Is lens dislocation or subluxation an ocular emergency?

Lens Dislocation/Subluxation as an Ocular Emergency

Lens dislocation or subluxation should be considered an ocular emergency requiring prompt evaluation and management to prevent vision-threatening complications. 1

Clinical Significance and Complications

• Lens dislocation/subluxation can lead to severe vision-threatening complications including angle-closure glaucoma, which may cause irreversible vision loss if not promptly addressed 2
• Forward mobilization of the lens can result in synechial angle-closure glaucoma, which is difficult to control with peripheral iridotomy alone 2
• Lens subluxation may be associated with retinal complications including retinal pigment epithelium disruption, chorioretinal atrophy, and retinal hemorrhaging 1
• Significant visual symptoms can occur including double vision, glare, and deterioration of vision to the point of functional aphakia 3

Urgent Evaluation Required

• Patients presenting with lens dislocation/subluxation require immediate ophthalmologic assessment as they may represent an important clinical indicator of an embolic, inflammatory, or other process requiring urgent systemic medical evaluation 1, 4
• Diffusion-weighted MRI should be performed urgently (within 24 hours) in cases where vascular etiology is suspected, as silent brain infarction is frequently present in patients with acute ocular vascular symptoms 4
• In traumatic cases, even with minimal signs and symptoms, immediate evaluation is necessary as delayed presentation can lead to complications including anterior chamber inflammation and pupillary margin abnormalities 5

Management Approach

Immediate Management:

• Surgical intervention is typically required for significant lens dislocation/subluxation 2, 6
• Conservative management with miotics may be attempted in mild cases of lens subluxation (such as mild sunset syndrome) 6
• In cases of anterior axial lens subluxation with progressive myopia, prophylactic lensectomy has proven to be the most reliable treatment to prevent angle-closure glaucoma 2

Special Considerations:

• In patients with Marfan syndrome, ophthalmological examination for lens dislocation should be performed soon after birth 1
• In cases of traumatic dislocation of implanted lenses (such as ICLs), surgical repositioning under pupillary dilation is typically required 5
• Patients with multifocal IOLs require special attention concerning symmetric capsulorhexis and positioning of haptics to prevent decentration 3

Systemic Associations

• Lens subluxation may be a manifestation of systemic conditions including:
  • Marfan syndrome (characterized by long, thin build with wide-looking faces, high palate, and long fingers) 1
  • Stickler (Marshall) syndrome (associated with high myopia, glaucoma, cleft palate, sensorineural hearing loss) 7
  • Zika virus infection (particularly in congenital cases) 1

Patient Education and Prevention

• Education of patients about the necessity for immediate examination after ocular trauma is essential 5
• Patients with conditions predisposing to lens dislocation should be advised to wear eye protection during activities with high risk of ocular trauma 5
• Regular ophthalmologic follow-up is crucial for patients with risk factors for lens dislocation/subluxation 2, 7

Prognosis

• With prompt surgical intervention, visual outcomes can be favorable in many cases 2, 6
• Delayed treatment may result in permanent vision loss due to complications such as angle-closure glaucoma 2
• Even after successful repositioning, patients may experience persistent complications including pigment on the lens, pupillary margin peaking, and anterior chamber inflammation 5