"Best Pick and Hold" with "Wrap and Roll" technique for extreme subluxated crystalline lens.

backgroundA severely subluxated crystalline lens refers to significant displacement of the eye's natural lens from its normal position, often due to zonular weakness or rupture.[1] This condition can result from trauma, connective tissue disorders like Marfan syndrome, or advanced pseudoexfoliation.[2,3] Visual symptoms include blurred vision, monocular diplopia, and glare. On examination, lens edge may be visible within the pupil, and phacodonesis (lens wobbling) may be noted. Severe subluxation increases the risk of complications such as angle-closure glaucoma, lens-induced uveitis, or retinal detachment. Management typically involves surgical removal of the lens, with or without intraocular lens implantation, depending on zonular support.[4] Sinha et al.[5] had described the intralenticular bimanual irrigation and aspiration in 2005 for a sublaxated lens in Marfan syndrome. Khokhar et al.[6] described the modified technique of endocapsular lens aspiration for severely subluxated lenses in 2018. In 2022, Urkude et al.[7] described the "Kissing microvitreoretinal (MVR) blade technique" for microspherophakia. The surgical challenges associated with such clinical conditions are as follows:[4,8] Poor capsular support makes the capsulorhexis difficult. Lens instability: The lens-bag complex is mobile and making the surgical process of lens aspiration extremely hard. There is always a possibility of lenticular matter or the capsular bag falling into the vitreous cavity. PURPOSE: The authors describe "Best Pick and Hold" with "Wrap and Roll" technique for extreme subluxated lens. These novel techniques can be used to perform lens aspiration with ease and negate the possibility of previously described complications. SYNOPSIS: The procedure starts with inserting two MVR blades through clear corneal incisions into the anterior chamber. Clear corneal incisions are preferred as technical challenges are anticipated in pediatric eyes, which have lower scleral rigidity, smaller axial lengths, thinner sclera, and more elastic tissues, making scleral tunnel construction and wound closure more difficult compared to adults. The first MVR blade is precisely advanced to enter the lens capsule and pick the subluxated lens to the central visual axis, followed by the entry of the second MVR blade at the opposite points, creating stable access. The surgeon then introduces a vitrectomy cutter and irrigation cannula, sequentially exchanging them for the MVRs. This strategic maneuver, referred to as the "Best Pick and Hold" technique, allows secure stabilization and controlled intralenticular lens aspiration while minimizing early stress to residual zonules. An MVR entry can also stabilize the lens; however, there is a risk of extension and cut-through caused by the sharp edge of the MVR. Hand-to-hand holding with the vitrectomy cutter and irrigation cannula provides better hold and stabilization of the lens. In the second phase, the capsule is wrapped over the irrigation cannula by using a vitrectomy probe, and the vitrectomy cutter is employed to excise it, a technique called "Wrap and Roll." This procedure helps to reduce capsular bag remnants falling into the vitreous cavity. HIGHLIGHTS: "Best Pick and Hold" with "Wrap and Roll" can be used in the management of severely sublaxated crystalline lens. VIDEO LINK: https://youtu.be/G0LgweQT0d0.