LAPORAN KASUS POLI

KATARAK & BEDAH

REFRAKSI
RESIDEN DIVISI KBR FEBRUARI – APRIL 2022
IDENTITAS PASIEN

Nama : NL
Jenis kelamin: Perempuan
Tanggal lahir : 12-11-1952 (69 th)
RM : 882328
MRS : RSWS 8-2-2-2022
ANAMNESIS
Keluhan utama : penglihatan kabur pada kedua mata sejak 4 bulan lalu.
Anamnesis terpimpin : penglihatan kabur pada kedua mata dirasakan sejak 4 bulan lalu
setelah pasien mengalami kecelakaan lalu lintas pada bulan Oktober 2021. Mekanisme
trauma menurut keluarga dikarenakan wajah pasien terbentur dashbord mobil sewaktu
KLL. Riwayat bengkak pada kedua mata disertai lecet pada daerah wajah ada sewaktu KLL.
keluar gel dan darah disangkal. Keluhan saat datang ke poli : nyeri pada mata tidak ada,
mata merah tidak ada, kotoran mata berlebih tidak ada, penglihatan ganda tidak ada.
Riwayat operasi : ekstraksi katarak tahun 2017 pad akedua mata di RS Lagaligo Luwu
Timur. Riwayat penyakit sistemik : pasien dengan CKD on HD selama 2 tahun terakhir, 2
kali/minggu, Diabetes melitus ada, Hipertensi ada, terkontrol.
Riwayat penggunaan obat tetes mata : tidak diketahui.
ANAMNESIS
Riwayat alergi dan pemakaian kacamata : disangkal.
Pasien rujukan dari RSUD Lagaligo dengan diagnosa ODS Dislokasi IOL Post Trauma.

Foto Klinis Mata Pasien Sewaktu KLL

4 bulan yang lalu
PEMERIKSAAN OFTALMOLOGI
9-2-2022
PEMERIKSAAN OFTALMOLOGI
( 9 FEBRUARI 2022)   OCULUS DEXTRA

VISUS 1/60 PH -

TIO 29

BULBUS OCULI Intak

PALPEBRA udem (-)

SILIA  silia sekret (-)

KONJUNGTIVA hiperemis (-)

SKLERA Intak
KORNEA Jernih
BMD VH4, tampak IOL (+) di anterior chamber
IRIS Coklat

unround, cell +3 di BMB, Vitreous (+)

PUPIL
diarah jam 10-12 BMB

LENSA Lensa IOL (+) dislokasi

PEMERIKSAAN SLITLAMP OCULUS DEXTRA
 OCULUS SINISTRA
PEMERIKSAAN OFTALMOLOGI
VISUS 1/300 PH - ( 9 FEBRUARI 2022)
TIO 15

BULBUS OCULI Intak

PALPEBRA Tidak udem

SILIA Tidak ada sekret

KONJUNGTIVA tidak hiperemis

SKLERA Intak

KORNEA jernih

BMD VH 4
IRIS coklat

PUPIL pupil unround

IOL dislokasi menuju keanterior bilik mata

LENSA
diarah jam 9-5 tepat dimargin pupil
PEMERIKSAAN SLITLAMP OCULUS SINISTRA
USG
OD :
Gain 70 db, Vitreous kesan membrane like
lession dengan peak yang tidak setinggi
retina, retina dan nervus optikus kesan intak.

OS :
Gain 70 db, Vitreous kesan membrane like
lession dengan peak tidak sestinggi retina,
nervus optik dan retina kesan intak.

ODS Kesan vitreous opacity

FUNDUSKOPI LENSA 90
ODS :
Refleks fundus (+), Detail lain sulit dievaluasi karena
kekeruhan vitreous.
DIAGNOSA
Oculus Dextra Luksasi IOL
Oculus Sinistra Subluksasi IOL
Oculus Dextra et Sinistra Vitreous Opacity

MANAGEMENT TERAPI
• Oculus Dextra et Sinistra Reposisi IOL
• Konsul Divisi Vitreo-Retina (Rencana ODS Vitrektomi Pars Plana
jika keadaan umum optimal)
MANAGEMENT TERAPI

• ODS Reposisi IOL

• Konsul Divisi Vitreo Retina

ODS Vitreous Opacity suspek TRD, OD Luksasi lensa, OS
Subluksasi Lensa  Rencana OS Vitrektomi Pars Plana (Join
Operasi Divisi KBR)
PROGNOSIS
Quo ad Vitam : Dubia
Quo ad Functionam : Dubia
Quo ad Sanationam : Dubia
Quo ad Cosmeticam : Dubia
KONTROL POLIKLINIK
(11 FEBRUARI 2022)
 OCULUS DEXTRA
VISUS 1/60
TIO 23

BULBUS OCULI Intak

PALPEBRA Udem tidak ada

SILIA Sekret tidak ada

Hiperemis (-), hiperlakrimasi

KONJUNGTIVA
(+), kemosis (+)

SKLERA Intak

KORNEA Jernih
BMD VH4
IRIS Coklat

PUPIL Unround, cell +3 di BMP

Vitreous (+) di arah jam 10-12,

LENSA Lensa IOL (+) dislokasi
 OCULUS SINISTRA
VISUS 1/300
TIO 13
BULBUS OCULI Intak
PALPEBRA Tidak udem

SILIA Tidak ada secret

KONJUNGTIVA Tidak hiperemis

SKLERA Intak

KORNEA Jernih

BMD VH 4
IRIS Coklat
PUPIL Pupil unround
IOL dislokasi menuju ke
LENSA anterior bilik mata di arah jam
9-5 tepat di margin pupil
PEMERIKSAAN LABORATORIUM
( 11 FEBRUARI 2022)
HASIL
WBC 3.700 /ul
RBC 2.850.000 /ul
HGB 8,8 gr/dl
HCT 26.3 %
PLT 154.000 /ul
CT 7 menit
BT 4 menit
GDS 75 mg/dl
Kreatinin 11,7 mg/dl
Ureum 196 mg/dl
DIAGNOSA
Oculus Dextra Luksasi Intraocular Lens
Oculus Sinistra Subluksasi Intraocular Lens
Oculus Dextra et Sinistra Vitreous Opacity
MANAGEMENT TERAPI
• Oculus Dextra et Sinistra Reposisi IOL
• Tropin 1 gtt/8 jam/ODS
• Konsul TS Interna (evaluasi & tatalaksana lanjutan kelayakan operasi)

Pasien terkonfirmasi Covid-19 (12-2-2022)

TEORI
SUBLUXATION & DISCLOCATION LENS
During a blunt injury to the eye, rapid expansion of the globe in an equatorial plane
immediately follows compression.
This rapid equatorial expansion can disrupt the zonular fibers  dislocation or
subluxation of the lens. The lens may be dislocated in any direction, including posteriorly
into the vitreous cavity or anteriorly into the anterior chamber.

Symptoms and signs of traumatic lens subluxation :

• fluctuation of vision
• impaired accommodation
• monocular diplopia
• high astigmatism
• Iridodonesis or phacodonesis is present (often)

Retroillumination of the lens at the slit lamp through

a dilated pupil may reveal the zonular disruption.

AAO Chapter 11 : Lens & Cataract. 2020 : P. 64.

 SUBLUXATION LENS

Subluxation of the lens may occur, secondary to

tearing of the suspensory ligament.
A subluxated lens tends to deviate towards the
meridian of intact zonules.
The anterior chamber may deepen over the area
of zonular dehiscence if the lens rotates
posteriorly.
The edge of a subluxated lens may be visible
under mydriasis,
Trembling of the iris (iridodonesis) or lens
(phakodonesis) may be seen on ocular
Salmon JF. Kanski’s Clinical Ophthalmology A Systematic Approach. Chapter 22 : Trauma. 9 th Edition. Elsevier. 2020 : P. 902-904
movement.
LENS SUBLUXATION

Richard S. Hoffman et al. Management of the subluxated crystalline lens. J Cataract Refract Surg 2013; 39:1904–1915 Q
2013 ASCRS and ESCRS
 LENS DISLOCATION
Dislocation due to 360° rupture of the zonular
fibres is rare.
The lens may dislocate into the vitreous or less
commonly, into the anterior chamber.
An underlying predisposing condition such as
pseudoexfoliation should considered.

Salmon JF. Kanski’s Clinical Ophthalmology A Systematic Approach. Chapter 22 : Trauma. 9th Edition. Elsevier. 2020 : P. 902-904
SUBLUXATED IOL
Some complications associated with primary cataract surgery are
:
• Incomplete placement of the IOL in the capsular bag
• Prolapse of vitreous through a posterior capsular tear or in an
area of zonular dehiscence
• Zonular instability or dehiscence and dislocation of the
IOL–capsular bag complex
• Migration of a haptic through an anterior capsular tear,
and
• Damage to a haptic during surgery
The haptic of a one-piece acrylic lens &
More often, however, lens subluxation occurs later in the surrounding vitreous strands can be seen
postoperative period as a result of progressive zonular laxity entrapped in the iris. This patient had a recent
in an eye with pseudoexfoliation, trauma, or subsequent history of blunt trauma to the right side of
intraocular surgery including pars plana vitrectomy. the head as a result of a fall.

Cathleen M. Mccabe. Managing Subluxated IOL in CATARACT & REFRACTIVE SURGERY TODAY. 2021.
SUBLUXATED IOL

Additionally, IOLs fixated with a 10-0 or 9-0 polypropylene suture

(Prolene, Ethicon) can move if the suture breaks because of trauma
or even eye rubbing or because the suture degrades over time.
DISLOCATED IOL
Dislocated intraocular lens (IOL) is a rare, yet serious complication whereby the intraocular lens moves
out of its normal position in the eye. IOL dislocation has been reported at a rate of 0.2% to 3%.
• It may occur as a result of an early or late complication of cataract surgery, prior vitreoretinal surgery, trauma,
or an inherent pathological process or connective tissue disorder contributing to lens zonular weakness.

ETIOLOGY/ RISK FACTORS

There are many predisposing conditions
that increase the risk of capsular bag
instability and zonular weakness: - diabetes mellitus
-cataract surgery - atopic dermatitis
-prior vitreoretinal surgery - mature cataract
-Aging - previous episodes of acute angle-
-axial myopia closure attack
-inflammation/uveitis  - connective tissue disorders e.g.
-trauma  - pseudoexfoliation syndrome
Stelzner sadiqa. 2021. Dislocated Intraocular Lens. American
-retinitis pigmentosa (being the most common risk
Academy of Ophthalmology. factor with more than 50% of
TYPES OF IOL DISLOCATION
Dislocation may present as :
1. phacodonesis
2. simple decentration within the bag or in
the sulcus
3. partial subluxation, or
4. complete dislocation of the lens within
or outside of the bag into the anterior or
posterior chamber
Phacodonesis and a Subluxated Crystalline Lens. Steven
H. Dewey et al. 2010.

If there is a posterior capsule defect or tear, the IOL may slide out of the bag, hence out-of-the-
bag dislocation.
 POSTERIOR DISLOCATION IOL
Complications include :
• vitreous haemorrhage,
• retinal detachment,
• uveitis and
• chronic CMO. Dislocated IOL
(Courtesy of S
Milewski)
•Treatment involves :
•pars plana vitrectomy with IOL removal,
•repositioning or exchange depending on the extent of capsular support.

Salmon JF. Kanski’s Clinical Ophthalmology A Systematic Approach. Chapter 10 : Lens. 9th Edition. Elsevier. 2020 : P. 325
TREATMENT
EARLY IOL SUBLUXATION OR
DECENTRATION
• Patient who presents early in the postoperative period with a subluxated or
decentered IOL due to incorrect placement or zonular instability may be
taken back to the OR.
• If one of the haptics was incorrectly placed in the sulcus, the IOL may be
repositioned so that both haptics are located in the capsular bag, with or
without the addition of a capsular tension ring and/or a capsular tension
segment fixated to the sclera,
EARLY IOL SUBLUXATION OR
DECENTRATION
• If an IOL placed in the sulcus has dislocated, one option for correction is to
reposition the lens in a different axis with better capsular support.
• Another option is to increase the stability of centration by capturing the
optic anteriorly through an anterior capsulotomy or posteriorly through a
posterior capsulotomy that is created intra- or preoperatively with an
Nd:YAG laser.
TREATMENT OPTIONS
• The most common indications for surgery are decreased visual acuity, monocular
diplopia, and halos.
• Less commonly, retinal detachment, glaucoma, and/or uveitis-glaucoma-
hyphema (UGH) syndrome portend surgical intervention.
• Several surgical options exist in management of dislocated IOL and should be
tailored to each individual. Surgery typically includes pars plana vitrectomy to
remove the dislocated lens with either an IOL cutter or through a scleral tunnel or
sclerocorneal incision. This is followed by secondary IOL implantation.
IOL EXCHANGE
• IOL exchange is possible, and likely the most common surgical
option.
• The dislocated IOL is removed and decision to place an IOL in the
anterior or posterior chamber becomes a matter of the integrity
of the capsular bag.
• If there is adequate capsular support, an IOL may be placed in
the posterior chamber and repositioned in the ciliary sulcus.
• If there is not enough capsular support, an IOL can be placed in
the anterior chamber (ACIOL) or sutured in place to either the
sclera or iris. There seems to be insufficient evidence, in terms of
relative safety or efficacy, to support ACIOL vs scleral or iris-
supported PCIOLs.
IOL FIXATION PROCEDURES
1. Transscleral Suture Fixation
IOL FIXATION PROCEDURES
2. Transscleral Haptic Fixation
Illustration of intra- scleral glued haptic
IOL fixation. A, Scleral flaps are created
180° apart. Intrascleral Scharioth tunnels
are created parallel to the limbus with a
bent 26-gauge needle. B, A 3-piece foldable
IOL is injected into the eye while a
microforceps is used to grasp the leading
haptic and externalize it. Similarly, the
trailing haptic is then externalized under
the opposite scleral flap. C, The haptics are
tucked into intrascleral tunnels. D. The
flaps and conjunctiva are sealed with tissue
glue .
IOL FIXATION PROCEDURES
3. Iris Suture Fixation
THANKYOU
BLUNT TRAUMA