Surgical strategies and protocols in the management of lens subluxation

Lens subluxation, or ectopia lentis, denotes partial displacement of the crystalline lens secondary to zonular weakness or absence, with complete dislocation occurring when all zonules are compromised. It may be congenital, associated with systemic conditions such as Marfan syndrome, Weill–Marchesani syndrome, and homocystinuria, or acquired, often resulting from pseudoexfoliation syndrome or ocular trauma. The management of subluxated lenses requires meticulous preoperative assessment, particularly regarding the extent and location of zonular deficiency. Surgical strategies aim to preserve the capsular bag whenever possible, providing a physiological environment for intraocular lens (IOL) fixation. Achieving a well-centered, appropriately sized continuous curvilinear capsulorhexis (CCC) is critical, facilitating the use of capsular retractors and capsular tension devices (CTDs) to stabilize the bag intraoperatively. In suitable cases, femtosecond laser-assisted capsulotomy offers enhanced precision, though parameter adjustments are necessary in younger patients with elastic capsules. During phacoemulsification, minimizing nucleus manipulation and avoiding lens rotation reduce zonular stress, thereby decreasing the risk of complications such as posterior capsular rupture or vitreous loss. Permanent capsular support devices are recommended in cases with extensive or progressive zonular damage. Successful outcomes hinge on comprehensive surgical planning, careful intraoperative technique, and vigilance in managing intraoperative challenges. With appropriate intervention, favorable long-term visual rehabilitation can be achieved in patients presenting with subluxated crystalline lenses.