the lens dislocating posteriorly or anteriorly 

observation with institution of amlyopia therapy is all 

that is necessary. 

If amplyopia cannot be effectively treated by 

conventional means such as glasses, contact lens, or 

patching, surgical treatment is advisable. 

Surgical treatment is also advisable if there is 

1. Progressive subluxation. 

2. Lens bisects pupil 

3. Threathened posterior or anterior dislocation 

4. Any case of poor visual acuity in an older child or 

adult. attributable to subluxated lens. 

Preoperative evaluation 

Comprehensive preoperative examination is necessary 

to increase the chances of surgical success. 

a) The surgeon should make a note of the ‘area of 

zonular weakness “ by drawing it. He should also 

i. Characterize the areas of zonular weakness in 

terms of degree of involvement. 

ii. Location of the defect. 

iii. Presence / absence of vitreous prolapse. 

iv. Presence / absence of phacodonesis: Phacodonesis 

is most dramatic prior to pupillary dilation, as 

dilation often stabilizes the CB and iris, dampening 

any iris - lens movement. 

A surgeon should be wary of inferiorly subluxated lens 

as such as sublaxation is often indicative of 360 0 of 

very significant zonular damage combined with the 

effect of gravity. When the patient is made to lie down 

the lens will fall back posteriorly. In this situation it is 

unlikely that the surgeon will be able to remove the 

lens while preserving the capsular bag for PC IOL 

support. PPL should be considered in these cases. 

b) Gonioscopy should be performed in older childrenn 

to acess for angle recession, synchiae etc if ACIOL 

implant is considered. 

Patients should be counseled with regards to a sutured 

PCIOL / or a CTR. 

c) The presence of comorbid conditions affecting visual 

outcome should be assessed. 

d) Evaluation by internists to rule out systemic 

associations is also necessary. 

e) Discontinuing oral anticoagulants as most if these 

patients have asso cardiovascular diseases and may be 

on anticoagulant therapy. 

A thorough ocular examination including a cycloplegic 

refraction, slit-lamp examination and detailed fundus 

evaluation should be done to assess the extent of 

subluxation and to plan the treatment approach. The


presence of iridodonesis, phacodonesis, lens edge and 

visible zonules, and relatively deep or an irregularly 

deep anterior chamber should be noted. If the lens is 

clear, look for irregular red reflex, displacement of 

“Y”sutures, and high refractive error. Intraocular 

pressure recording (IOP) and gonioscopy must be 

carried out. 

Systemic examination is important. A thorough family 

history, complete cardiovascular and musculoskeletal 

evaluation may be needed in Marfan”s syndrome. In 

doubtful cases sodium nitroprusside test for 

homocystinuria must be done before subjecting the 

patient for general anesthesia. 

Management of Clear Subluxated Lens 

Conservative Approach 

A minimally subluxated crystalline lens requires only 

observation and periodic follow-up. If the subluxation 

causes visual disturbances due to induced astigmatism 

or myopia, the management includes a cycloplegic 

refraction and subjectiveverification with prescription 

of full correction. Examination of undilated, aphakic 

and phakic portions of the pupil should be done to 

ascertain whether the patient has got unilateral 

diplopia or confusion. Appropriate spectacle correction 

with aphakic glasses, contact lenses or prisms is 

provided which gives better visual improvement than 

phakic correction. Argon or Nd:YAG laser iridoplasty 

can be tried to enlarge the aphakic portion of pupil. 

Management of Subluxated Cataract 

Lens extraction via a small incision PE and PCIOL 

implantation should be attempted in every case and 

the basic surgical principles are described below. 

Surgical principles to be understood include 

1. Incision should be placed away from area of zonular 

weakness to help reduce stress on the existing 

zonules during PE. Unfortunately majority of the 

patients have generalized zonular weakness. In 

this situation the surgeon should place the incision 

in the gradient opposite to the zone of maximum 

zonular weakness However, the surgeon should 

not jeopardize his surgical ability by operating 

in a meridian he is uncomfortable with. 

2. Surgeon should work through the smallest incision 

possible without compromising the ability to 

perform necessary maneuvers. This will minimize 

fluid egress through the incision and prevent 

anterior chamber collapse. The initial AC entry 

should be just large enough to introduce a visco 

cannula. 

3. A generous amount of highly retentive viscoelastic 

is placed over the area of zonular dialysis to help 

tamponade the vitreous and to maintain a deep 

non collapsingAC. 

4. The capsulorhexis is started in an area remote 

from the dialysis to help utilize the counter acting 

forces of the remaining healthy zonules. 

5. A second instrument is used for counter traction 

or to push the lens into view if it is significantly 

decentered under the iris 

6. When there is extensive zonular loss or weakness 

it may be a good strategy to start the rhexis by 

cutting the anterior capsule with a sharp tipped 

blade. 

7. A rhexis of 5.5 mm – 6mm will facilitate all 

manipulations of the nucleus. 

8. Hydrodissection: should be performed carefully 

yet thoroughly to maximally free the nucleus 

thereby decreasing zonular stress while 

manipulating the nucleus. 

9. A soft nucleus can be completely prolapsed into 

the anterior chamber to simplify removal and 

virtually eliminate all zonular stress. 

10. Phacoemulsification should be performed using 

low vacuum and aspiration settings in order to 

keep the bottle height at a minimum, a technique 

known as ‘slow-motion Phaco developed by Robert 

Osher. 

11. Bottle height : it is important to keep the bottle at 

an optimum height, neither too high nor too low. 

a. Very high bottle height can in turn force fluid 

through weak areas of the zonules hydrating the 

vitreous resulting in positive pressure, anterior 

chamber shallowing and vitreous prolapse. 

b. Too low bottle height can result in an out flow, 

which is greater than inflow again resulting in


shallowing of anterior chamber, a negative 

pressure in AC and further vitreous prolapse as 

the anterior segment is less pressurised than the 

posterior segment. 

12. Divide and or chop technique are preferred in eyes 

with zonular weakness. This technique minimises 

zonular stress during phacoemulsification if 

surgeon is careful to apply equal forces in opposing 

directions to avoid displacing the nucleus. 

13. “Visco dissect” nuclear halves / quadrants in areas 

of zonular weakness. The viscoelastic should be 

injected below the nuclear fragment and the 

capsular bag- lifting the nuclear fragment as well 

as expanding and stabilizing the capsular bag. 

Additional cortical removal by visco dissection 

will limit stress on the remaining zonules during 

aspiration of cortex. 

14. Automated Irrigation and Aspiration device is not 

preferred for cortex removal as it can hydrate 

vitreous and increase vit prolapse. Manually 

aspirate with a 24/ 27 G canula striping cortex in 

a tangential manner instead of radially to limit 

stress on zonules. A ‘J’ cannula can be used for 

sub incisional cortex .Ensure removal of all 

vitreous from the anterior chamber if it is present. 

Use ‘Dry vitrectomy’ with automated vitrector 

after filling anterior chamber with viscoelastics. 

For significant vitreous loss a bimanual vitrectomy 

should be performed. 

IOL placement options 

1. The surgeon should decide if it is safe to use an 

ACIOL or PCIOL. 

2. If an ACIOL is used the remnants of the capsular 

bag should be removed to prevent contraction and 

opacification. 

3. If the surgeon uses a PCIOL it should be either 

a. Sutured to the scleral wall or 

b. Placed in the capsular bag 

Ciliary sulcus placement of PCIOL without suture 

fixation in an eye with significant zonular compromise 

is not recommended. 

Placement of PCIOL into the capsular bag 

1. Placement of PCIOL into the capsular bag is 

challenging when there is significant zonular 

weakness as one must achieve IOL centration, and 

maximize long term stability. 

2. Use of 6 mm optic diametre IOL decreases the 

chances of undesirable edge - glare symptoms 

should lens decentration occur post operatively. 

Haptic configuration designed for broad contact 

with equatorial capsular bag increases the chances 

of long term centration. Use of silicone plate haptic 

IOL. should be avoided in the presence of zonular 

dialysis as there is greater chance of capsular 

contraction and decentration. 

3. Insertion of CTR to provide 360 0 capsular bag 

expansion and greater stabilization. 

4. If the ZD is located at the incision site, lens 

placement is more difficult. 

a. One Option is to first place the entire lens into 

the AC. Then using a two handed technique, the 

superior haptic is inserted into the capsular bag 

followed by a similar maneuvre for the inferior 

haptic. 

5. Orientation of the IOL: There are 2 schools of 

thought. 

a. Orienting the IOL in a plane parallel to the zonular 

dialysis (ZD) in order to take advantage of the 

remaining intact zonules. This orientation will 

provide optimum support but may induce ovaling 

of the capsular bag and an increased risk of 

postoperative decentration. 

b. Placing one haptic in area of ZD will ensure 

stretching of the bag and decrease ovaling. 

However it should be borne in mind that only one 

haptic is adequately supported. 

It is recommended to orient the haptics in whichever 

axis that provides the best centration intraoperatively. 

This is accomplished by careful rotation of PCIOL. 

Capsular Tension Ring (CTRs) 

Drs Witschel and Legler (1993) from Germany 

demonstrated that CTRs could provide both 

intraoperative and postoperative stabilization of


the capsular bag. Produced by Morcher Gmbh, in 

Stuttgarf, Germany and made of polymethyl 

methacrylate (PMMA), this ring can be inserted 

into capsular bag at any point after a continuous 

curvilinear capsulorhexis has been completed. 

Use of CTR is contra indicated if a CCC is not 

attained or if a posterior capsular rent occurs. 

In eyes with profound zonular compromise or lens 

subluxation may not achieve adequate 

stabilization or centration despite CTR placement. 

Long term stability even in presence of CTR is doubtful 

in eyes with progressive zonular weakness such as 

Marfans, PXF etc. Phacoemulsification with the proper 

use of endocapsular device can give excellent results 

in patients with subluxated cataracts 

Fig 3. Capsular tension rings of commonly used sizes ,Geuder 

injector and intraoperative still photography to 

demonstrate CTR insertion 

Step1: Injection of VE under the surface of the residual 

anterior capsular ring to create a path for the CTR. 

Viscoelastic agents dissect peripheral cortex away from 

the capsular fornices and make up cortex entrapment 

by CTR less likely. 

Step 2 : 

a) CTR is introduced either using a smooth forceps 

through the main wound or a paracentesis or by 

b) Using a CTR injector / CTR shooter (Geuder) 

Step 3 : In eyes where CTR is introduced prior to 

phacoemulsification a safety suture is looped through 

the leading eyelet and is allowed to trial out of the eye 

Fig. 4. Intraoperative stillphotography demonstrating CTR 

insertion 

at the main incision during PE and cortical aspiration. 

This guiding suture is used to retrieve the CTR from 

the eye should a posterior capsular rent occur during 

phacoemulsification or cortex removal. If the procedure 

is uneventful the suture is cut and removed. 

Standard capsular tension ring 

Credit goes to Hara and Yamada 12 for introducing 

endocapsular ring in the year 1991 for maintenance of 

the circular diameter of capsular bag. Later the device 

Fig. 5. Standard capsular tension ring 

was further refined and modified for managing severe 

degree of subluxated lenses 12-16 . 

The standard CTR in made of polymethyl 

methacrylate(PMMA) material and has an oval shaped 

cross section with eyelets at both free ends (Fig.5). 

It is a compressible circular ring with two smooth edged 

end terminals. 

CTR is manufactured by Morcher GmbH (Struttgarf, 

Germany) and Ophtek (Groningen, The Netherlands)


Fig. 6. Morcher CTRs 

Type 14, MR – 1400, 

For Normal Eyes 

Expanded 12.3mm, 

Compressibility 10.0mm, 

Axial Length < 24mm 

Type 14A, MR – 1410, 

For Highly Myopic Eyes 



Axial Length < 28mm 

Type 14C, MR – 1420, 

For Normal or Myopic Eyes 



Axial Length 24 - 28mm 

and is US-FDA approved. The Morcher ring, also known 

as Reform ring, comes in three different sizes based on 

the uncompressed diameter (Fig.6). 

Capsular ring size 

Selection of CTR size is based on capsular bag 

dimensions. A large capsular bag usually requires a 

larger ring; 13mm ring is being most commonly used. 

White to white corneal measurement and axial length 

can be used as a rough guide in the selection of CTR. It 

would be appropriate to use a larger CTR in adults with 

highly myopic eyes. 

Step 4: Placement of IOL in the bag and has the CTR is 

no different than routine cases, infact it may be even 

easier as the bag is better supported. 

Step 5: Suturing the CTR to Scleral wall for support. 

although it works well involves risk of rupturing 

the capsular bag since it is under stretch due to 

presence of CTR. 

Vladimic Pfizer’s technique involves needle passage thro 

a small peripheral capsulorhexis. However the integrity 

of the capsular bag is violated and the risk of rupture is 

present. 

In more severe subluxation, modified CTR, like Cionni’s 

M-CTR with one or two eyelets attached to the central 

ring is used and a posterior chamber IOL (PCIOL) 

placed in-the-bag. 

Robert Cionni:s Modified CTR (MCTR) 8,9,10 has an 

unique fixation hooklet designed for scleral fixation 

without violating the integrity of capsular bag. The 

fixation hook courses anteriorly and centrally in a 

second plane, wraps around the capsulorhexis edge 

and rests on the residual anterior capsular rim. 

Modified capsular tension ring (M- CTR) 

The standard CTR is unable to provide adequate 

intraoperative support and centration of the bag in 

Ring with single eyelet Ring with double eyelets 

Fig. 7. Cionni’s modified capsular tension ring 

a) Robert Osher has desired a technique of suturing 

the CTR to the scleral wall by straddling the CTR 

with 10 0 prolene double suture. This technique Fig. 8. Cionni’s modified Capsular Tension Segments


grossly subluxated cataracts or lenses. Cionni 5 

developed the modified CTR (M-CTR) (Morcher – 

GmbH) called Cionni ring in the year 1998. This ring 

provides a solution to extensive zonular deficiency or 

damage or progressive zonular damage by allowing the 

surgeon to anchor the capsular bag to the sclera. 

3 modules are currently available. 

Model 1 L : Single fixation hook distant from insertion 

end of the ring. 

Model 2 C: Single fixation hook near insertion end of 

the ring. 

Model 2 L: has 2 fixation hooks which is very useful in 

patients with significant zonular weakness and may be 

the ring of choice in patients with progressive zonular 

weakness as in Marfan’s Syndrome. 

The Cionni’s modified ring has an open ring design 

with one (model I-L or I-R) or two (model 2-L) 

fixation eyelets attached to the central ring (Fig 7). 

The eyelet allows the ring to be sutured to the sclera. 

It protrudes 0.25mm forward from the body of the 

ring and then sits anterior to the anterior capsular rim 

and allows maintenance of capsular bag integrity on 

suturing to the sclera. A 9.0 prolene is preferred over 

10.0 prolene as the incidence of breakage is less with 

the former. An adequately sized rhexis is essential to 

prevent iris chaffing, pigment dispersion and chronic 

uveitis. 

An eccentric rhexis has to be performed in order to be 

certain that after the bag is recentred, the capsulorhexis 

opening is recentered as well. 

Fig. 9. Capsular tension segment 

Capsular tension segment 

Capsular tension segment (CTS) is a partial ring of 

90-120 circumference, and is made of PMMA 

(Fig. 8 & 9). It has a radius of 5mm and an anteriorly 

positioned fixation eyelet like M- CTR. This was 

designed by Ahmed 17 . and was manufactured by 

Morcher GmbH. CTS is useful for cases with profound 

zonular insufficiency. The CTS provides support in the 

transverse plane, when sutured to the scleral wall. 

When circumferential support is needed, a CTR may 

be implanted in conjunction with an already positioned 

CTS. The CTS in available in 3 sizes having radus of 

curvature of 4.5 mm , 5 mm and 5.5 mm. 

The choice of endocapsular support device depends 

mainly on the nature of zonular weakness, degree of 

zonular loss, and the extent of zonular instablity. CTRs 

are indicated in cases of mild, generalized zonular 

weakness or in small localized zonular dialysis of less 

than 3-4 clock hours. In more advanced or progressive 

Table 1: Indications of capsular tension ring, modified-capsular tension ring and capsular tension segment 

CTR M-CTR CTS 

Requires continuous curvilinear capsulorhexis Yes Yes No 

May be placed prior to lens removal With difficulty With difficulty Yes 

Use with anterior capsule tear No No Yes 

Use with posterior capsule rent No No Yes 

Use with large zonular dialysis (more than 8 clock hours) No Yes Yes 

( multiple segments) 

Use in progressive zonulysis No Yes Yes 

Allow for suture fixation to sclera No Yes Yes 

May be easily removed from eye if needed No No Yes 

Cortical removal difficulty Yes Yes No 

CTR: capsular tension ring, M-CTR: modified-capsular tension ring, CTS: capsular tension segment


Fig. 10.Successful outcome of surgery in a case of subluxated 

Lens 

cases of zonular instability, the Cionni M- CTR or the 

CTS is indicated. Indications of CTR, M-CTR and CTS 

are given in Table 1. 

Closed chamber endocapsular phacoemulsification 

combined with ECR, in patients with mild to moderate 

subluxation of lens not associated with complications 

such as secondary glaucoma and retinal detachment, 

often gives encouraging visual results. The implantation 

of ECR has provided safety and efficiency during 

phacoemulsification and IOL implantation, significantly 

reduced the rate of complications and overall improved 

visual results. 

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Management of Subluxated Lenses - KSOS

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