Video of the month | Nov 2023 | Carlevale IOL implantation in a case of Marfan syndrome - related lens subluxation - a best match scenario

Presented by: Miltos Balidis MD, PhD, FEBOphth, ICOphth

Edited by: Penelope Burle de Politis MD

Marfan syndrome is the main cause of heritable ectopia lentis, the most common ocular manifestation of the condition, occurring in 3 out of 4 patients. Lens subluxation in Marfan syndrome results from altered fibrillin microfibrils leading to loose zonular fibers and lens capsule. Dislocation of the lens in Marfan patients is usually bilateral and typically in the superotemporal direction.

Replacing the crystalline lens in a Marfan patient is particularly challenging because of the inherent abnormal elasticity of the zonule and capsule in such eyes – added to the fact that most cases are of young individuals, thus with soft lenses. Therefore, every step, from capsulorhexis to lens implantation, becomes less predictable and less controllable than in a regular phacoemulsification procedure.

Having been specifically designed for eyes lacking capsular or zonule support, Carlevale IOL is an excellent choice for lens replacement in Marfan patients. The implantation technique for this posterior chamber IOL consists of fashioning diametrically opposed intrascleral sockets for the haptics, from which the lens will lie suspended. For being positioned this way, Carlevale poses a lesser risk to other ocular structures and functions than other secondary intraocular implants.

In this video, recorded in the main operating room of the Ophthalmica Eye Institute, in Thessaloniki, Greece, Dr. Miltos Balidis, MD, PhD, FEBOphth, ICOphth performs a clear lens phacoemulsification and Carlevale IOL implantation in the left eye of a patient with lens subluxation due to Marfan syndrome. The surgical steps and timing in the video are as follows: a medium-sized, as round and as centered as possible capsulorhexis is performed (00:30). Viscoelastic is injected in preparation for the next step (01:25). Capsule hooks are placed in order to hold the rhexis and stabilize the nucleus (01:45). Phacoemulsification is carried out using slow settings for soft nucleus: low vacuum and irrigation – low bottle –, medium aspiration (02:44). Mass aspiration is completed carefully (03:16). Dissection of temporal and nasal conjunctiva for confection of the sockets follows (03:28). Limbal distance for proper positioning of the IOL haptics is measured (03:33). Eventually,  an anterior vitrectomy is proved necessary and completed (03:39). The sockets for the IOL haptics are created temporally and nasally (04:56). The IOL is injected (05:05). The haptics are inserted in their respective intrascleral pouches (06:22). A safety suture is done in order to tighten the sockets, securing the haptics inside the scleral pouches (07:28). The procedure ends with a centered and stable IOL.

“Stay centered, do not overstretch. Extend from your center, return to your center.” (Buddha)