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      Late spontaneous bilateral intraocular lens subluxation accompanied with intraocular pressure elevation in a patient with acromegaly

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          Abstract

          A 53-year-old male with newly diagnosed acromegaly came to our clinic with the chief complaint of diplopia. He had the past ocular history of uneventful phacoemulsification cataract surgery with intraocular lens (IOL) implantation in the right eye 17 years ago and left eye 15 years ago. Postoperative examination showed remarkable improvement in visual acuity. Two years ago, he developed elevated intraocular pressure (IOP) in both eyes, which was well-controlled with the use of travoprost 0.004%/timolol 0.5%. At the clinic, slit-lamp examination revealed inferiorly subluxated IOL bilaterally. The patient received IOL repositioning with pars plana vitrectomy and scleral fixation in the left eye smoothly. We hypothesize that excess growth hormone is associated with dysregulation of fibrillin, resulting in zonular weakness, which causes late bilateral IOL subluxation. Elevated IOP may also be related to acromegaly. To the best of our knowledge, this is the first report to describe the association between IOL subluxation and acromegaly.

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          Late in-the-bag spontaneous intraocular lens dislocation: evaluation of 86 consecutive cases.

          As techniques for cataract surgery have evolved, spontaneous intraocular lens (IOL) dislocation has decreased overall. However, since 2006 the Intermountain Ocular Research Center has received an increased number of explanted IOLs within the capsular bag forwarded for pathologic evaluation. Late, spontaneous dislocation of IOLs results from zonular insufficiency and zonulysis that has been associated with pseudoexfoliation, trauma, and other risk factors. The findings of 86 consecutive cases of this complication, analyzed in the laboratory, are described. Retrospective case series. Eighty-six IOLs explanted within the capsular bag, submitted in formalin. Standard light microscopy of specimens, as well as questionnaire sent to explanting surgeons and patient chart review, when available. Lens design, material, and abnormalities; capsular bag anomalies; patient demographic data; surgical dates; and presence or absence of known risk factors. This series included polymethyl methacrylate, silicone, and hydrophobic acrylic lenses, manufactured with both 1-piece and 3-piece designs. The mean time from surgery to spontaneous IOL dislocation was 8.5 years. The main conditions associated with the cases of IOL dislocation were as follows: pseudoexfoliation, 50%; prior vitreoretinal surgery, 19%; history of trauma, 6%; uveitis, 2%; and none or unknown, 23%. Patients with any type of IOL are at risk for late in-the-bag dislocation. Pseudoexfoliation and vitreoretinal surgery were the most common associated conditions in this series. Regardless of the presence of known risk factors, IOLs dislocated on average 8.5 years after phacoemulsification and IOL implantation.
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            Possible predisposing factors for in-the-bag and out-of-the-bag intraocular lens dislocation and outcomes of intraocular lens exchange surgery.

            To examine the possible predisposing factors for intraocular lens (IOL) dislocation within the capsular bag (in-the-bag dislocation) and IOL dislocation outside of the capsule (out-of-the-bag dislocation) and to study surgical outcomes of explantation of dislocated IOLs and scleral suturing of posterior chamber IOLs. Retrospective interventional case series. Thirty-eight eyes of 38 patients who developed in-the-bag IOL dislocation and 24 eyes of 24 patients who experienced out-of-the-bag dislocation. Medical records of 62 consecutive patients who underwent IOL exchange surgery for dislocation between 1999 and 2005 were reviewed. Possible predisposing factors and the other characteristics of in-the-bag and out-of-the-bag IOL dislocations; outcomes of IOL exchange surgery, including visual acuity (VA) and refractive status before and at 12 months after surgery; and serious postoperative complications. Possible major predisposing factors for in-the-bag IOL dislocation were pseudoexfoliation (17/38 [44.7%]), retinitis pigmentosa (4/38 [10.5%]), the status after vitrectomy (2/38 [5.3%]), trauma (2/38 [5.3%]), and a long axis (2/38 [5.3%]), whereas those for out-of-the-bag dislocation were secondary IOL implantation (11/24 [45.8%]), surgical complications (3/24 [12.5%]), mature cataract (3/24 [12.5%]), and pseudoexfoliation (2/24 [8.3%]). The interval between IOL implantation and exchange surgery was significantly shorter for the in-the-bag dislocation group than for the out-of-the-bag dislocation group (P = 0.0006). Mean uncorrected VA improved significantly after IOL exchange (P = 0.0080), and corrected VA also tended to improve, although the improvement was not significant (P = 0.0704). Mean absolute value of spherical power decreased significantly after surgery (P = 0.0008), whereas refractive astigmatism showed a significant increase (P = 0.0003). The primary serious complications after surgery were a marked rise in intraocular pressure (12/62, 19.4%), retinal detachment (4/62, 6.5%), and redislocation (2/62, 3.2%). Possible major predisposing factors for in-the-bag IOL dislocation are pseudoexfoliation, retinitis pigmentosa, the status after vitrectomy, and trauma, whereas those for out-of-the-bag dislocation are secondary implantation, surgical complications, and mature cataract. After IOL exchange surgery, corrected VA does not improve markedly. Because the incidence of postoperative complications after IOL exchange with scleral suturing is high, the use of other surgical techniques should be considered.
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              Fibrillin degradation by matrix metalloproteinases: implications for connective tissue remodelling.

              Fibrillin is the principal structural component of the 10-12 nm diameter elastic microfibrils of the extracellular matrix. We have previously shown that both fibrillin molecules and assembled microfibrils are susceptible to degradation by serine proteases. In this study, we have investigated the potential catabolic effects of six matrix metalloproteinases (MMP-2, MMP-3, MMP-9, MMP-12, MMP-13 and MMP-14) on fibrillin molecules and on intact fibrillin-rich microfibrils isolated from ciliary zonules. Using newly synthesized recombinant fibrillin molecules, major cleavage sites within fibrillin-1 were identified. In particular, the six different MMPs generated a major degradation product of approximately 45 kDa from the N-terminal region of the molecule, whereas treatment of truncated, unprocessed and furin-processed C-termini also generated large degradation products. Introduction of a single ectopia lentis-causing amino acid substitution (E2447K; one-letter symbols for amino acids) in a calcium-binding epidermal growth factor-like domain, predicted to disrupt calcium binding, markedly altered the pattern of C-terminal fibrillin-1 degradation. However, the fragmentation pattern of a mutant fibrillin-1 with a comparable E-->K substitution in an upstream calcium-binding epidermal growth factor-like domain was indistinguishable from wild-type molecules. Ultrastructural examination highlighted that fibrillin-rich microfibrils isolated from ciliary zonules were grossly disrupted by MMPs. This is the first demonstration that fibrillin molecules and fibrillin-rich microfibrils are degraded by MMPs and that certain amino acid substitutions change the fragmentation patterns. These studies have important implications for physiological and pathological fibrillin catabolism and for loss of connective tissue elasticity in ageing and disease.
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                Author and article information

                Journal
                Taiwan J Ophthalmol
                Taiwan J Ophthalmol
                TJO
                Taiwan Journal of Ophthalmology
                Wolters Kluwer - Medknow (India )
                2211-5056
                2211-5072
                Apr-Jun 2020
                06 April 2020
                : 10
                : 2
                : 147-150
                Affiliations
                [1 ] Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
                [2 ] School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
                [3 ] Department of Ophthalmology, Changhua Christian Hospital, Changhua, Taiwan
                [4 ] School of Medicine, Chung-Shan Medical University, Taichung, Taiwan
                [5 ] School of Medicine, Kaohsiung Medical University, Kaohsiung, Changhua, Taiwan
                [6 ] Department of Optometry, Da-Yeh University, Changhua, Taiwan
                Author notes
                [* ] Address for correspondence: Dr. San-Ni Chen, Department of Ophthalmology, Changhua Christian Hospital, 135, Nanhsiao Street, Changhua 500, Taiwan. E-mail: 108562@ 123456cch.org.tw
                Article
                TJO-10-147
                10.4103/tjo.tjo_76_19
                7442100
                Copyright: © 2020 Taiwan J Ophthalmol

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

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