Ординатура / Офтальмология / Учебные материалы / Clinical Diagnosis and Management of ocular trauma
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Clinical Diagnosis and Management of Ocular Trauma |
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• In cases of posterior dislocation without glaucoma, |
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– Sulcus fixation is safe if posterior capsule is |
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inflammation, or visual obstruction, surgery may |
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compromised but zonular support is maintained. |
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be avoided. |
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– Suture fixation is chosen if both capsular and |
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Indications for surgery include the following: |
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zonular supports are insufficient and the angle |
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Unacceptable decreased vision |
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is damaged minimally. |
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– Obstructed view of posterior pathology |
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– Anterior chamber placement is an option if no |
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– Lens-induced inflammation or glaucoma |
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posterior support remains and iris or ciliary body |
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– Capsular rupture with lens swelling |
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trauma prevents suture fixation. |
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– |
Other trauma-induced ocular pathology |
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– Aphakia may be a better choice in young |
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necessitating surgery. |
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children and patients with highly inflamed eyes; |
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Standard phacoemulsification or manual small |
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they may experience better outcomes if lens |
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incision cataract surgery may be performed if lens |
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implantation is deferred. |
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capsule is intact and sufficient zonular support |
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remains. |
COMPLICATIONS |
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• Intracapsular cataract extraction is required in cases |
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Surgery for traumatic cataract is associated with high |
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of anterior dislocation or extreme zonular instability. |
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incidence of complications and surgeon should |
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Anterior dislocation of the lens into the anterior |
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anticipate and be prepared for complications during |
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chamber requires emergency surgery for its |
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the |
surgery. The different complications during |
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removal, as it can cause pupillary block glaucoma. |
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traumatic cataract surgery can be: |
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• Pars plana lensectomy and vitrectomy may be best |
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Posterior capsular rent |
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in cases of posterior capsular rupture, posterior |
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dislocation, or extreme zonular instability. |
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Zonular dialysis |
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•Automated irrigation/aspiration can be used in patients younger than 35 years. Look for the posterior capsular support preoperatively, should be careful while performing automated irrigation aspiration and while switching the anterior chamber maintainer on as the fluid flow inside the eye can enlarge the pre-existing posterior capsular dehiscence and can result in lens matter drop or nucleus drop.
•Lens implantation:
–Capsular fixation is the preferred placement if lens capsule and zonular support are intact. In the case of surgery to remove a traumatic cataract, the CTR may be implanted before or after phacoemulsification. Although early inser-
tion provides support during phacoemulsifi-
cation, it may create additional zonular trauma. Fig. 15.1: CTR in bag The use of iris or capsule retractors at the
capsulorhexis’ edge or the use of a capsular tension segment (CTS; Morcher GmbH, Stuttgart, Germany (not currently approved by the FDA]) during phacoemulsification are other alternatives that do not induce significant capsular torque during insertion. The CTS is a partial PMMA ring segment containing an anteriorly offset eyelet through which an iris retractor or suture may be placed.
–Capsular tension ring should never be implanted in cases with broken capsulorrhexis and in eyes with pre existing posterior capsular rent.
–Polymethyl methacrylate (PMMA) capsular tension rings allow capsular fixation in cases of
zonular dialysis less than 180 degrees. Fig. 15.2: Traumatic cataract with torn anterior capsule
Management of Traumatic Cataract |
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Fig. 15.3: Deposits on IOL |
Fig. 15.6: Traumatic cataract with breached AC |
Fig. 15.4: Partial lens abscess |
Fig. 15.7: Traumatic cataract with foreign body |
Fig. 15.5: Postcataract surgery with partially |
Fig. 15.8: Traumatic cataract with haem |
repaired iris |
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Clinical Diagnosis and Management of Ocular Trauma |
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Fig. 15.9: Traumatic cataract with IOL in torn bag |
Fig. 15.11: Traumatic cataract with loose lens mattter in AC |
Fig. 15.10: Traumatic cataract with iris hole |
Fig. 15.12: Traumatic cataract with subluxation of lens |
Fig. 15.13: Early Rosete cataract
•Nucleus or lens matter drop
•Postoperative unusual inflammation
•Posterior capsular opacification
•Pupillary capture of IOL
•Postoperative refractive surprise.
Bibliography
1.Benezra D, Cohen E, Rose L. Traumatic cataract in children: correction of aphakia by contact lens or intraocular lens. Am J Ophthalmol. 1997;123(6):773-82.
Management of Traumatic Cataract |
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2. Eckstein M, Vijayalakshmi P, killedar M, Gilbert C, Foster |
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Krishnamachary M, Rathi V, Gupta S. Management of |
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A. Use of intraocular lenses in children with traumatic |
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traumatic cataract in children. J Cataract Refract Surg |
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cataract in south India. Br J Ophthalmol 1998;82(8): |
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1997;23(Suppl 1):681-87. |
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Mian SI, Azar DT, Colby K. Management of traumatic |
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911-15. |
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cataracts. Int Ophthalmol Clin Review 2002 Summer; |
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3. Gain P, Thuret G, Maugery J. Management of traumatic |
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42(3):23-31. |
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cataracts. J Fr Ophtalmol. Review French 2003; |
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8. |
Moreno J, Sainz C, Maldonado MJ. Intraoperative and |
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26(5):512-20. |
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postoperative complications of Cionni endocapsular ring |
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4. Jacob S, Agrawal A, Agrawal A, Agrawal S, Patel N, Lal |
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implantation. J Cataract Refract Surg 2003;29(3):492-97. |
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V. Efficacy of a capsular tension ring for phaco- |
9. |
Panda A, Kumar S, Das H, Badhu BP. Striving for the |
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emulsification in eyes with zonular dialysis. J Cataract |
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perfect surgery in traumatic cataract following penetrating |
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trauma in a tertiary care hospital at eastern Nepal.JNMA |
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Refract Surg 2003;29(2):315-21. |
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J Nepal Med Assoc 2007;46(167):119-25. |
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5. Kazem MA, Behbehbani JH, Uboweja AK, Parmasivam |
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10. |
Praveen MR, Vasavada AR, Singh R. Phacoemulsification |
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MB. Traumatic cataract surgery assisted by trypan blue. |
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in subluxated cataract. Indian J Ophthalmol 2003; |
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Ophthalmic Surg Lasers Imaging 2007;38(2):160-63. |
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51(2):147-54. |
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C H A P T E R
16Management of Traumatic Luxation
of the Crystalline Lens
Arturo Pèrez-Arteaga, Yuri Flores (Mexico)
Introduction
This chapter will cover different criteria regarding the management of the Traumatic Luxation of the Lens. Many authors have spoke about this topic worldwide and the clinical and surgical concepts are not uniform. These differences might be in some cases because the blunt eye trauma is different from one patient to another, and so the degree of zonular damage can be different, and also some associated lesions-, but furthermore, as new technologies are arising in the ophthalmic field (e.g. iris claw IOLs, iris fixation IOL techniques), some ophthalmic surgeons developed more experience in some particular technique or device, and so the management can be complete different from one surgeon to another.
We will try to review different approaches according the current literature and our personal experience, but the reader must consider that science is always working ahead in benefit of the patients, so some criteria might be “out of site” after a short period of time.
Blunt Eye Trauma
As the reader has noticed viewing this book, the possibilities of damage (going from mild, to moderate and severe) to the eye structures during a blunt trauma are enormous; no one particular case is exactly the same than another, and distinctive considerations must be taken in count in each clinical evaluation and approach. It is also known that the clinical condition of the eye can have variations according the time of evolution of the lesion, clinical management, preexistent eye diseases (e.g. high myopia, pseudoexfoliation), and many other possibilities that can influence the clinical course and so the management of the case, and finally the outcome.
We will describe the condition in which the crystalline lens has been moved from its anatomical position because of a blunt eye trauma, either
associated or not, to some other damage to the eye structures; if well not all the possibilities of damage can be review (even in the whole textbook), a didactic classification has been done in this chapter, trying this way to cover as much alternative lesions as possible, in order to obtain a didactic scheme useful during the clinical evaluation, the plan of a surgical approach, the intraoperative management, the eventual postoperative complications and the clinical prognosis.
Luxation and Subluxation of the Crystalline Lens
(Figs 16.1 and 16.2)
In many circumstances these conditions are not easy even to distinguish between them, since the finding of a proper definition; for some authors when some zonular attachments still exist the condition is defined as subluxation, and the complete crystalline lens luxation is defined by the whole loose of zonular attachments. Even so, sometimes the clinical evaluation of these two forms of crystalline lens dislocation can be difficult to perform; if well this might be difficult in a non-traumatized eye (e.g. Marfan syndrome), you can now imagine an evaluation of this condition in a traumatized eye, when sometimes some other lesions can decrease the visualization of the examinator (e.g. hyphema, suprachoroid hemorrhage), not only at the clinical approach, but furthermore, at the paraclinical evaluation (e.g. eye ultrasound, eye scan). Because of this, sometimes the final definitions are performed at the intraoperative period, and so the clinical evaluation and transoperative decisions are the rule. So, we think that for the starting point of evaluation of these cases of dislocated crystalline lens because of a traumatic condition, the surgeon must think from the start, that all the zonular attachments have been lost, and only during the intraoperative period the real dimension
Management of Traumatic Luxation of the Crystalline Lens |
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appraise, in order to establish an adequate medical criteria of management. Keep always in mind during the diagnostic period, the proper evaluation of damage to the rest of the structures of the eye and the evolution that the lesions might have, by their own, during a certain period of time.
Previous Medical Conditions
Fig. 16.1: Traumatic lens dislocation with cataract formation
Fig. 16.2: Traumatic lens subluxation
The medical history of some previous conditions of the particular patient, have great importance. Systemic conditions like diabetes, connective tissues diseases, coagulation pathologies between others, enhance our multidisciplinary point of view of the case; systemic medication like aspirin or other anticoagulants are mandatory to know.
Previous eye diseases and/or ocular surgeries and trauma, are of course mandatory to ask to the patient; but furthermore, and of particular importance for the evaluation of the crystalline lens feature, some particular eye conditions like diseases associated with progressive zonular weakening and capsular contraction (e.g. pseudoexfoliation syndrome, uveitis, myopia, Marfan syndrome); the possibility of a previous zonular weak, can change by complete our point of view, and so our surgical approach; with some previous condition of zonular weakening, even a minor ocular trauma, can dislocate by complete the crystalline lens.
Also alternative treatments (prescribed or not) that the patient had has, in an attempt to solve the traumatic condition of the eye before our first contact with him, are very value to appraise; some of them are able to affect the initial lesion and even convert it into a worst scenario; keep in mind and ask for them.
Sometimes because the anxiety experienced by the patient, relatives and medical personal, a complete clinical history is not properly taken; the surgeon must be aware of the previous medical conditions of the patient, because some factors of the medical history might be decisive in the decision taking process.
of the zonular damage can be seen. Even so, sometimes after and accurate evaluation and management of a subdislocated crystalline lens, with cataract surgery and “in-the-bag” IOL implantation, a late IOL dislocation can be seen; it means that a long term complication is still changing our first clinical impression.
CLINICALEVALUATION
A complete preoperative evaluation of the condition and situation of the crystalline lens, is of crucial importance for the design of the management of these lesions. Situations like position, movement, degree of opacity, integrity of the capsular bag and degree of hydration, are maybe the most important features to
Trauma Mechanism
The evaluation of the trauma mechanism is of critical importance in the possibility of a zonular weakening; because of the transmission of forces into the ocular globe, sometimes the surgeon can see an eye almost free of damage during the first clinical evaluation (maybe some low degree of traumatic uveitis), but the eye might have severe zonular damage (even without cataract formation); so the proper history taking about the trauma mechanism is mandatory. As you might see in different parts of this book, there are currently types of trauma mechanism that cause a particular kind of damage in the eye; they are well known.
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Clinical Diagnosis and Management of Ocular Trauma |
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Associated Lesions to the Lens Luxation |
ultrasonic evaluation of the globe (eye echography); |
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It is difficult to find a traumatic lesion of the ocular |
I do believe, that echograhy must be performed in |
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globe capable to cause only zonular weakening and |
all cases of eye trauma, not only because it helps |
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a luxation or subluxation of the crystalline lens as an |
evaluate the integrity of the globe and some other |
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unique lesion; if well it can happen, it is almost a rule |
associated features in presence of not-clear media, but |
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that the crystalline damage is accompanied by injury |
also because it helps demonstrate the weakening of |
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to some other ocular and extraocular (e.g. orbital) |
the zonula in cases of suspected lens subluxation, and |
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structure, that must be complete addressed during a |
furthermore, in cases of complete luxation helps |
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clinical and paraclinical approach. Also, the surgeon |
achieve the location of the crystalline lens within the |
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must keep in mind that some conditions might change |
eye. |
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with the running of time; sometimes the initial clinical |
So, thinking in performing echography in all cases |
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features are not related to the crystalline lens lesion |
of ocular trauma (even in the presence of clear media), |
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itself (e.g. increase in the intraocular bleeding, |
not only some subclinical conditions can be discovered |
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presentation of retinal detachment, increase in the |
by this way, moreover the weak of the zonula is very |
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intraocular pressure because an angular recession), but |
easy to evaluate with this method; remember to have |
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within the evolution, a non-primary lens-related |
a good communication with your echographist, and |
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situation, can become an indication of lens removal |
even think that you must be present during the study, |
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(e.g. evolution from a subluxation to a complete |
because the dynamic ultrasonography (echography |
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luxation, development of phacomorphic, phacolitic or |
under ocular movement) is very helpful to achieve |
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narrow-angle glaucoma). So, the critical observation |
some subclinical zonular damage. Finally, in cases of |
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of associated lesions in the first and ulterior evaluations, |
complete luxation, echography helps the surgeon |
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are of critical importance. |
achieve integrity of the capsular bag and movement |
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capacity of the crystalline lens inside the vitreous cavity |
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Zonular evaluation (dynamic evaluation, |
(dynamic echography with changes in the patient |
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clinical and with ultrasound) |
position), of particular importance for planning the |
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Is mandatory to consider the possibility of zonular |
surgical strategies. |
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Some other studies can be very helpful in the |
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damage in all cases of ocular trauma; the condition |
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evaluation of the traumatized (and maybe dislocated) |
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of the crystalline lens attachments conforms an |
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lens (e.g. Computed Tomography), but the dynamic |
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important part of the design of further activities in the |
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ultrasonic evaluation conforms a nice approach to |
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management of these patients. |
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obtain a mostly complete information regarding the |
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The first clinical evaluation is the observation; |
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crystalline lens conditions and associated features. |
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despite the complete clinical view of the anterior and |
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posterior segments of the eye, a particular focus must |
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be pointed into the crystalline lens. Integrity of it, |
Surgical Approach |
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presence of opacities, integrity of the capsular bag and |
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possible clinical visualization of the zonules under |
Despite the whole evaluation of the complete damage |
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maximum pupil dilation, are between others, |
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to the intraand extraocular structures caused by the |
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mandatory points that must be seen during the |
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trauma, the management of the dislocated crystalline |
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ophthalmic exploration of a traumatized eye; a |
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lens will be pointed here. The management includes |
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dynamic clinical |
evaluation of the lens, is also |
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a broad spectrums of actions, going from “doing |
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obligatory; it means to ask the patient to move the |
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nothing” in case of a moderate dislocation without |
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eye in slow and rapid movements, in order to achieve |
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cataract formation, until a complete cataract extraction |
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phacodonesis. |
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from the vitreous cavity and an IOL implantation |
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Sometimes the degree of subluxation is easy to |
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without capsular support. |
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observe, but even so the dynamic evaluation is very |
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The surgical approach must take in count also as |
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useful to achieve a clinical approach to the degree of |
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zonular weakening. If a complete luxation is present, |
a very important concept, “the correct time to act”; |
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a complete clinical indication in the ocular fundus is |
it means that sometimes the surgeon has to wait and |
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mandatory, with the objective to plan the surgical |
not to plan a surgical approach until some particular |
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approach. |
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features have been solved (e.g. bleeding resolution, |
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In some cases, because of media opacities and |
decrease in inflammation), but in some other occasions |
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inflammatory process, it is not easy to evaluate the |
the urgent surgery indication must be the rule to follow |
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real condition of the zonular attachments; this |
(e.g. development of phacolitic or phacomorphic |
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conforms for many surgeons the indication of an |
glaucoma, high intraocular pressure because of |
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Management of Traumatic Luxation of the Crystalline Lens |
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hydrated cataract, incomplete dislocation with weak |
INTRACAPSULAR EXTRACTION |
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zonulas and possibility to develop a drop nucleus into |
Intracapsular extraction means to take outside the |
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the vitreous cavity). This is why the management of |
eye the entire crystalline lens contained in its capsular |
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this type of conditions requires knowledge but also |
bag. It is a maneuver that even in our times should |
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a good dose of common sense; sometimes to share |
be considered in some special cases, for example |
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the case with some colleagues can be useful. |
complete lens luxation to the anterior chamber, or |
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The concept of the touch of the crystalline as the |
furthermore into the subconjuntival space, as we saw |
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first step in case of a surgical approach, is still alive; |
in some occasion, in which a simple conjunctival |
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it is a very objective method to evaluate the integrity |
incision was enough to remove he entire dislocated |
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and the weakness of the zonula and can corroborate |
lens. If well, the entire lens removal through a wide |
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or change by complete the tentative surgical plan; it |
incision is not frequently seen in the ophthalmic surgery |
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must be carefully performed in order to avoid cause |
in our days, it is something that must be keep inside |
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more zonular damage; it is a useful maneuver that |
the surgeon’s mind for some particular cases of |
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helps obtain more information about the case. |
complete lens luxation after severe eye trauma. |
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Anyhow, during the entire time of a surgical approach, |
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the surgeon must be aware to experience surprises |
PARSPLANA VITRECTOMY PLUS |
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because it is a traumatized eye; these precautions must |
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PHACOEMULSIFICATION IN |
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be in the mind even in the postoperative period, |
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THE VITREOUS CAVITY |
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because unexpected complications are the rule. |
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It is indicated in cases of complete lens luxation into |
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Now we will describe some different possibilities of |
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the vitreous cavity; should be performed after a |
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surgical approaches, depending upon the complete |
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complete study that allows the surgeon to obtain |
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diagnostic, trying to cover diagnostic and technique |
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information about the position of the crystalline lens |
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of choice. |
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and the additional damage caused by the eye trauma; |
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PHACOEMULSIFICATION |
the medical indication for this technique increases when |
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there is a suggestion of inflammatory process or some |
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AND IOL PLACEMENT IN SUBLUXATED |
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structural damage caused by the subluxated lens. |
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CRYSTALLINE LENS |
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A complete pars plana vitrectomy must be |
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The indication should be subluxated cataractous lens, |
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performed prior to remove the lens from inside the |
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or subluxated non-cataractous lens that compromises |
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vitreous cavity; it helps increase visualization inside the |
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the vision. Remember that sometimes, is better “not |
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globe (remove of vitreous opacities), but also helps |
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to perform surgery”, and this possibility must be |
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decrease the retinal traction during the lens removal. |
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discussed with the patient according the particular case. |
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After the vitrectomy, many techniques have been |
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For the special purpose of lens extraction in |
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described to remove the lens like phacoemulsification |
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subluxation, helpful maneuvers and devices can be |
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in the vitreous cavity, chopstick, FAVIT, phacoemulsi- |
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used; some examples are wide capsulorhexis to avoid |
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fication in the anterior segment and for soft lenses the |
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pressure over the capsular bag, capsulectomy instead |
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lensectomy during the vitrectomy by itself, between |
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to capsulotomy to avoid pull the capsule, iris retractors |
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others. The goal is to remove the complete lens |
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inserted in the capsular bag to center it during phaco, |
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material just after a complete vitrectomy has been |
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capsular tension rings for subluxated lens, ultra-small |
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performed; after that a complete review of the |
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incision technology, phacoemulsification “out of the |
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retina, periphery and optic nerve is done, and some |
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bag” (phaco at the iris plane to avoid force applied |
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other maneuvers if needed like endophotocoagulation, |
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to the capsular bag), positive intraocular pressure |
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subretinal |
fluid drainage or |
silicon oil insertion if |
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during the entire procedure, bi-axial irrigation/ |
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required; |
remember that |
always the surgeon |
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aspiration, continuous viscoelastic injection inside the |
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must be aware of surprises because of the traumatized |
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capsular bag and transscleral bag fixation with sutures |
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eye. |
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(with or without capsular rings) between others. When |
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performing these techniques, the objective is to |
PERFORMING A COMPLETE PLACEMENT OF |
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maintain the integrity and the center position of the |
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capsular bag with the main objective of an IOL |
CRYSTALLINE LENS INTO THE VITREOUS |
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implantation, “in the bag” and, as much as possible, |
CAVITY |
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in the center of the pupil. |
“Just like in the old times of cataract surgery”, the |
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Remember wait for surprises any time during the |
complete luxation to the crystalline lens (with cataract |
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surgery and at the postoperative period, because it |
or not), or the non-surgical approach in case of a |
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is a traumatized eye. |
complete lens dislocation into the vitreous cavity, is |
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84 |
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Clinical Diagnosis and Management of Ocular Trauma |
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also an option that must be inside the mind of the |
emmetropia in eyes without capsular support; |
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attending surgeon of these traumatized eyes. |
controversies still are in the field, because if well they |
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It was demonstrated, since the early days of cataract |
have not angle complications, they still have the corneal |
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surgery, that in presence of integrity of the capsular |
features, with the consequent need to long-term |
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bag, the crystalline lens must remain inside the vitreous |
follow-up. Anterior chamber lenses, angle supported |
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cavity for many years without consequences. So, |
or iris supported, are a good option for correction of |
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depending upon the case, the surgeon has the option |
aphakia in traumatized eyes according the needs of |
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of leave it for years inside the vitreous cavity, if it is |
the case. |
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already there, and there is not inflammatory response |
Posterior chamber lenses are preferred because they |
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or mechanical damage; sometimes the principle “better |
are far away from the corneal endothelium and it has |
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not to damage” applies very well; if the case has an |
been demonstrated the less incidence of corneal |
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almost complete luxation, sometimes the surgical |
edema. Many techniques have been described for the |
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technique to follow can be to convert it to a complete |
implantation of a posterior chamber lens without the |
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vitreous luxation, with particular careful of not to |
posterior capsule support; scleral fixation, iris suture |
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damage the capsular bag; if this occurs, a complete |
and scleral glue between others; the technique of |
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lens extraction is mandatory. |
choice will depend upon the particular features of the |
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If the surgeon choose this option talking with the |
traumatized eyes and the preferences of the surgeon. |
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patient, both must be aware that when a reaction |
It has been demonstrated the long-term safety of the |
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|
occurs inside the eye any time during the life (e.g. |
posterior chamber IOLs, so it can be described as the |
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|
inflammatory process), the lens extraction must be |
method of choice for correction of aphakia in |
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performed; a good communication is mandatory; |
traumatized eyes, any time that it can be possible and |
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anyhow, the IOL implantation can be performed even |
the surgeon has the experience enough to implant |
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|
with the lens inside the vitreous cavity. |
this mode. |
IOL PLACEMENT CONSIDERATIONS
If well some particular patients because of the conditions of the eye should not be implanted and must be managed with contact lens, in most of the cases the rule to follow is to obtain the maximum of visual rehabilitation by replacing the crystalline lens with a IOL; even so, sometimes because of the particular lesions caused by the eye trauma, some individual considerations must be done.
We can divide this topic in two big fields:
1.With capsular support: If during the surgery the capsular bag was conserved (with or without capsular tension ring), an “in the bag” IOL implantation is feasible. Just think about the possibilities between “one piece” or “three pieces” IOL`s according your particular case and needs. Never forget that a IOL placed in the capsular bag with a zonular lesion, can lead to long term complications; you are not safe forever…
2.Without capsular support: We can divide this point between anterior chamber and posterior chamber
lens.
An anterior chamber lens is still an option for many surgeons; some others try not to use them because of the endothelial cells consequences; some surgeons feel more frightened to use them in traumatized eyes, because of some potential lesions in the anterior chamber structures, like iris lesions, trabecular lesions, and angle structure lesions, between others. Some surgeons are using iris claw IOLs (e.g. Artisan) to achieve
Prognosis and Long-term
Considerations
The luxation of the crystalline lens, after a traumatic lesion of the eye is a severe medical condition that much of the times is not coming alone, if well accompanied by some other severe injuries if the eye that can lead to potential bad visual recovery. A perfect evaluation of the conditions associated to the luxation are mandatory in order to establish the priorities of action to solve the injuries; sometimes other lesions, like retinal detachment or acute glaucoma, have priority of action; sometimes during a single surgical procedure, many features can be corrected, including the luxation or subluxation of the lens; in some other traumatic lesions is better not to do nothing; the criteria will depend upon the severity of the lesions, a perfect evaluation of all of them, the experience of the surgeon, the surgical findings and the possible postoperative complications. It is not an easy thing to do, and sometimes long-life follow-up is needed.
A particular condition will be mentioned at the end of this chapter as a remainder that a traumatic lesion of the lens can lead to long term complications; it is the late in-the-bag IOL dislocation, condition that has been studied for many authors and that if well it is not exclusive of the traumatic lesions of the eye (e.g. pseudoexfoliation, high myopia, Marfan syndrome), it is a severe condition that allows us to keep in mind
Management of Traumatic Luxation of the Crystalline Lens |
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85 |
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that a good communication with our patients and |
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capsular tension ring. Journal of Cataract and Refractive |
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Surgery. 2006;32(10):1756-8. |
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the years is mandatory. |
7. |
Khalid Hasanee, Iqbal Ike K. Ahmed. Capsular tension |
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rings: update on endocapsular |
support devices. |
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Ophthalmology Clinics of North America December |
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perform an individualized informed consent, with the |
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enumeration of each and every preoperative diagnosis |
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8. |
Manuel Monteiro, Antonio Marinho, Salgado Borges, |
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and possible short and long term complications; never |
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Lucas Ribeiro, Castro Correia. Scleral fixation in eyes with |
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give a definitive prognosis to these patients. |
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loss of capsule or zonule support. Journal of Cataract |
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