Secondary intraocular lens implantation: a large retrospective analysis

New Device for the Correction of Aphakia Without Capsular Support

PURPOSE

This study describes a prototype developed for aphakia without capsular support (AWCS) and its proof of concept.

METHODS

This descriptive study used a 3D software to create and analyze virtual prototypes before manufacturing. A nylon-6/nylon-6.6 copolymer filament and a 3D printer were used for prototyping. A device implantation technique was developed using a 23-gauge hypodermic needle. Two opposing markings, 2 mm posterior to the limbus, were made to determine the location of the scleral punctures and the final position of the device. After adequate centralization and positioning of the device, its haptics were cut and cauterized to generate thermal modeling of the extremity and allow the thickening of the tips (flange), serving as an anchoring mechanism to the sclera. The efficacy and adequacy of the technique and device were then evaluated.

RESULTS

Vitreous tissue extrusion was not observed during the sclerotomy. The device was well fixed to the sclera; however, adequate IOL stability and centralization still needed to be achieved. The surgeon evaluated the adequacy of all the other devices' characteristics.

CONCLUSIONS

The development of a technology prototype for correcting AWCS was possible. Although the proposed prototype met most of the established concept guidelines, the stability of the IOL position remains challenging.

Adjustable flanged technique for secondary implantation of four-point scleral‑fixated posterior chamber intraocular lenses using two parallel 6-0 polyglactin sutures

OBJECTIVE

To assess the efficacy and safety of using the adjustable flanged technique for secondary implantation of four-point scleral‑fixated posterior chamber intraocular lenses with two parallel 6-0 polyglactin sutures.

METHODS

Two parallel 6-0 polyglactin sutures were passed separately through the two haptics on the horizontal line of the 4-haptic IOL. The four externalized sutures were then trimmed and cauterized to form flanges. The best corrected visual acuity, intraocular pressure, and complications in all patients were observed and recorded.

RESULTS

The flanged technique using two parallel 6-0 polyglactin sutures was applied to 14 aphakic eyes. The average preoperative best corrected visual acuity was 1.00 ± 0.88 LogMAR (Snellen 20/200), which improved to 0.42 ± 0.38 LogMAR (Snellen 20/48) at the final follow-up (P = 0.004). None of the patients experienced vitreous hemorrhage, low intraocular pressure, or issues with exposed or broken sutures.

CONCLUSION

The simplicity of the technique, along with its ability to accommodate adjustments post-implantation, allows for optimal positioning and reduces risks like IOL tilt or dislocation. Overall, this is a promising approach to secondary IOL implantation, with potential benefits for both patient outcomes and surgical efficiency.

Accuracy of intraocular lens power calculation formulae for the Yamane technique of secondary fixation: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aims to assess the refractive outcomes of the Yamane technique for intrascleral fixation of intraocular lenses (SF-IOL) and compare the predictive ability of the various intraocular lens power calculation formulae commonly used in conjunction with the technique.

METHODS

A literature search was conducted in the Medline, Scopus, and Cochrane Library databases for articles published from January 2014 to May 2023. Studies that met the predetermined inclusion criteria were included and subjected to analysis. The primary outcome evaluated was the refractive predictive error, defined as the difference between predicted refraction and post-operative manifest refraction.

RESULTS

Eleven studies met the inclusion criteria, with a cumulative sample size of 615 patients (mean age: 66.6 years). Various IOL formulae were used, with SRK/T being the most frequently adopted formula. The overall mean refractive predictive error for all formulae combined was -0.02 D, which was not statistically significant (p = 0.99). Subgroup analysis for individual formulae also showed no significant difference from predicted error for any formula (p > 0.05).

CONCLUSION

The Yamane technique for SF-IOL shows promising refractive outcomes, and the choice of IOL power calculation formula should be tailored based on patient characteristics and surgeon preference. No formula demonstrated superior predictive ability over others. Further research is needed to develop formulae specifically for eyes with secondary aphakia and poor capsular support.

VITREORETINAL OUTCOMES FOLLOWING SECONDARY INTRAOCULAR LENS IMPLANTATION WITH PARS PLANA VITRECTOMY

BACKGROUND

Retrospective cohort study of 561 adult patients undergoing secondary intraocular lens (IOL) implantation by vitreoretinal surgeons at a single institution from April 2015 to December 2020.

METHODS

Patient historical factors, intraoperative/postoperative complications, and outcomes of IOL type (anterior chamber IOL versus scleral sutured IOL versus scleral fixated IOL versus. sulcus) were assessed. Primary outcomes were rates of postoperative retinal tears and rhegmatogenous retinal detachment. Secondary outcomes were rates of intraoperative endolaser, intraoperative retinal tear, and further IOL surgery.

RESULTS

The incidence of intraoperative retinal tears was 7.3% and not significantly different between techniques. Rates of intraoperative endolaser use were 17.5% among all techniques and not significantly different between techniques. Rates of postoperative retinal tear were low (0%-2.7%). Rates of postoperative rhegmatogenous retinal detachment were not significantly different between techniques (anterior chamber IOL 9/198 [4.5%], SFIOL 1/54 [1.9%], scleral sutured IOL 14/274 [5.1%], sulcus 2/35 [5.7%], total 26/561 [4.6%], P = 0.79). Rates of repeat IOL surgery trended higher in sulcus lenses (anterior chamber IOL 5/198 [2.5%], SFIOL 4/54 [7.4%], scleral sutured IOL 16/274 [5.8%], sulcus 5/35 [14.3%], total 30/561 [5.3%], P = 0.12).

CONCLUSION

Intraoperative endolaser use and intraoperative retinal tear are not uncommon in secondary IOL surgery and underscore the importance of careful vitreoretinal management among these patients.

Refractive Outcomes After Scleral Fixation of the Carlevale Intraocular Lens

PURPOSE

To assess the refractive predictability of the Carlevale sutureless scleral fixation intraocular lens (IOL) (Sole-ko IOL Division) power calculation.

METHODS

This retrospective, non-comparative, interventional case series included patients without a capsular support having undergone sutureless scleral fixation IOL implantation in two French hospitals between October 2019 and April 2022. IOL calculation was performed with the Barrett Universal II, Hoffer Q, Holladay 1, and SRK/T formulas with constant optimization to achieve a mean arithmetic prediction error equal to zero. The main outcomes were prediction error (PE) and its standard deviation (SD-PE), the median absolute error (MedAE), the mean absolute error (MAE), and the percentage of eyes with PE within ±0.50, ±1.00 and ±2.00 diopters (D) 6 months after surgery.

RESULTS

Thirty eyes of 30 patients were included in the study. The mean age was 66.6 years, the mean axial length was 24.31 mm, and the mean keratometry was 43.07 D. SDPE ranged from 0.73 to 0.87 D depending on the formula. MedAE ranged from 0.38 to 0.61 D, and MAE from 0.52 to 0.68 D. Between 46.7% and 56.7% of eyes were within ±0.50 D, 76.7% and 90.0% were within ±1.00 D, and 96.7% were within ±2.00 D of target equivalent. No statistically significant difference was observed between the four formulas for any outcomes.

CONCLUSIONS

This study confirmed that the design of the Carlevale sutureless scleral fixation IOL provides satisfactory refractive results. [J Refract Surg. 2024;40(8):e527-e532.].

Long-term functional outcome between Yamane technique and retropupillary iris-claw technique in a large study cohort

PURPOSE

To evaluate which secondary intraocular lens (IOL) implantation technique was more successful in achieving the best postoperative results and refractive outcomes between retropupillary iris-claw IOL (ICIOL) and flanged intrascleral IOL (FIIOL) fixation with the Yamane technique.

SETTING

Eye Clinic of the University of Trieste, Trieste, Italy.

DESIGN

Retrospective observational study.

METHODS

116 eyes of 110 patients who underwent ICIOL or FIIOL were analyzed. Patients with follow-up shorter than 6 months or with incomplete clinical data were excluded. Collected data included demographics, ocular comorbidity, indication of surgery, intraocular pressure, early (≤1 month) and late (>1 month) postoperative complications, corrected distance visual acuity (CDVA), and manifest refraction at the last follow-up visit.

RESULTS

50% (n = 58) of eyes underwent FIIOL and 50% (n = 58) ICIOL implantation for aphakia (n = 44, 38%) and IOL dislocation (n = 72, 62%). No statistically significant differences in demographics, comorbidity, follow-up duration, postoperative complications, and surgical indications were found. The refractive prediction error (RPE) was 0.69 ± 0.94 diopter (D) in the FIIOL group and 0.21 ± 0.75 D in the ICIOL group ( P = .03), indicating residual hyperopia after both techniques. RPE, mean absolute error, and median absolute error were higher in the FIIOL group ( P = .003). ICIOL implantation was more successful in obtaining a RPE between -0.50 D and +0.50 D (52% of ICIOL, n = 30, and 31% of FIIOL, n = 18).

CONCLUSIONS

Both techniques were effective in increasing preoperative CDVA with no statistical difference between them. Although complication rates did not significantly differ, the FIIOL group exhibited less predictable refractive outcomes. Adjusting the dioptric power of the 3-piece IOL, as performed in ciliary sulcus implantation, to prevent myopic shift, is not recommended.

Indications and Outcomes of Intraocular Lens Explantation in a Tertiary Eyecare Center in Hungary between 2006 and 2020

Purpose

Our study aimed to evaluate the indications and outcomes of intraocular lens (IOL) explantation surgeries in a tertiary eyecare center in Hungary.

Materials and Methods

This retrospective study included all IOL explantation surgeries performed between 2006 and 2020 at the Department of Ophthalmology of Semmelweis University, Budapest, Hungary. There were no exclusion criteria for this study. For each patient, the demographics, clinical history, preoperative status, indications for IOL explantation, and operative and postoperative details were reviewed. Primary outcomes included explantation indications and the type of secondary implanted IOL.

Results

A total of 161 eyes from 153 patients were included (96 males; 62.7%); age at the time of the IOL explantation was 65.0 ± 17.4 years. The mean time between primary cataract surgery and IOL explantation was 8.5 ± 7.7 years. In total, 139 (86.3%) PCIOLs and 22 (13.7%) ACIOLs were explanted. The main indications for IOL explantation were dislocation (n = 133; 95.7%) and refractive cause (n = 2; 1.4%) in the PCIOL group. Among ACIOL explantations, the main reasons were pseudophakic bullous keratopathy (n = 14; 63.6%), dislocation (n = 4; 18.2%), and refractive cause (n = 2; 9.1%). In the PCIOL group, 115 (82.7%) primary IOLs were implanted in the capsular bag, 16 (11.5%) were sulcus fixated, and 8 (5.8%) were scleral fixated. The most frequent ocular comorbidities were previous vitrectomy (n = 50, 31.1%), previous ocular trauma (n = 45, 28.0%), glaucoma (n = 16, 9.9%), pseudoexfoliation syndrome (n = 15, 9.3%), and high axial myopia (n = 14, 8.7%). The most commonly used secondary IOL implant was the prepupillary iris-claw IOL (n = 115, 73.7%), followed by the retropupillary iris-claw IOL (n = 32, 20.5%). Uncorrected visual acuity (UCVA) was significantly better following IOL exchange in the entire sample (1.57 ± 0.61 (range: 2.40-0.05) vs. 0.77 ± 0.56 (range: 2.40-0.00); p < 0.001). Best-corrected visual acuity (BCVA) was maintained or improved in 80.7% of cases after IOL explantation.

Conclusions

The most common indication for IOL explantation at a tertiary eyecare center in Hungary is IOL dislocation, followed by pseudophakic bullous keratopathy. Prepupillary and retropupillary iris-claw IOL are the most frequently used secondary implants and their use resulted in a significant UCVA improvement following IOL exchange.

Comparison of Refractive Prediction Error by Axial Length in Flanged Intrascleral Intraocular Lens Fixation

Purpose

To evaluate the refractive prediction error in flanged intrascleral intraocular lens (IOL) fixation using the SRK/T formula and compare the axial length using a single IOL.

Methods

Seventy-six eyes from 70 patients (45 males and 25 females) were included in this study. The mean age at the time of surgery was 73.4 ±12.3 years. The patients underwent flanged IOL fixation using a PN6A (Kowa). All surgeries were performed by two surgeons (Y. K. and T. O.) between Jan 2020 and Dec 2022 at Jikei University Daisan Hospital. IOL power was calculated using the SRK/T formula with IOL Master 700 (Carl Zeiss) as the bag power. The recommended value of 119.0 was used for the A-constant. The actual refractive spherical equivalent was calculated and compared with preoperative predictions. Refractive prediction errors were defined as the deviation of the actual postoperative spherical equivalent refraction in diopters from the predicted preoperative spherical equivalent refraction. The patients were divided into three groups according to axial length: <22.0 mm (short eyes), 22.0-24.5 mm (medium eyes), and >24.5 mm (long eyes), and the refractive prediction errors and mean absolute errors were compared.

Results

The mean refractive prediction error was -0.20 ± 0.52D. The mean absolute error was 0.44 ± 0.33D. The mean refractive prediction errors were not significantly different between the 22.0-24.5 mm (medium eyes) and >24.5 mm (long eyes) groups. (P=0.06) The mean absolute errors were not significantly different between the two groups (P=0.10).

Conclusion

The SRK/T formula worked well regardless of whether the eyes were medium or long according to the axial length in the flanged intrascleral IOL fixation.

Visual Outcomes and Complications of Intraocular Lens Placement in the Absence of Capsular Support in a Philippine Tertiary Hospital

Background

Surgical correction of aphakia without capsular support continues to be a challenge. Improvements in the technology of cataract surgery have provided advancements in techniques in surgical management of aphakia. Locally, we have limited data on the outcomes of the different intraocular lenses used in aphakia.

Objective

This study aimed to determine visual outcomes and complications associated with different techniques of intraocular lens implantation in the absence of capsular support.

Methods

We reviewed the medical charts of 207 patients who underwent intraocular lens implantation without capsular support. Excluded were patients with incomplete follow up, pediatric patients, and lost records. Best corrected visual acuity at day 1, 1st month, 3rd month and 6th month postoperatively, and the complications were noted.

Results

Mean age was 60 and 51% (n=105) were females. The mean follow-up time was 9.33 ± 0.71 months. Loss of capsular support was most frequently caused by intraoperative complication (n=146, 70%) and trauma. Retropupillary fixation iris claw intraocular lens was frequently used (n=93, 44.9%). Across all patients, visual acuities showed excellent outcomes with 20/50 or better. Across IOL types, the most frequent postoperative complication was increase in IOP. Statistically significant results were set at P <0.05.

Conclusion

There is a notable preference towards iris claw retropupillary lenses through time. Iris claw lenses showed the shortest operative time. All intraocular lenses used in aphakia showed comparably good postoperative visual acuities, except for the superior visual acuity trend seen among retropupillary iris claw and anterior chamber IOL groups. Complications included elevated intraocular pressures, corneal edema, and pigment dispersion.

Long-term outcomes of iris-sutured subluxated intraocular lenses

PURPOSE

This study evaluated the long-term outcomes of managing posterior chamber intra-ocular lens (IOL) (PCIOL) subluxation through pars plana vitrectomy (PPV) with IOL iris suturing.

SETTINGS AND DESIGN

Retrospective chart review.

METHODS

Patients who underwent PPV with iris-sutured IOL (IS-IOL) for IOL subluxation between January 2008 and April 2021 at a tertiary center with a minimum of 6 months of follow-up were included. The patients were divided into two groups: those who had prior PPV and those who had not undergone the procedure.

RESULTS

A total of 54 patients underwent iris suturing of a subluxated IOL. Among them, 36 (66%) had previously undergone PPV, while 18 patients (33%) had not. The etiology of PCIOL subluxation was uncertain in 20 (37.0%), prior PPV in 17 (32%), and following complicated cataract surgery in 11 (20%) cases. The mean time between original IOL insertion and IS-IOL was 6.1 ± 7.0 years. The mean follow-up duration was 46.8 ± 39.7 months. The mean post-operative best corrected visual acuity (BCVA) was logMAR 0.43 ± 0.52 at final follow-up, a significant improvement from pre-operative BCVA. Vision was significantly better in the group with no prior PPV (logMAR 0.54 ± 0.59 vs. 0.21 ± 0.23 at final follow-up, P = 0.026). At final follow-up, 34 (63%) eyes had BCVA of 20/40 or better. The most common complication was cystoid macular edema, attributed to the IS-IOL in 13 (21.4%) eyes, 11 (68.6%) of which resolved or improved.

CONCLUSIONS

The management of posterior chamber IOL subluxations with PPV and iris suturing of the subluxated IOL is a safe technique that provides excellent long-term visual outcomes.

A mini-invasive surgical technique for Carlevale IOL implantation: case series study and description of concomitant surgery

PURPOSE

To examine the feasibility and outcomes of a modified technique for the implantation of scleral fixated Carlevale intraocular lens (IOL) (I71 FIL SSF. Soleko IOL Division, Pontecorvo, Italy), and to analyze the occurrence of adverse events.

METHODS

This is a retrospective observational study conducted revising patients charts from 2018 to 2023. Thirty-five eyes of 33 patients were included. Patients requiring IOL explantation had either IOL dislocation or opacification. The implantation of the Carlevale IOL was performed with the subconjunctival positioning of the anchors without any scleral flap. All maneuvers were performed transconjunctivally. The anatomical outcomes considered were IOL positioning, and the absence of postoperative complications. The functional outcomes analyzed were best correctedvisual acuity (BCVA) and refraction.

RESULTS

In all the cases, the IOL was well positioned and centered postoperatively. No cases of conjunctival erosion were recorded. The best corrected visual acuity (BCVA) was 0.9±0.6 logMar (mean±standard deviation) preoperatively and 0.5±0.5 logMar (mean±standard deviation) postoperatively. The mean preoperative spherical equivalent was +6.8±7.7 dioptres, while postoperatively it was -1.1±1.6 dioptres. The most frequent procedure associated to secondary IOL implantation was posterior vitrectomy (25 eyes, 71.4%), which was performed with 25-gauge transconjunctival cannulas in the ciliary sulcus. The follow-up period was 24.5±16.9 months (mean±standard deviation).

CONCLUSION

The described mini-invasive technique for Carlevale IOL implantation is safe and effective. It can be recommended either as a stand-alone operation or associated to concurrent surgical procedures.

Outcomes of Secondary Intracapsular Intraocular Lens Implantation in Patients following Rhegmatogenous Retinal Detachment

This study reports the outcomes of a secondary IOL implantation technique in patients that suffered from rhegmatogenous retinal detachment combined with a cataract, which included reopening the capsular bag, enabling secondary intracapsular intraocular lens (IOL) implantation. We included consecutive cases with rhegmatogenous retinal detachment (RRD) treated with vitrectomy and silicone oil tamponade, and subsequent secondary IOL implantation during silicone oil removal between September 2019 and June 2022. Demographics, pre- and postoperative clinical data, and complications were collected. Visual and refractive outcomes and IOL position were evaluated. Thirty eyes were included and followed up for a mean of 24.2 ± 5.06 months. Compared with the preoperative values, no significant changes were observed in the intraocular pressure (p = 0.170) and endothelial cell density (p = 0.336); however, the best-corrected visual acuity (Snellen: 20/83 vs. 20/38; logMAR: 0.66 ± 0.23 vs. 0.37 ± 0.32; p < 0.001) and spherical equivalent (p < 0.001) improved significantly. The mean prediction error (ME) was -0.45 ± 0.68 D (-1.9-0.54 D), and the mean absolute prediction error (MAE) was 0.62 ± 0.52 D (0.01-1.9 D). The macula-on subgroup demonstrated significantly better refractive outcomes than the macula-off subgroup (ME, p = 0.046; MAE, p = 0.008). The IOL was well positioned, with a mean horizontal and vertical tilt and decentration of 0.53 ± 0.49° and 0.21 ± 0.16 mm, and 0.54 ± 0.45° and 0.22 ± 0.16 mm, respectively. Secondary intracapsular IOL implantation provided a good and stable IOL position and satisfactory refractive outcomes, and is a feasible treatment option for patients with RRD.

Trends in Secondary Intraocular Lens Surgery among Vitreoretinal Surgeons

OBJECTIVE

To identify changes in secondary lens techniques over time and to determine common complications of each technique.

DESIGN

Retrospective cohort study.

PARTICIPANTS

All patients in the database from January 2015 to December 2021 who underwent secondary lens placement (anterior chamber intraocular lens [IOL, ACIOL], scleral-fixated IOL [SFIOL], or scleral-sutured IOL [SSIOL]).

METHODS

Rates of secondary IOL surgery techniques were analyzed in 3597 participants in a nationwide aggregated electronic health care database using 2-sample independent t tests. Rates of postoperative rhegmatogenous retinal detachment (RRD) after secondary IOL surgery were assessed using chi-square test of proportion. Postoperative visual acuity (VA) was assessed using 2-sample independent t tests.

MAIN OUTCOME MEASURES

The primary outcome was change in IOL technique over time. Secondary data points examined were the development of postoperative RRD after secondary IOL surgery, VA changes, the development of endophthalmitis, suture erosion, haptic erosion, or corneal edema after IOL surgery.

RESULTS

Anterior chamber IOL use decreased over the 7-year period from 93% of cases to 36% of cases (P < 0.0001), while SFIOL use increased from 3% to 34% (P < 0.0001) and SSIOL use increased from 4% to 30% (P < 0.0001). Visual acuity increased for each surgical technique (ACIOL: 44.1 vs. 49.2 ETDRS letters, P < 0.001; SFIOL: 48.7 vs. 57.6 letters, P < 0.001; SSIOL: 51.5 vs. 61.2 letters, P < 0.001), with larger VA gains seen in SFIOL and SSIOL use (ACIOL vs. SFIOL, P = 0.004; ACIOL vs. SSIOL, P = 0.002; SFIOL vs. SSIOL, P = 0.64). Average RRD rates did not significantly differ between techniques. Rates of endophthalmitis, haptic erosion, and suture erosion were low and did not significantly differ between techniques. Rates of corneal edema were significantly higher in ACIOL cases (vs. SFIOL, P < 0.0001; vs. SSIOL, P < 0.0001).

CONCLUSIONS

Rates of ACIOL implantation performed by vitreoretinal surgeons have decreased over time with more vitreoretinal surgeons electing to place either an SFIOL or SSIOL toward the end of the study period; complication profiles among the 3 techniques may be similar.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Long term outcomes of Yamane technique in various indications

INTRODUCTION

To describe the clinical and refractive outcomes of Yamane transconjunctival sutureless intrascleral intraocular lens (SIS IOL) fixation technique in aphakic and dislocated IOLs.

METHODS

The aphakic and IOL dispositioned patients who underwent Yamane surgery in Bozyaka Research and Training Hospital were evaluated retrospectively. The demographic data, preoperative & postoperative best-corrected visual acuity (BCVA), spherical equivalent (SE), indication for surgery, additional surgical interventions, complications, the final status of retina, and central macular thickness (CMT) through spectral-domain optic coherence tomography (SD-OCT) were recorded.

RESULTS

A total of 30 eyes of 30 patients were evaluated. The indication for surgery was aphakia in 24 patients, lens dislocation in 1 patient, and IOL dislocation in 5 patients. The mean age of participants was 64.17 ± 14.69 years, and the mean follow-up was 46.07 ± 7.96 months. The mean BCVA was improved from 0.25 ± 0.22 (-0.94 ± 0.83 log MAR) to 0.49 ± 0.24 in decimals (-0.37 ± 0.27 log MAR) (p:0.041). The mean subjective refraction improved from 10.06 ± 3.10 to -1.45 ± 0.73 D in the final visit (p < 0.05). The mean of cylindrical refraction was -1.22 ± 1.03 D in the postoperative period. At the time surgery, 36.6% of patients required at least one additional surgical procedure. During follow-up period, two (6.7%) out of 30 of patients had retinal detachment, two of the patients (6.7%) occured epiretinal membrane, one of the patients (3.3%) had cystoid macular edema.

CONCLUSION

Yamane SIS IOL fixation technique is an effective and reliable surgical option in complicated cases that require additional surgical interventions in long-term follow-up.

Long-Term Outcome and Complications of IOL-Exchange

Purpose

To describe the long-term outcome after intraocular lens (IOL) exchange for IOL-opacification with a focus on any occurring complications.

Patients and Methods

Patients with an IOL exchange for opacified IOLs (Lentis LS-502-1) were identified. Medical records and information from the treating ophthalmologists were reviewed. Visual outcomes and any occurring complications after the IOL exchange were analyzed.

Results

IOL exchange was performed in 48 eyes of 46 patients and significantly improved best-corrected distance visual acuity from 0.42 ± 0.32 logMar (mean ± SD) in opacified lenses to 0.25 ± 0.28 logMar after IOL exchange. Nine of the 48 eyes (19%) underwent 11 further surgical procedures for complications due to four indications: IOL dislocation (n = 2, 4%), retinal detachment (RD) (n = 6, 12%), epiretinal membrane (n = 2, 4%), and pupillary block (n = 1, 2%). Three eyes (6%) developed a temporarily elevated intraocular pressure. Temporary postoperative cystoid macular edema was found in 2 eyes (4%).

Conclusion

IOL exchange can restore vision owing to IOL opacification in most cases. Nonetheless, IOL exchange is not an easy or risk-free procedure. This may lead to sight-threatening complications, even in eyes without predisposing ocular comorbidities.

Secondary in-the-bag Intraocular Lens Implantation in Aphakic Eyes After Vitrectomy and Silicone Oil Tamponade for Rhegmatogenous Retinal Detachment

PURPOSE

To describe a novel technique for capsular bag reopening and secondary in-the-bag intraocular lens (IOL) implantation in aphakic eyes after vitreoretinal surgery and intraocular tamponade.

METHODS

We enrolled 14 eyes of 14 patients who underwent primary vitreoretinal surgery with silicone oil tamponade for rhegmatogenous retinal detachment between September 2018 and September 2019. The novel technique was used for capsular bag reopening and foldable single-piece IOL implantation. Patients were followed up at least 24 weeks with routine ophthalmic examinations, corneal endothelial cell density, and IOL tilt and decentration measurement.

RESULTS

The procedure was successfully completed in 13 cases; in one case, because of posterior capsular tear, the IOL was implanted with ciliary sulcus fixation. After a mean follow-up of 48.8 ± 14.8 (range, 24.9-65.9) weeks, the best-corrected visual acuity (before 20/76 Snellen, 0.63 ± 0.23 logarithm of the minimum angle of resolution equivalent and after 20/35 Snellen, 0.32 ± 0.32 logarithm of the minimum angle of resolution equivalent; P = 0.001) and spherical equivalent (before +8.22 ± 4.08, after -2.39 ± 1.77 D; P < 0.001) improved, intraocular pressure (before 15.93 ± 4.40, after 16.25 ± 4.25 mmHg; P = 0.743) remained unchanged. The IOL was well centered with a mean horizontal and vertical tilt of 0.5070 ± 0.3319° and 0.4652 ± 0.3465°, respectively, and decentration of 0.1705 ± 0.1334 mm and 0.1712 ± 0.1576 mm, respectively.

CONCLUSION

With this technique, capsular bag reopening and secondary in-the-bag IOL implantation could be achieved in most cases with satisfactory visual outcome and IOL position.

Face and Content Validity of an Artificial Eye Model for Secondary Intraocular Lens Fixation via Yamane Technique

Purpose

To assess the face and content validity of an artificial eye model for secondary intraocular lens (IOL) fixation via the Yamane technique.

Methods

Ophthalmologists and residents participated in a 90-minute simulation session on secondary IOL fixation via the Yamane technique. Hands-on practice of this technique was performed on an artificial eye, the Bioniko Okulo BR8. After, all ophthalmologists answered an 18-question survey assessing the face and content validity of the model. Survey responses were recorded on a 5-point double-headed Likert scale, ranging from strongly agree (1)-to-strongly disagree (5) (Figure 1).

Results

Twenty-three surveys were completed. Respondents rated the survey with a median response of 1 (strongly agree)-to-3 (neutral). Highest ratings for the model were received for "usefulness for training residents", and "easier to set up and clean-up compared to a cadaver". Lowest ratings were received for realism of the model compared to cadaveric eyes. Statistical analysis revealed no significant difference among identified groups. Ratings for face and content validity were viewed favorably, both with an overall median response of 2.00 (agree).

Conclusion

The Bioniko Okulo BR8 shows promise as a valid tool for practicing secondary IOL fixation via the Yamane technique. Considering recent guidelines in competency-based ophthalmology education programs, this model may be a valuable tool over traditional techniques for teaching and improving surgical skill amongst trainees.

Indications and outcomes of intraocular Lens Exchange among pseudophakic eyes in a Tertiary Referral Center

PURPOSE

To determine the indications and surgical outcomes of intraocular lens (IOL) exchange in pseudophakic patients at Labbafinejad Tertiary Referral Center between 2014 and 2019.

METHODS

In this retrospective interventional case series, the medical records of 193 patients with a history of IOL exchange were reviewed. Preoperative data, including clinical characteristics, indications of the first and second IOL implantation, intra- and postoperative complications due to IOL exchange, and the pre-and postoperative refractive error and best-corrected visual acuity (BCVA) were considered the outcome measures in this study. All postoperative data were analyzed at least six months after follow-up.

RESULTS

The mean age of our participants was 59.13 ± 20.97 years old at the time of the IOL exchange, with a male percentage of 63.2%. The mean follow-up after the IOL exchange was 15.72 ± 16.28 months. The main indications of IOL exchange were IOL decentration (50.3%), corneal decompensation (30.6%), and residual refractive errors (8.3%). 57.10% of patients with the postoperative spherical equivalent at -2.00 diopter (D) to + 2.00D. The mean best-corrected visual acuity was 0.82 ± 0.76 LogMAR before the IOL exchange and was improved to 0.73 ± 0.79 LogMAR after the surgery. Corneal decompensation (6.2%), glaucoma (4.7%), retinal detachment (4.1%), cystoid macular edema (2.1%), and uveitis (1%) were found as the postoperative complications. There was only one case with suprachoroidal hemorrhage during IOL exchange.

CONCLUSIONS

IOL decentration followed by corneal decompensation was the most common indication of IOL exchange. After IOL exchange, the most complications during follow-up were corneal decompensation, glaucoma, retinal detachment, and cystoid macular edema.

[Secondary implantation of retropupillary fixated iris-claw intraocular lenses]

BACKGROUND

There is no standard for the treatment of functional aphakia in cases with a compromised capsular system. Retropupillary fixation of an Artisan iris-claw IOL ("Intraokularlinse") is one of the established procedures.

OBJECTIVE

Aim of this study was the evaluation of indications, visual and refractive long-term results and complication rates after retropupillary implantation of an iris-claw lens.

MATERIAL AND METHODS

This retrospective study comprised 366 eyes that received a retropupillary Artisan intraocular lens (IOL) in a single center between January 2009 and December 2019. The mean follow-up period was 249 days (8 months) ±516 days.

RESULTS

IOL dislocation (68%) was the most common reason for a retropupillary iris-claw implantation. Previous vitrectomy was a significant preoperative risk factor for IOL dislocation (p = 0.0001). Best corrected visual acuity improved from 0.65 ± 0.64 (logMAR) preoperatively to 0.57 ± 0.51 (logMAR) 4-6 weeks after the surgery. The mean deviation from the planned refraction was +0.40 ± 1.37 dpt and 73% of the patients had a deviation within ±1 dpt of the planned refraction. Relevant postoperative complications during the first 4 weeks were pupillary distortion (42%), ocular hypotony (15%) and transient hyphema (14%). Late complications (≥4 weeks after the surgery) included persistent pupillary distortion (20%), cystoid macular edema (13%) and iris-claw disenclavation (6%).

CONCLUSION

The retropupillary Artisan implantation is an efficient method for treating aphakia without capsular support and provides good visual and refractive results with an acceptable surgical risk profile.

Comparison of Visual and Aberrometric Outcomes in Suture-Free Scleral Fixation: Three-Piece Lenses versus Carlevale Lenses

Purpose: To compare the refractive results between sutureless scleral fixation intraocular lens (IOLs) (Carlevale, Soleko) and suture-free scleral fixation three-piece IOLs (Sensar AR40, Johnson & Johnson) for secondary implantation in patients with IOL dislocation or aphakia. Methods: This is a monocentric retrospective study on 28 patients (28 eyes) with sutureless scleral fixation Carlevale IOL and 25 patients (25 eyes) with suture-free scleral fixation three-piece IOL. Best-corrected visual acuity (BCVA) evaluation, refractive measures and IOL tilt evaluation with anterior segment optical coherence tomography were conducted at one, three, six and twelve months after surgery. Point Spread Function (PSF) was measured using a total ocular aberrometer. Results: BCVA in both groups improved since the postoperative visit at 1 month and reached a stable value at 3 months At month 12, mean BCVA was 0.23 logMAR in group one and 0.32 logMAR in group two. Mean IOL tilt angle at 12 months was 2.76° ± 1.87 in group one and 2.51° ± 1.80 in group two. PSF at 12 months was 0.18 ± 0.09 in group one and 0.15 ± 0.05 in group two. There were no statistically significant differences (p > 0.05) for all comparisons. The post-operative complications were similar within the two groups. Conclusions: Our results show that secondary IOL implantation has similar visual and surgical outcomes when a sutureless Carlevale lens scleral fixation and a suture-free scleral fixation three-piece IOL are used.

An improved two-steps method for secondary in-the-bag intraocular lens implantation in aphakia eye

PURPOSE

To describe an improved technique for secondary IOL implantation in constricted capsular bag in aphakic eyes.

SETTING

This study was designed and carried out in the department of Ophthalmology, Shanghai General Hospital (Shanghai First People's Hospital).

DESIGN

This is a retrospective study which evaluate the post-operative effect of the two-steps secondary IOL implantation.

METHOD

21 eyes of 21 patients who underwent primary cataract surgery from June 2020 to September 2020 were enrolled. Two-steps IOL implantation was performed. Patients were followed up with ophthalmic examinations.

RESULTS

Of all 21 eyes, the capsular bags were reopened and the IOL were implanted into the bag. During follow-up, the mean age was 62.3 ± 7.3 (range, 44-81) years and mean interval between the primary surgery and secondary IOL implantation was 23.5 ± 9.6 (range, 4.1-78.3) weeks. A marked improvement of postoperative mean BCVA was noticed (pre 20/84 Snellen, 0.62 ± 0.26 logMAR equivalent, and post 20/44 Snellen, 0.34 ± 0.33 logMAR equivalent; p = 0.001). The mean SE also improved from + 10.32 ± 5.05D at baseline to -2.68 ± 1.36D at the last follow-up time (p < 0.001). The mean IOP showed no significant difference (pre 17.62 ± 4.66 mmHg, post16.84 ± 4.73 mmHg; p = 0.6860) and the corneal endothelial cell density decreased about 11.04 ± 10.84% (from 2483 ± 218.43 cells/mm2 to 2190 ± 361.36 cells/mm2 p = 0.0029).

CONCLUSION

The two-steps capsular bag reopening method can be achieved in majority of cases with stable IOL position and better visual outcome.

Intraocular lens dislocation: manifestation, ocular and systemic risk factors

PURPOSE

The aim of this study was to evaluate ocular and systemic risk factors for posterior chamber intraocular lens dislocation, as well as forms of manifestation.

METHODS

A retrospective case-control study were all patients presented in the period 2012-2016 having intraocular lens dislocation and being treated with implantation of an iris-fixated intraocular lens was conducted at the University Hospital Mainz. As controls, pseudophakic patients presenting for other reasons were included.

RESULTS

150 eyes of 150 patients (mean age 72.7 ± 12.4 years, range 24-93 years) with IOL dislocation and 150 eyes of 103 controls were included in this study. The average time between primary implantation and IOL luxation was 86 months (iQR: 39.25-127 months) for all dislocations. Previous pars plana vitrectomy (PPV) (crudeOR = 2.14 (95% CI 1.23, 3.72), p = 0.011) and PEX (crudeOR = 11.6 (4.79, 28.12), p < 0.001) was linked with a higher risk of IOL luxation. Luxation occurs also earlier in patients with previous PPV and PEX than in eyes with neither PEX nor previous PPV (82.2 vs. 127 months). Rhegmatogenous retinal detachment was the major pathology that required a previous PPV for eyes with an IOL dislocation (57%). The average time between PPV and IOL dislocation was 74.67 months (range 0-186 months).

CONCLUSION

Patients with a coexistence of both: PEX and a previous PPV had an elevated risk of IOL dislocation, and also had a shorter time interval between primary IOL implantation and IOL dislocation followed by eyes with PEX only and eyes with only a previous PPV.

Efficacy of a Secondary Trifocal Sulcus IOL in Providing Near and Intermediate Vision in Patients with Prior Myopic Laser Vision Correction and Cataract Surgery

Purpose

To evaluate the visual function of patients with a history of prior laser vision correction and cataract surgery with implantation of a monofocal primary IOL after subsequent implantation of a secondary sulcus trifocal intraocular lens (IOL).

Setting

One clinical practice in Haugesund, Norway.

Design

Prospective, single arm, non-interventional unmasked study.

Methods

Eligible subjects who had previous laser vision correction and cataract surgery involving implantation of a monofocal IOL in the capsular bag of one or both eyes were subsequently implanted with a secondary IOL in the sulcus. Postoperative uncorrected and best distance-corrected visual acuities (VAs) were measured at distance (4 m), intermediate (60 cm), and near (40 cm), along with low contrast visual acuity and the monocular distance corrected defocus curve.

Results

Twenty-five eyes were evaluated from 7 to 24 months after trifocal implantation. The mean monocular uncorrected VAs were 0.06, 0.21 and 0.10 logMAR at distance, intermediate and near, respectively. Uncorrected near VA was 0.2 logMAR or better in 80% of eyes (20/25). VA of 0.2 logMAR or better at all test distances was achieved in 15/25 eyes (60%) in the uncorrected state and 17/25 eyes (68%) when corrected for distance vision. Binocular uncorrected distance visual acuity was 0.1 logMAR or better in all subjects while binocular uncorrected near visual acuity was 0.1 logMAR or better in all but one subject. The defocus curve showed a range of functional vision from distance to 30 cm. No adverse events were identified.

Conclusion

The trifocal sulcus IOL provided excellent distance and near vision and a good range of functional vision, similar to results obtained when a primary trifocal IOL is implanted. It is a viable option to provide better intermediate and near vision to patients with a prior history of refractive surgery and a monofocal IOL implanted.

OUTCOMES OF RETROPUPILLARY IRIS CLAW INTRAOCULAR LENS IMPLANTATION COMBINED WITH PARS PLANA VITRECTOMY

PURPOSE

To report 12-month visual outcomes, incidence of intraocular pressure (IOP) changes and postoperative complications after pars plana vitrectomy with retropupillary implantation of an iris claw intraocular lens (IOL) in aphakic eyes after complicated cataract surgery and eyes with a dislocation of the IOL.

METHODS

This is a retrospective analysis of eyes undergoing implantation of an iris claw IOL combined with pars plana vitrectomy from 1st of January 2009 until 30th of June 2018 after complicated cataract extraction with capsular loss (Group A) or dislocation of an IOL (Group B). Corrected distance visual acuity was analyzed in logarithm of the minimum angle of resolution (logMAR) units, IOP was recorded in mmHg.

RESULTS

Eyes in Group A (n = 49) improved from a preoperative median visual acuity of 0.523 logMAR (Snellen 20/65) to 0.201 logMAR (Snellen 20/30), P < 0.01. Eyes in Group B (n = 126) showed stable median visual acuity, preoperative 0.301 logMAR (Snellen 20/40) versus postoperative 0.222 logMAR (Snellen 20/30), P > 0.05. During 12 months in Group A, IOP >21 mmHg occurred in 9 (18.4%) eyes; no eye had an IOP <6 mmHg. In Group B, IOP >21 mmHg occurred in 15 (11.9%) eyes, IOP <6 mmHg in 5 (4%) cases. None of the eyes in Group A and B had IOP >21 mmHg or <6 mmHg at 12 months follow-up.

CONCLUSION

The retropupillary implantation of an iris claw IOL with pars plana vitrectomy provides adequate visual rehabilitation and seems to be safe in IOP changes.

Refractive and Visual Outcomes After Implantation of a Secondary Sulcus Intraocular Lens with an Extended Depth of Focus

Purpose

To evaluate the range of vision, visual function, and quality of vision after implantation of a secondary extended depth of focus intraocular lens (EDOF IOL) implanted in the sulcus.

Setting

One clinical practice in Haugesund, Norway.

Design

Prospective single arm non-interventional study.

Methods

Eligible subjects presenting for surgery, or who had previous successful primary cataract or refractive lens exchange surgery in both eyes were subsequently implanted with the AddOn® secondary EDOF IOL in the sulcus. Manifest refraction and visual acuity at distance, intermediate and near were measured 3 months after surgery, along with the monocular defocus curve. Subjects also completed a visual function and a quality of vision questionnaire.

Results

The study included 32 eyes of 16 subjects. At 3 months postoperative, the mean refraction spherical equivalent (MRSE) was −0.16 ± 0.30 D, with a residual cylinder of 0.29 ± 0.27 D. The mean monocular uncorrected VA was 0.1 logMAR (20/25) or better at all test distances. The monocular defocus curves showed a depth of focus of 2.0 D. For every category except reading fine print, all but one subject (94%) had no difficulty or little difficulty with near tasks. Glare and halos were the most common visual disturbances, with no reports of starbursts. There was no evidence of any intralenticular opacification in any of the eyes, and no evidence of iris chafing/depigmentation.

Conclusion

This secondary EDOF IOL provided excellent distance and intermediate vision, and very good near vision to subjects. Subject reported near visual function was also very good and visual disturbances were limited. This lens appears to be a good option for patients who would like to improve their range of vision. Results appear as good or better than those reported for primary EDOF lenses.

Retrospective study of secondary implantation of retroiridial fixation lenses in patients without capsular support: functional results and complications

INTRODUCTION

The correction of aphakia when there is no adequate capsular support remains a therapeutic challenge. The use of retroiridial fixation lenses has been extended given their lower complication rate compared to other available options.

MATERIAL AND METHODS

Retrospective study including all cases operated with an Artisan® retropupillary aphakia implant.

RESULTS

33 eyes were included out of a total of 28 patients. The follow-up period has been 38.55 months (1-96). 32.3% had a lens dislocation and 67.7% had an intraocular lens dislocation. The previous mean best corrected visual acuity (BCVA) was 1.18 ± 0.79 logMAR and post-intervention 0.36 ± 0.62 (p < 0.01). 93.8% of the patients presented a final BCVA equal to or better and 62.5% an improvement of 3 or more lines. The most frequent complication was corectopia (31.3%) and hypotony in the immediate postoperative period (21.9%). An epiretinal membrane (ERM) developed in 18.8% and cystic macular oedema (CME) in 9.4%. The presence of complications in the postoperative period did not statistically influence the final BCVA.

CONCLUSIONS

The retropupillary Artisan® lens allows the correction of aphakia with satisfactory visual results and a low rate of complications.

Visual and refractive outcomes following secondary intraocular lens implantation

PURPOSE

To analyze the visual and refractive results after secondary IOL implantation using different surgical techniques - iris-claw aphakic IOL through a corneal incision or scleral tunnel, and 3-piece IOL into the ciliary sulcus.

PATIENTS AND METHODS

Retrospective study including patients that were submitted to secondary IOL implantation from January 2017 to December 2019 at the Department of Ophthalmology of Hospital de Braga, Portugal. We collected demographic data (age, surgical indication, comorbidities, surgical technique, IOL implanted, and intra and postoperative complications) and visual and refractive data [preoperative and 3-month, 6-month, and 12-month postoperative corrected-distance visual acuity (CDVA), spherical equivalent (SE), manifest cylinder, and intraocular pressure].

RESULTS

128 eyes from 123 patients were included. The most frequent surgical indications were IOL subluxation/luxation (62.5%) and intraoperative posterior capsular rupture (23.4%). CDVA improved from 1.26 ± 0.51 to 0.47 ± 0.49 logMar (p < .001). CDVA was significantly better in the 3-piece into the ciliary sulcus IOL group than both other groups. The final SE was -0.68 ± 0.94 diopters. The mean manifest refractive cylinder remained stable until the 6th month after the surgery (p = .454) and improved in the last 6 months of follow-up (p = .015). In the postoperative period, the cylinder was higher in the corneal incision iris-claw aphakic IOL group and lower in the 3-piece IOL into the ciliary sulcus group (p < 0,05). The corneal incision iris-claw aphakic IOL group presented the most postoperative complications.

CONCLUSION

All techniques showed satisfying results. The 3-piece IOL into the ciliary sulcus group showed the best visual and refractive performance, followed by the scleral tunnel iris-claw IOL group and the corneal incision iris-claw IOL group.

Implantation of retropupillary iris-claw lenses: A review on surgical management and outcomes

Iris-claw lenses have gained increasing popularity over the last years and are by many surgeons regarded as viable options in eyes with insufficient capsular or zonular support. The iris-claw lens has two haptics with fine fissures for folding (enclavating) the mid-peripheral part of the iris stroma and can either be placed in front of or posterior to the iris. In particular, the retropupillary implantation has been increasingly chosen probably due to having an anatomical position similar to that of the crystalline lens. The present review is based on a literature review and also on the authors' clinical experience with this lens, and it focuses on surgical techniques and outcomes especially related to the characteristics of this lens, having haptics with claws that fixate the lens to the posterior iris. Implanting retropupillary iris-claw lenses has a relatively short learning curve, and there are only few complications reported during surgery. Retropupillary iris-claw lenses have demonstrated generally favourable efficiency and safety. However, the outcomes are probably more influenced by the reason for surgery and eye comorbidity than the lens itself. Albeit seldom reported, the postoperative complications have mostly been related to atrophy of the iris at the site of the haptics, or IOL decentration or disenclavation of one of the haptics. To date, however, there are few randomized clinical trials comparing this lens to other lens alternatives in eyes exhibiting insufficient capsular or zonular support for placing the lens in the ciliary sulcus. In the future, prospective studies with large samples should be performed to gain insights into the long-term safety of retropupillary placed iris-claw lenses, and for comparisons with the various other techniques of lens fixation.

Reopening the severely contracted lens capsular bag post-phacovitrectomy by injecting OVD and removing the fibrous membranous material

Implantation of an intraocular lens (IOL) after combined vitrectomy and cataract surgery is usually required to reduce postoperative refraction errors. However, because of the severe fibrosis of the anterior capsule and the adhesion between the anterior and posterior capsules, it is difficult to reopen the capsular bag to complete the secondary IOL implantation. In this study, a surgical approach is described for reopening the severe adhesion between capsules and removing the significant fibroproliferative membranous material by injecting ophthalmic viscosurgical device into the periphery of the capsular bag to separate the anterior and posterior capsules. The IOL was implanted into the capsular bag without any zonular rupture or posterior capsule tear. The position of the IOL was stable during postoperative follow-up up to 3 months. This procedure to open a severely fibrosis capsule was safe and effective.

Clinical outcomes of combined pars plana vitrectomy and scleral fixation of the intraocular lens with a suspension bridge method in eyes with aphakia or insufficient capsular support

Purpose

To describe a modified technique of scleral fixation for intraocular lens (IOL) implantation and report the clinical outcomes of combined pars plana vitrectomy and scleral IOL fixation using the suspension bridge method.

Methods

This retrospective case series included 57 eyes (56 patients) of aphakia or phakic and pseudophakic eyes with insufficient capsular support that underwent IOL implantation or dislocated IOL repositioning with scleral fixation using the ‘suspension bridge’ method by a single surgeon between 1 July 2010 and 1 March 2019. Preoperative status, changes in visual acuity, refractive outcomes as spherical equivalent and related complications were assessed with a minimum follow‐up of 3 months.

Results

The mean follow‐up period was 25.5 ± 25.4 months. Preoperative visual acuity (logarithm of the minimum angle of resolution) was 1.32 ± 0.68 (20/400 Snellen), and it significantly improved to 0.80 ± 0.53 (20/125), 0.59 ± 0.56 (20/80) and 0.24 ± 0.37 (20/35) at 1 week, 1 month and 3 months, respectively (p < 0.001). Postoperative complications included corneal wound dehiscence (n = 1), vitreous incarceration (n = 1), optic‐iris capture (n = 6) and cystoid macular oedema (n = 1). The above‐mentioned complications were successfully corrected with simple procedures. However, one case of IOL dislocation required reoperation.

Conclusion

The modified technique of the suspension bridge method precludes the need for a scleral flap, with the advantage of easy adjustment of the IOL position. It is a simple and feasible technique with good surgical results and low complication rates.

Scleral-fixated intraocular lens implants-evolution of surgical techniques and future developments

Varied options are available for the implantation of secondary intraocular lens implants in the absence of zonular or capsular support. Loss of the capsule can occur in the context of complicated cataract surgery, trauma or inherited conditions such as Marfan syndrome or pseudoexfoliation. Approaches to overcome this include optical measures such as the use of spectacles or contact lenses, and surgical therapy incorporating the use of anterior chamber, iris-fixated or scleral-fixated lenses. Surgical techniques to implant scleral-fixated lenses have undergone various modifications, since the first publication of sutured intrascleral fixation described in the 1980s. However, despite the advances in surgical techniques, studies are limited either by their retrospective nature, small sample size and most importantly small duration of follow-up. This comprehensive review aims to amalgamate the evolution of various surgical techniques with regards to intrascleral lens fixation and suggests areas for future development.

Combined transconjunctival sutureless three-port vitrectomy and scleral fixation of intraocular lens

PURPOSE

The aim of this article is to describe an innovative and minimally invasive surgical technique for posterior vitrectomy combined with secondary intraocular lens implantation, using a sutureless scleral fixation Carlevale intraocular lens (I71 FIL SSF Carlevale lens. Soleko IOL Division, Italy).

METHODS

The technique was conducted with only three transconjunctival sclerotomies and a corneal tunnel to perform intraocular lens explantation, posterior vitrectomy and Carlevale intraocular lens implantation. It is easier, quicker, and less invasive than the traditional technique with conjunctival peritomy, two scleral flaps and five sclerotomies.

RESULTS

Surgery was performed uneventfully on three eyes of three patients. Two of them presented a luxation of the intraocular lens into the vitreous chamber, while one patient presented an intraocular lens subluxation. No complications were observed after a 5 to 8 months of follow-up. The intraocular lenses were well positioned, no conjunctival erosion was noted, and the intraocular pressure remained normal at all stages.

CONCLUSIONS

This is the first report of a combined procedure of IOL explantation, posterior vitrectomy and secondary IOL implantation using only three transconjunctival sclerotomies. This appears to be less invasive and it causes less discomfort to the patient. We suggest considering this technique in all those cases requiring a combined procedure in absence of a proper capsular support.

Iris-Claw Intraocular Lens: Anterior Chamber or Retropupillary Implantation? A Systematic Review and Meta-Analysis

Background and Objectives: Iris-claw intraocular lens (ICIOL) could be implanted in the anterior chamber (AC) or retropupillary (RP) in eyes lacking capsular and/or zonular support. Several studies have focused on comparing the efficacy and complications of these two techniques and we designed this research to review the published literatures. Materials and Methods: Peer-reviewed studies were collected through network databases (PubMed, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov) and analyzed. The primary outcome was the standardized mean differences (SMDs) of pre- and post-operative corrected distant visual acuity (CDVA). The secondary outcome was the SMDs of pre- and post-operative intraocular pressure (IOP), endothelial cell counts (ECC), and the odds ratios (ORs) of post-operative IOP elevation and cystoid macular edema (CME). Comprehensive Meta-Analysis software was utilized to conduct statistical analysis. Results: Six studies (one randomized controlled trial and five retrospective case series) were relevant and included a total of 516 eyes (255 and 261 eyes in the AC ICIOL and RP ICIOL groups, respectively). The quantitative analysis showed no significant differences in CDVA (SMD: 0.164, 95% confidence interval (CI): -0.171 to 0.500), ECC (SMD: -0.011, 95% CI: -0.195 to 0.173), and IOP elevation events (OR: 0.797, 95% CI: 0.459 to 1.383). Lesser IOP reduction (SMD: 0.257, 95%CI: 0.023 to 0.490) and a relative increase in the incidence of CME (OR:2.315, 95% CI: 0.950 to 5.637) were observed in the AC ICIOL group compared with RP ICIOL group. Conclusions: Our meta-analysis indicated that AC and RP ICIOL seem to have equivalent visual outcomes. RP ICIOL may perform slightly better with more IOP reduction and lesser CME. More randomized controlled trials, which have higher patient participation and more outcomes are needed to confirm our conclusions.

In vivo evaluation of a 1-piece foldable sutureless intrascleral fixation intraocular lens using ultrasound biomicroscopy and anterior segment OCT

PURPOSE

To evaluate the optic plate and haptics of a specially designed sutureless intrascleral-fixated intraocular lens (IOL) using ultrasound biomicroscopy and anterior segment optical coherence tomography (AS-OCT).

SETTING

Department of Ophthalmology, San Marino Hospital, Republic of San Marino.

DESIGN

Retrospective observational case series.

METHODS

Eyes that underwent intrascleral fixation with IOL implantation (Carlevale) were included. Preoperative and postoperative refractive outcomes were reported. Optic plate tilt and haptics position were assessed with ultrasound biomicroscopy, whereas intrascleral plug depth and conformation were evaluated with AS-OCT.

RESULTS

The study comprised 10 aphakic eyes. Postoperative visual acuity improved in all patients. At postoperative month 3, 3 eyes (30%) had a vertical tilt of more than 100 μm, whereas no horizontal tilt was observed in any patient. The mean vertical intraocular tilt was 0.19 ± 0.22 mm. Of 20 haptics, 13 (65%) passed through the ciliary sulcus, 4 (20%) posterior to the ciliary body, and 3 (15%) through the ciliary body. AS-OCT scans showed a mean intrascleral plug depth of 247.20 ± 62.82 μm in the nasal sector and 265.50 ± 30.11 μm in the temporal sector, with adequate integration of the T-shaped plugs in the scleral tissue.

CONCLUSIONS

This secondary IOL showed good intraocular stability and safe haptics fixation, making it suitable for the intrascleral fixation technique. The specific foldable design results in a low predisposition to optic plate tilt and haptic torsion. In long eyes, the sulcus-to-sulcus distance should be carefully evaluated preoperatively because the flexible structure of the IOL could be subjected to excessive stretching.

Clinical outcome and endothelial loss following prepupillary and retropupillary implantation of iris claw intraocular lenses

PURPOSE

Iris claw intraocular lenses (IOLs) were successfully used for the management of aphakia in patients that lack capsular support. The aim of this study was to compare the clinical outcome of prepupillary and retropupillary implantation of these IOLs.

METHODS

The files of the 26 patients that had an iris claw IOL implantation between 2010 and 2020 were retrospectively reviewed. Detailed ophthalmological examination findings including corrected distance visual acuity (CDVA), intraocular pressure, endothelial cell counts, slit lamp and dilated fundus examination findings were specifically tabulated. Intraoperative and postoperative complications were also specifically recorded.

RESULTS

There were 18 patients in the prepupillary implantation group and eight patients in the retropupillary implantation group. Age and gender distribution were similar between the groups. CDVA significantly increased in prepupillary and retropupillary implantation groups (p = 0.001 and p = 0.012, respectively). Median endothelial cell loss was 6.7% in prepupillary group and 7.2% in retropupillary group. The only intraoperative complication was iridodialysis (n = 1). Postoperative complications included retinal detachment (n = 1), cystoid macular edema (n = 2) and IOL tilt (n = 1). All of these complications occurred in the prepupillary implantation group.

CONCLUSION

Prepupillary and retropupillary implantation of iris claw IOLs resulted with similar visual gain and endothelial loss rates in a follow-up time of 6 months. There was an insignificant trend toward a reduced complication rate following retropupillary implantation.

Late in-the-bag intraocular lens dislocation

This review aimed to evaluate the cumulative incidence, patient characteristics, predisposing conditions, and treatment outcomes for late in-the-bag intraocular lens (IOL) dislocation. Literature searches in PubMed (MEDLINE), Embase, and Cochrane Library Central database identified 1 randomized clinical trial, 1 prospective case series, 2 prospective cohort studies, and 36 retrospective studies of this condition, which showed that the cumulative incidence was 0.5% to 3%, it occurred on average 6 to 12 years after cataract surgery, and mean patient age was 65 to 85 years. Pseudoexfoliation syndrome, myopia, and previous vitreoretinal surgery were the most common predisposing conditions. Studies indicated that IOL repositioning and IOL exchange provided similar visual outcomes and were equally safe. The long-term visual outcome seemed satisfactory. However, the quality of evidence regarding treatment was in general quite low. More studies of late in-the-bag IOL dislocation are needed, and in particular, different surgical techniques should be included in high-quality clinical trials.

Retropupillary Iris-Claw Intraocular Lenses: A Literature Review

Retropupillary iris-claw intraocular lenses (ICIOLs) have been increasingly chosen by surgeons nowadays as a primary or secondary procedure of IOL implantation in eyes with insufficient capsular or zonular support. They have gained popularity due to their simple fast technique, favourable functional outcomes, and safety. The transition in the ICIOL fixation from prepupillary to a more biologically appropriate retropupillary position and change in the optic design from biconvex to convex-concave have provided better visual outcomes and improved safety. A peer-reviewed literature search was conducted in Medline (PubMed), Embase, and Cochrane Library using the keywords "retropupillary iris claw" and "iris claw". The search yielded 310 articles that were screened. Forty-three articles on retropupillary ICIOLs were finally found to be relevant and reviewed in full-text versions. The functional outcomes following retropupillary implantation of ICIOLs have been acceptable in eyes with no ocular co-morbidities otherwise. However, the indications for surgery may affect the outcomes. The major postoperative complications directly associated with ICIOLs include pupil ovalization and redislocation. Nevertheless, the rate of disenclavation depends on the experience and skill of the surgeon. This review is based on a literature review, and it focuses on the preoperative evaluation, surgical technique, postoperative outcomes, and associated complications. Prospective randomized trials with a larger sample size and longer follow-up are needed for comparison with other techniques of IOL fixation and confirmation of long-term safety profile.

Double-Needle Yamane Technique Using Flanged Haptics in Ocular Trauma-A Retrospective Survey of Visual Outcomes and Safety

To evaluate visual outcomes and safety of the double-needle technique using flanged haptics (Yamane technique) in patients with aphakia caused by ocular trauma at a trauma referral center. Retrospective: Consecutive interventional case series of 30 patients who underwent the Yamane technique due to posttraumatic aphakia. The double-needle technique using flanged haptics was combined with anterior vitrectomy (group A) in 14 patients, and with pars plana vitrectomy (PPV) (group B) due to retinal detachment, nucleus dislocation into the vitreous cavity, or intraocular lens (IOL) displacement in 16 patients. No intraoperative complications were noted. There was significant improvement in the visual acuity in both groups at the second postoperative visit. However, the visual acuity was significantly worse in the group treated with the Yamane technique combined with PPV. Silicone oil tamponade in PPV group was associated with worse visual acuity, whereas post lensectomy status was associated with poor visual function result in the anterior vitrectomy group. There was one case of slight IOL decentration and one retinal detachment during the postoperative follow-up period in the group with PPV. In this case series, the Yamane technique applied in traumatized eyes was found to be an efficacious and safe procedure. Combining the Yamane technique with PPV due to posterior segment ocular trauma was associated with worse functional results in the follow-up at three months. Further studies with longer follow-up evaluations are required to verify long-term complications.

Intraocular lens implantation in the absence of capsular support: scleral-fixated vs retropupillary iris-claw intraocular lenses

Cataract surgery via phacoemulsification with intraocular lens (IOL) placement in the capsular bag is the gold standard in the presence of adequate capsular support. However, when capsule and/or zonular fibers are weak or absent, alternate fixation strategies are required. Common alternative options include retropupillary iris-claw IOLs (RP-IC IOLs) and scleral-fixated IOLs (SF IOLs). In the present review of 87 articles with 2174 eyes implanted with RP-IC IOLs and 2980 eyes with SF IOLs, we discuss the published literature with respect to safety and efficacy. Although the studies reporting outcomes of these IOLs have been performed in patients with different concomitant conditions, visual and refractive outcomes were found to be comparable between RP-IC IOLs and SF IOLs. RP-IC IOL implantation seemed to provide equivalent or a potentially lower rate of complications than SF IOL implantation. Data from the literature also suggest that the surgical technique of RP-IC IOL implantation is relatively simpler with correspondingly shorter surgical times.

Safety and Efficacy of Current Sclera Fixation Methods for Intraocular Lenses and Literature Overview

BACKGROUND

Evaluation of the three currently most common techniques for intraocular lens (IOL) sclera fixation: (1) Prolene suture with Hoffman sclera pocket (2) four-point GoreTex suture technique (3) sutureless flanged intrascleral IOL fixation with double-needle ("Yamane") technique.

MATERIAL AND METHODS

Retrospective, clinical case series (chart review) at the Department of Ophthalmology, Ludwig-Maximilians-University (LMU), Munich, Germany. Enrolled in the study were 51 patients with 55 eyes. Best-corrected visual acuity (BCVA); manifest refraction (OR); corneal tomography (central corneal thickness, CCT); biometry; central macular thickness (CMT) by optical coherence tomography (OCT); intraocular pressure (IOP); and IOL type and IOL power were recorded and compared prior to and 3 - 12 months post IOL sclera fixation surgery. Pre- and postsurgery difference analysis was performed by Wilcoxon rank sum testing (z).

RESULTS

Intrascleral fixation by GoreTex suture was performed in 14 (25.5%) eyes, by Prolene suture in 19 (34.5%,) and by Yamane technique in 22 (40.0%) eyes. Within the 3 - 12 months follow-up post scleral fixation, a total of 2 (14.3%) eyes from the GoreTex, 3 (15.8%) from the Prolene and 1 (4.5%) eye from the Yamane group required refixation. Pre- and post-surgery analysis revealed a statistically significant difference in the total patient population BCVA (exact Wilcoxon test: z = - 3.202; p = 0.001; n = 55) and the Yamane subgroup (exact Wilcoxon test: z = - 2.068; p = 0.001; n = 22). The GoreTex (n = 14) and Prolene (n = 19) subgroups revealed no statistically significant differences versus preoperative baseline. Across groups, there was no statistically significant difference in IOP, CMT, and CCT. No retinal complications were observed, neither intraoperatively nor during follow-up.

CONCLUSION

The volume of IOL revision surgery is increasing. Often, the only option left for visual rehabilitation is scleral IOL fixation. All three scleral fixation techniques studied demonstrated a good safety profile with no statistically significant impact on IOP, CMT, CCT, but with a notable revision rate. Visual rehabilitation to preoperative baseline levels (GoreTex [n = 14] and Prolene [n = 19]) and a statistically significant increase in visual acuity (total cohort [n = 55] and Yamane [n = 22]) seems possible. Unlike iris fixation, scleral fixation is surgically more complex and the surgeon must master a steeper learning curve.

Analysis of opacification patterns in intraocular lenses (IOL)

Objective

Intraocular lens (IOL) opacification may cause severe visual impairment. The pathogenesis remains unclear. The aim of this study was to analyse opacification patterns in different IOLs. Therefore, this multicentre, retrospective, observational study was conducted at Ludwig-Maximilians-University, Munich, Germany and University-Hospital Basel, Switzerland.

Methods and analysis

In this study, 75 opacified IOLs were identified and classified after extraction. Macroscopical photo documentation, light and electron microscopic analysis were done.

Results

68 acrylic-hydrophilic single-piece-IOLs, 1 acrylic-hydrophilic 3-piece-IOL, 6 acrylic-hydrophobic 3-piece-IOLs were extracted. The dataset comprised IOLs known for opacification and IOLs not having been reported yet. 67 IOLs showed a fine-granular and 8 IOLs a crust-like opacification pattern. According to literature, 62 of the fine-granular opacified IOLs were graded into type 1 (processing/packaging-induced primary opacification) and 13 into type 2 (secondary opacification of unknown aetiology). The anterior surface of the IOLs was affected in all 75 IOLs, the posterior surface only in 23 cases. Of all 67 fine-granular IOLs, 43 had a central defect and 21 had a zone without opacification (clear islet).

Conclusion

In our series, the morphology of IOL opacification did not follow the existing pathogenetic classification that strictly discriminates between primary and secondary causes. Fine-granular IOL opacification occurs with similar patterns in both type 1 and type 2 IOL opacification, while a crust-like pattern was only detected in type 2 IOL opacifications. Consequently, susceptibility of an IOL to opacification is caused by a multifactorial combination of material and processing properties as well as individual (pathological) conditions of the patient.

Secondary Posterior Chamber Intraocular Lens Fixation Using Flanged Prolene Sutures as an Alternative to an Anterior Chamber Intraocular Lens Implantation

Purpose

To describe and evaluate the clinical outcomes of the Flanged Prolene Suture intraocular lens fixation (PIF) technique and compare it to anterior chamber IOL (ACIOL) implantation.

Design

A retrospective comparative review.

Methods

A retrospective comparative review of consecutive patients undergoing secondary IOL implantation was performed. A comparison between patients that had ACIOL and PIF technique was conducted. The main outcome measures were changes in best-corrected visual acuity (VA), IOL position and complications.

Results

In the study period, fourteen eyes had ACIOL implantation and ten eyes had PIF surgery. VA acuity for both groups combined improved from 1.27 ± 0.65 logMAR preoperatively to 0.84 ± 0.65 logMAR (P<0.0001). Seventeen patients had VA measurements in the year before the IOL dislocation. In those seventeen patients, VA changed from a baseline of 0.90 ± 0.68 to 0.97 ± 0.61 logMAR in the PIF group (p=0.334) and from 0.54 ± 0.27 to 0.85 ± 0.65 logMAR in the ACIOL group (p=0.145). No intraoperative or early postoperative complications were documented in either group. Two (20%) patients in the PIF group developed CME and one patient developed corneal edema. In the ACIOL group, one patient developed significant CME and two patients developed visual significant corneal edema.

Conclusion

The PIF technique seems to offer a simple, fast and safe way to fixate an IOL posteriorly. In our experience, the learning curve of the technique is short with a low complication rate and good visual outcomes.

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[Intraocular lens explantation and retroiridal iris claw lens implantation via the pars plana : Video article]

OBJECTIVE OF SURGERY

The aim is the explantation of an intraocular lens (IOL) due to dislocation into the vitreous cavity with subsequent secondary implantation of a retropupillary iris claw IOL via the pars plana without creating a large corneal incision. The aim of the operative technique is to avoid corneal astigmatism after secondary IOL implantation, faster recovery of visual acuity and reduction of invasive maneuvers in the anterior chamber.

INDICATIONS

The surgery is indicated by an in-the-bag dislocation of a posterior chamber lens into the vitreous cavity without the possibility of refixation due to zonulopathy.

CONTRAINDICATIONS

Contraindications are extensive iris stromal defects, iritis, scleromalacia, ischemic retinopathies.

SURGICAL TECHNIQUE

The technique consists of explantation of the IOL during a standard pars plana vitrectomy (20 gauge) with an extended sclerotomy and subsequent secondary implantation of a retropupillary iris claw IOL using the same sclerotomy. The operation video is available online.

FOLLOW-UP

Treatment is carried out with local steroids and antibiotic eyedrops for 3 weeks. In the case of a corneal suture, removal is recommended after 14 days.

EVIDENCE

The implantation of a retroiridal iris claw lens is an established procedure. The introduction via the pars plana in the presented form is a first description.

Outcomes and complications of iris-fixated intraocular lenses in cases with inadequate capsular support and complex ophthalmic history

BACKGROUND

To report the indications, visual outcomes, and intra-operative and post-operative complications of iris-sutured posterior chamber intraocular lens (IOL) in eyes with inadequate capsular support and complex ocular history.

METHODS

A chart review and data analysis of eyes that underwent iris fixation of posterior chamber (PC) IOL for correction of aphakia, dislocated and subluxed IOLs, ectopia lentis, and IOL exchange. Data included clinical risk factors, associated eye conditions, previous surgeries, and concomitant procedures. The pre-operative and post-operative vision, manifest refraction, endothelial cell density, intraocular pressure (IOP), as well as intra-operative and post-operative complications were also recorded.

RESULTS

One hundred and seventeen eyes from 114 patients were examined with a mean follow-up of 22.4 months. The most common identifiable predisposing risk factor was high myopia in 23 eyes. A significant improvement in uncorrected and best corrected visual acuity compared with baseline was observed. The most common post-operative complications included recurrent IOL subluxation in 16 (13.7%) eyes, IOP spike in 7 (5.9%) eyes, cystoid macular oedema in 5 (4.3%) eyes, and epiretinal membrane formation in 4 (3.4%) eyes. There was one (0.85%) case of sterile endophthalmitis.

CONCLUSIONS

Iris suture fixation of PC IOLs is a good treatment option for eyes with inadequate capsular support and complex ocular history.

Outcomes of sutureless secondary intraocular lens fixation with haptic flanging in a cohort of surgically complex eyes

PURPOSE

To describe clinical outcomes of secondary intraocular lens (IOL) implantation using sutureless trans-scleral techniques in surgically complex eyes.

METHODS

Retrospective surgical case series of 45 eyes that underwent secondary IOL implantation using a sutureless haptic flange technique. Demographic data of age, sex, primary diagnosis, best-corrected visual acuity (BCVA), refractive error, intraocular pressure, full ophthalmic exam findings, surgical approach, and any intraoperative complications were noted.

RESULTS

The most common indication for secondary IOL implantation was aphakia, most commonly after ocular trauma. The primary outcome measures were pre-operative and post-operative BCVA, which revealed recovery of pre-operative vision levels by post-operative week 1 and improved vision by post-operative month 1 (p = 0.03). Secondary outcome measures of target refraction pre-operatively and post-operatively revealed significant reduction in post-operative spherical equivalent to achieve BCVA (p < 0.001). Targeting of the secondary IOLs using Barrett Universal II, Holladay 1, Holladay 2, and SRK/T all exhibited a hyperopic shift post-operatively in post-traumatic aphakic eyes and a myopic shift in the post complicated cataract extraction eyes. No intraoperative adverse events were noted. The most common post-operative complication was transient IOP elevation, with most patients completing 6 months of follow-up.

CONCLUSION

There is rapid visual rehabilitation and reduction of spherical equivalent correction to attain BCVA in eyes with a history of ocular trauma that undergo secondary IOL implantation using a trans-scleral flange technique. Moreover, this study highlights that a specific IOL power formula can be more predictive of the desired refractive outcome depending on the indication for secondary IOL implantation.

Novel use of an adjustable single 8-0 polypropylene suture of scleral fixation without conjunctival dissection

Background

This report serves to describe the use of a novel adjustable single 8–0 polypropylene suture for scleral fixation without conjunctival dissection, and to describe related clinical outcomes associated with this approach.

Methods

In this study, we retrospectively reviewed 28 eyes from 27 patients that underwent scleral fixation of the intraocular lens (IOL) without conjunctival dissection using an adjustable single 8–0 polypropylene suture at the Beijing Tongren Eye Center between April 2018 and April 2019. For this surgical approach, a 23-gauge infusion cannula was set, after which two Hoffmann scleral pockets were created. Next, 8–0 polypropylene sutures were inserted into the eye guided by 10–0 polypropylene sutures of a long straight needle. The 8–0 suture was then used to fix the haptic IOs. Finally, these 8–0 polypropylene sutures were removed from the scleral pockets, and knots were tightened with the adjustable single suture. Primary outcomes included visual acuity and postoperative complication incidence.

Results

For this study, outcomes for 28 eyes from 27 patients (9 female, 18 male) were assessed. Patients had a mean age of 54 ± 15.11 years-old and were followed for an average of 10.18 ± 2.76 months postoperatively. Uncorrected visual acuity in these patients improved significantly from a preoperative value of 1.269 ± 0.464 logMAR to a 3-month postoperative value of 0.409 ± 0.413 logMAR (p = 0.000). The majority of postoperative complications in these patients were temporary and self-limiting, including corneal edema (35.71%), hypotony (14.29%), elevated intraocular pressure (28.58%), and mild hyphema (7.14%). No evidence of exposure or erosion of the trimmed suture end was detected in any patients. An ultrasound biomicroscope was able to readily detect the IOL and all sutures, and IOLs were found to be well-centered without any dislocation, tilting, or subluxation upon follow-up.

Conclusions

An adjustable single 8–0 polypropylene suture can reliably and effectively be used for scleral fixation without conjunctival dissection for the treatment of patients with aphakia or inadequate posterior capsule support. The novel procedure described herein may therefore be an effective means of minimizing the risk of suture-related complications in patients undergoing scleral-fixated IOL implantation.

Trial registration

Retrospective case series study, not applicable. NCT04476264.

Management of subluxed and dislocated intraocular lenses in patients with uveitis: a practical approach

PURPOSE

To describe practical approaches to the management of subluxed or dislocated intraocular lenses (IOL) in patients with uveitis.

PATIENTS AND METHODS

Retrospective case series from a specialist uveitis clinic.

RESULTS

Fifteen IOLs in 13 patients were subluxed inferiorly (12) or dislocated into anterior chamber (2) or vitreous (1) at a mean delay of 12 years after cataract surgery. Six eyes required vitrectomy and seven IOL explantation. A dislocated IOL was repositioned by scleral fixation in one, and a new IOL was implanted in three (two scleral-sutured, one iris-claw). Eight were observed without surgery and 7 were left functionally aphakic (4 corrected with contact lens). The mean final best-corrected visual acuity was 0.6 LogMAR.

CONCLUSIONS

There are several management choices for IOL dislocation which should take into account the degree of uveitis, patient age and expectations. We present a pragmatic approach: surgery can often be avoided in this high-risk group.

Artisan iris-claw intraocular lens implantation in vitrectomised eyes

OBJECTIVES

To present the visual acuity (VA) results and complication rates following Artisan intraocular lens (IOL) insertion in vitrectomised eyes.

METHODS

Outcome data were collected for all vitrectomised patients who had undergone Artisan IOL insertion between January 2014 and May 2019 at Moorfields Eye Hospital. All those with follow-up greater than 2 months were included in the analysis.

RESULTS

Sixty-nine eyes from 61 patients were included. Average follow up was 2 years. Fifty-five (80%) eyes had at least one ocular comorbidity prior to Artisan IOL insertion. At final follow up 46 (67%) eyes had best-corrected VA better than 6/12. Sixty-three eyes (91%) either gained or maintained VA. Mean post-operative spherical equivalent was -0.2D. Two (3%) lenses became de-enclavated requiring further surgery. Two (3%) eyes developed acute post-operative cystoid macular oedema. Two (3%) required additional topical IOP-lowering therapy to their pre-operative glaucoma regimen. One eye had mild corneal oedema, which persisted for 1 year following surgery and subsequently resolved.

CONCLUSIONS

Artisan IOL insertion is a safe and effective option for the surgical correction of aphakia in vitrectomised eyes lacking capsular support. Refractive results comparable to posterior chamber IOL placement can be achieved with these lenses.

Sutureless intrascleral fixation using different three-piece posterior chamber intraocular lenses: a literature review of surgical techniques in cases of insufficient capsular support and a retrospective multicentre study

We present a literature review of surgical techniques of intraocular lens placement in eyes with insufficient capsular support, focusing on the most recent publications, together with a retrospective multicentre consecutive case series analysis of 103 eyes undergoing pars plana vitrectomy and sutureless intrascleral (SIS) fixation of a standard three-piece PCIOL. Many different approaches appear in the literature without any specific procedure achieving superior outcomes. Advantages and disadvantages vary between techniques. Common complications related to IOL fixation techniques were as follow: anterior chamber IOL: transient/permanent corneal oedema (9-66.6%), uveitis (1.1-39.3%); iris-fixated IOL: pupil ovalization (16-47.7%); and sutured scleral-fixated IOL: suture breakage/exposure (6.1-11%), vitreous haemorrhage: (5.5-16.6%). In our retrospective case series, indications for surgery were postoperative aphakia in 50 eyes (49%), IOL dislocation in 38 eyes (37%) and natural lens dislocation in 15 eyes (14%). Scleral tunnels for haptic fixation were created with (28 eyes, 27.2%) or without (75 eyes, 72.8%) 25 gauge trocar cannulas. Complications included transient hypotony (n = 20; 19.4%), corneal decompensation (n = 7; 6.7%), IOL dislocation (n = 6; 5.8%), cystoid macular oedema (n = 5; 4.8%), vitreous haemorrhage (n = 4; 3.8%) and retinal detachment (n = 4; 3.8%). Mean best corrected visual acuity improved from logMAR 0.65 to 0.36 at the final visit (p = 0.001). In conclusion, SIS fixation provides good anatomical and functional outcomes; however, complications can occur. The number of surgical approaches for IOL dislocation described in the literature indicates that optimal treatment remains to be found.