Flanged Intrascleral Intraocular Lens Fixation with Double-Needle Technique

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.

Severe Spontaneous Tilt of Scleral-Fixated Intraocular Lenses

PURPOSE

To report and evaluate a multicenter series of 18 cases of severe, spontaneous IOL tilt involving the flanged intrascleral haptic fixation technique (FISHF).

DESIGN

Clinical study with historical controls.

METHODS

We report a cross-sectional study of 46 FISHF cases using the CT Lucia 602 IOL at a single academic center over a period of 24 weeks to determine the incidence of severe rotisserie-style rotational tilt. These rates were then compared with the same time-frame the prior year to help determine if this is a new phenomenon. Additional cases of severe tilt were solicited from another 4 academic centers.

RESULTS

Among 46 FISHF cases at a single center, 5 developed severe tilt. No clear pattern in surgical technique, ocular history, or ocular anatomy was evident in these cases compared with controls, although the involved IOLs clustered within a narrow diopter range, indicative of a batch effect. In the same 24-week interval the year before, 33 FISHF cases were performed, none of which exhibited severe rotational tilt. In our multicenter dataset, 18 cases of tilt were identified. Surgeons included fellow and early-career physicians as well as surgeons with multiple years of experience with the Yamane technique. A variety of surgical approaches for FISHF were represented. In at least 8 of the cases, haptic rotation and/or dehiscence at the optic-haptic junction were documented.

CONCLUSIONS

The identification of haptic rotation and dehiscence intraoperatively in several cases may reflect a new stability issue involving the optic-haptic junction.

Haptic curing with endolaser after lens tilt in the Yamane technique

Purpose

To describe a case of intraocular lens (IOL) tilt following transscleral IOL fixation with the Yamane technique and subsequent correction of tilt using 810-nm endoscopic diode laser.

Observations

Our patient required lens exchange and secondary IOL implantation due to a dislocated 1-piece IOL in the bag causing iris chafe. After routine IOL fixation with the Yamane technique and a Zeiss CT Lucia 602 lens, the IOL tilted significantly in the immediate postoperative period. The lens tilt was subsequently corrected in the operating room using endolaser to melt and reshape (cure) the optic-haptic junction.

Conclusions

IOL tilt is a known complication associated with the Yamane technique, which has seen increasing reports with the Zeiss CT Lucia 602 lens. Using endolaser to reconfigure the tilted optic into the desired orientation is a more novel procedure that can correct the lens tilt without the need for IOL exchange.

Fusion-Flanged Intrascleral Intraocular Lens Fixation Technique: Simple, Safe, Efficient

PURPOSE

To develop a new, sutureless intrascleral intraocular lens (IOL) fixation technique based on the Yamane double-needle and Canabrava 4-flanged techniques.

METHODS

The Fusion-Flanged technique involves using a 7-0 polypropylene suture loop threaded through the eyelets of the IOL. Afterward, both ends of the suture are passed outside the eye through a 27-gauge needle. This technique creates a single flange by joining the 2 suture ends through handheld cautery, and this flange is then embedded into the scleral tunnel to securely fix the IOL in place.

RESULTS

This technique was performed on a total of 7 aphakic patients. Four of them had encountered complications following manual small incision cataract surgery, while the remaining 3 experienced complications after phacoemulsification. The results indicated a significant improvement in visual acuity, with mean preoperative and postoperative corrected distance visual acuities of 0.77 ± 0.11 and 0.27 ± 0.08 (logarithm of the minimum angle of resolution [logMAR] units), respectively.

CONCLUSIONS

The Fusion-Flanged intrascleral IOL fixation technique offers improvements in simplicity, safety, and the overall efficiency when compared to existing sutureless intrascleral fixation techniques. Notably, this technique is versatile and can be applied to both non-foldable and foldable IOLs.

LONG-TERM OUTCOME OF TRANSSCLERAL FOUR-POINT FIXATION OF AKREOS INTRAOCULAR LENS WITH CLOSED CONTINUOUS-LOOP SUTURE

PURPOSE

To report the long-term clinical outcomes of transscleral four-point fixation of Akreos intraocular lens using a closed continuous-loop suture technique.

METHODS

This was a retrospective, multicenter, interventional case series. Primary outcome measures were best-corrected visual acuity, intraocular pressure, corneal endothelial cell density, and complications with a minimum of 1-year follow-up.

RESULTS

One hundred and ninety-two eyes of 177 patients from two surgical hospital sites were identified. The mean best-corrected visual acuity improved from 0.88 ± 0.74 logarithm of the minimum angle of resolution (Snellen 20/152) preoperatively to 0.42 ± 0.52 logarithm of the minimum angle of resolution (Snellen 20/53) postoperatively ( P < 0.001). The mean preoperative intraocular pressure was 17.51 ± 8.67 mmHg, and the mean postoperative intraocular pressure at final follow-up was 15.08 ± 4.18 mmHg ( P = 0.001). The mean corneal endothelial cell density significantly reduced from 2,259 ± 729 cells/mm 2 to 2077 ± 659 cells/mm 2 , representing a cell loss of 5.73% ( P < 0.001). The intraocular lens was fixed well during follow-up. There were no intraoperative complications noted. Postoperative complications included transient ocular hypertension in 15 eyes (7.81%), hypotony in two eyes (1.04%), retinal detachment in one eye (0.52%), and macular edema in one eye (0.52%).

CONCLUSION

The transscleral four-point fixation Akreos intraocular lens using the closed continuous-loop suture technique was effective and safe with satisfactory visual acuity with a minimum of 1-year follow-up.

Comparison of Safety and Efficacy of Four-Point Scleral Intraocular Lens Fixation and the Yamane Technique

INTRODUCTION

The purpose of our study was to compare the safety and efficacy of two scleral fixation intraocular lens (IOL) methods of four-point scleral fixation (Akreos AO60) and the Yamane technique (AcrySof MA60AC).

METHODS

This prospective, randomized study was conducted at the Military Institute of Medicine-National Research Institute in Warsaw between 2021 and 2023. We compared both groups for cause of aphakia, ocular history, refractive status, and complication.

RESULTS

Our study included 50 eyes from 47 patients. Four-point fixation was performed in 25 eyes (group 1), and the Yamane technique was used in 25 eyes (group 2). Surgical time was 24.1 min ± 8.9 in group 1 and 25.1 min ± 9.9 in group 2 (p > 0.05). The postoperative BCVA (best-corrected visual acuity) for group 1 and group 2 at 1 year's observation was 0.10 ± 0.15 and 0.09 ± 0.17 logMAR, respectively (p > 0.05). Postoperative total refractive error (RE) was - 0.06 ± 0.71 diopters (D) for four-point scleral fixation and 0.83 ± 0.70 D for Yamane technique (p < 0.05). Endothelial cell density (ECD) loss was 0.9% in group 1 and 3.5% in group 2 (p > 0.05). Bleeding into the anterior chamber and vitreous body was more frequent in the group of patients operated on with the use of the Yamane technique (10 cases, 20%, p = 0.01). IOL displacement was found in one case (2%) in group 2.

CONCLUSIONS

Both analyzed techniques are well tolerated and ensure good refractive results (extremely predictable in four-point scleral fixation) and have a similar safety profile. Four-point scleral fixation of IOL would appear to be safe, effective and beneficial for young, active patients, especially after trauma or recurrent subluxation.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT06389643.

GIANT INTRAOPERATIVE CORNEAL BULLA MANAGED WITH BANDAGE LENS TECHNIQUE DURING VITRECTOMY SURGERY

PURPOSE

To report a case of giant intraoperative corneal bulla formation in a patient with a history of recent phacoemulsification with clear corneal incision that was managed with a bandage contact lens intraoperatively.

METHODS

Retrospective case report with anterior segment optical coherence tomography.

RESULTS

A 77-year-old woman with a history of recent complicated cataract surgery with retained lens fragments underwent pars plana vitrectomy and scleral-fixated intraocular lens placement. During pars plana vitrectomy, a large corneal bulla formed at the site of the main corneal incision, confirmed with anterior segment optical coherence tomography. A bandage contact lens with viscoelastic was used to overcome visualization challenges and safely proceed with the surgery.

CONCLUSION

This is the first report of corneal bullae formation during pars plana vitrectomy that is confirmed by anterior segment optical coherence tomography and successfully managed with a bandage contact lens intraoperatively.

Flange depth for scleral pocket vs no pocket techniques for intrascleral intraocular lens fixation

PURPOSE

To compare flange depth for a modified scleral pocket (SP) vs no scleral pocket (NSP) technique (Yamane technique) for intrascleral intraocular lens (IOL) fixation.

SETTING

Instituto de Oftalmología Santa Fe, Santa Fe, Argentina.

DESIGN

Prospective, randomized, single-surgeon, observational study.

METHODS

Eyes with aphakia and no capsular support were included. They were divided into 2 groups: one was programmed for a double-needle flanged intrascleral IOL fixation as originally described by Shin Yamane with NSP and the second group had a modified SP technique. Flange depth was measured with anterior-segment optical coherence tomography (AS-OCT) at 1 month, 3 months, 6 months, and 12 months postoperatively, and the results were compared.

RESULTS

Each group comprised 18 eyes of 18 patients, giving a total of 36 flanges per group. The groups were comparable preoperatively. At 12 months, uncorrected distance visual acuity and corrected distance visual acuity (CDVA) were not statistically different for both groups (P = .333; P = .448). Spherical equivalent (SEQ) was not significantly different between groups at 12 months postoperatively (P = .078). AS-OCT revealed a significantly deeper flange position for the SP group at 1 month, 3 months, 6 months, and 12 months postoperatively (P < .05).

CONCLUSIONS

When performing a double-needle intrascleral IOL fixation in aphakic eyes with no capsular support, a modified scleral pocket technique provides a significantly deeper flange position with no difference in CDVA or SEQ 12 months postoperatively.

Intrascleral intraocular lens fixation with ab interno trabeculotomy in patients with exfoliation glaucoma with lens subluxation

PURPOSE

To evaluate the surgical outcomes of intrascleral intraocular lens (IOL) fixation using ab interno trabeculotomy (LOT) in patients with exfoliation glaucoma with lens subluxation.

STUDY DESIGN

Retrospective case series.

METHODS

Twenty eyes of 18 patients with exfoliation glaucoma and lens or IOL subluxations were included. Three success criteria were based on postoperative intraocular pressure (IOP) (A, ≤15 mmHg; B, ≤18 mmHg; C, ≤21 mmHg). The IOP, number of glaucoma medications, and visual acuity were compared before and after surgery. Success probability was analyzed using Kaplan-Meier survival curves. Cox proportional hazards' regression models were used to examine prognostic factors for surgical failure.

RESULTS

The mean follow-up period was 23.4 ± 7.8 months. The mean IOP significantly decreased from 23.2 ± 6.8 mmHg preoperatively to 14.0 ± 4.4 mmHg at 1 year postoperative (P<0.001). Postoperative hyphema and vitreous hemorrhage were observed in seven and 15 eyes, respectively, and washout in the anterior chamber or vitreous cavity was performed in four eyes. Postoperative IOP spikes and hypotony were observed in four eyes each. Glaucoma reoperation was performed in two eyes. The success rates at 12 months were 65%, 85%, and 90% using criteria A, B, and C, respectively. The IOP at 1 month after surgery was a significant prognostic factor for surgical failure according to criterion A (hazard ratio: 1.08; P=0.034).

CONCLUSION

Intrascleral IOL fixation combined with microhook LOT is a promising option in cases of exfoliation glaucoma with subluxated lens/IOL; however, the high rate of postoperative hyphema and vitreous hemorrhage should be noted.

Long-term results of anterior chamber iris claw intraocular lens implantation in children with ectopia lentis in Marfan syndrome

PURPOSE

To report the long-term clinical and endothelial cell count (ECC) results of lensectomy with primary anterior chamber iris claw lens implantation in the eyes of patients ≤18-year-old with ectopia lentis due to Marfan syndrome.

METHODS

The medical records of Marfan patients operated on at a single institution from September 2007 to August 2020, with minimum follow-up of 2 years, were reviewed retrospectively. The following data were analyzed: sex, age at surgery, indication for surgery, the position of the lens in relation to the undilated and dilated pupil, corneal endothelial cell counts (ECC), peri- and postoperative complications, pre- and postoperative best-corrected visual acuity.

RESULTS

A total of forty-two eyes of 23 patients (12 girls and 11 boys) were included. At least two or more postoperative ECCs were collected from 33 eyes (17 patients). Median age at IOL implantation was 6.1 years (range, 1.8-18). Median overall follow-up time was 6.2 years (range, 2-13.5). Median ECC follow-up time was 6.2 years (range, 2-10). Mean best-corrected visual acuity was 0.71 ± 0.38 logMAR before surgery and 0.02 ± 0.25 logMAR at final follow-up. The mean annual ECC decline was 0.71% ± 2.24. Total cell loss from first to last postoperative measurement was 150 cells ± 394 cells/mm2 (4.81%). Pre- and first postoperative data were available for 17 eyes of 10 patients, with a mean cell loss before and directly after surgery of 269 ± 268 cells (7.94%). Surgery related complications were iris bombé due to blockage of peripheral iridectomy in 3 eyes and claw dislocation due to direct impact trauma in 3 eyes.

CONCLUSIONS

In our large, pediatric study cohort, anterior chamber iris claw IOL implantation resulted in an excellent visual outcome and normal endothelial cell loss compared with normative data. Safety measures are recommended to avoid traumatic dislocation of IOLs.

Comparison of flanged polypropylene scleral intraocular lens fixation with scleral sutured fixation

OBJECTIVE

To compare the outcome of 2 intraocular lens (IOL) scleral fixation techniques: double-flanged polypropylene and Hoffman scleral pocket.

METHODS

Retrospective case series of all patients who underwent IOL scleral fixation by either the flange (flange group) or Hoffman scleral pocket (Hoffman group) techniques at the Kaplan Medical Center and the Edith Wolfson Medical Center.

RESULTS

A total of 140 patients were included (63 flange, 77 Hoffman). The final distance-corrected visual acuity was similar between the flange and Hoffman groups (0.42 ± 0.5 and 0.51 ± 0.5 logMAR, respectively; p = 0.23), but the spherical equivalent was less myopic in the flange group (-0.63 ± 2 and -2.3 ± 1.3 D, respectively; p = 0.003). In the flange group, there were more cases of elevated IOP (17.5% vs 5.2%; p = 0.02), corneal edema (11.1% vs 1.3%; p = 0.02), cystoid macular edema (15.9% vs 2.6%; p = 0.005), and IOL decentration (19% vs 7.8%; p = 0.07). The flange group had a higher rate of combined additional procedures during the fixation surgery (68.3% vs 32%; p < 0.001), but surgery duration was not prolonged (70 vs 77 minutes; p = 0.29).

CONCLUSION

Comparison of scleral IOL fixations performed with the recently developed flange technique to the conventional Hoffman scleral pocket technique resulted in similar visual outcomes and less myopization. There were more complications in the newly adopted flange technique, which may be related to the higher rate of combined anterior vitrectomy and pars plana vitrectomy. The flange technique is effective, with a shorter learning curve and similar surgical time. Therefore, it can become a viable method for scleral IOL fixation in the absence of zonular support.

Reverse pupillary block, in contemporary scleral intraocular lens procedures

BACKGROUND

To evaluate the frequency and anterior segment optical coherence tomography parameters of patients with scleral fixated intraocular lenses (IOL) and reverse pupillary block (RPB).

METHODS

Retrospective analysis at a tertiary care centre (Department for Ophthalmology and Optometry, Medical University of Vienna, Austria). We researched our records for patients who underwent scleral fixated IOL implantation from January 2018 till February 2023. Patients were included only if there was at least one adequate post-operative scan of anterior segment optical coherence tomography (AS-OCT) available. Initially, AS-OCT scans were assessed for IOL tilt and decentration employing a 3D scan and then later for anterior chamber angle (ACA), aqueous anterior chamber depth (AQD), pupil diameter and iris-IOL distance using the 2D scan at a 0° angle. Both an iris-IOL distance of 0 or less and an ACA of more than 70° were required to define an RPB.

RESULTS

A total of 110 patients met the inclusion criteria, 41 were treated using the Carlevale, 33 the four flanged, 24 the Yamane and 12 the Scharioth technique, respectively. RPB was found in 32 patients (29%). Twenty patients with RPB were treated using YAG peripheral iridotomy, mean ACA decreased from 91.91° ± 13.77 to 61.02° ± 8.52, (p < 0.001), mean AQD decreased from 4.67 mm ± 0.47 to 4.31 ± 0.36 mm (p < 0.001) and mean iris-IOL distance increased from -0.09 ± 0.04 to 0.33 ± 0.30 (p < 0.001).

CONCLUSIONS

RPB is found in a third of eyes who have undergone scleral fixated IOL implantation without iridectomy. YAG peripheral iridotomy is a potent option to treat RPB, and subsequently reduce the risk of iris chafing and secondary inflammation or glaucoma.

Comparison of complications of intrascleral fixation according to the extent of vitrectomy

BACKGROUND

Intraocular lens (IOL) fixation is performed after intraoperative anterior or total vitrectomy. This study aimed to compare the intraoperative and postoperative complications of these two techniques.

METHODS

This retrospective study included 235 eyes that underwent intrascleral fixation surgery at our hospital between July 2014 and January 2021. The eyes were classified into the anterior vitrectomy group (A-vit group; 134 eyes) and the pars plana vitrectomy group (PPV group; 101 eyes). The age, preoperative and postoperative best-corrected visual acuity, observation period, preoperative and postoperative intraocular pressure, and the incidence of intraoperative and postoperative complications were assessed.

RESULTS

Intrascleral fixation was performed more frequently in the PPV group, and a significant difference was observed between the eyes with a history of vitrectomy and eyes with scleral buckles (p = 0.00041). In terms of the incidence of postoperative complications following intrascleral fixation, the incidence of low intraocular pressure postoperative was higher in the PPV group than that in the A-vit group, and a significant difference was observed between the two groups (p = 0.01).

CONCLUSIONS

The visual outcome and complications following intrascleral fixation did not differ according to the extent of vitreous excision.

Scleral Fixation of Toric Intraocular Lens in the Absence of Capsular Support

The study is aimed at describing a technique for scleral fixation of toric intraocular lens (TIOL) in the eyes without capsular support coexisting with corneal astigmatism. A monofocal toric hydrophobic lens with eyelets at the optic-haptic junction (enVista One-Piece Hydrophobic Acrylic MX60T Toric IOL; Bausch & Lomb) was fixated to the sclera using two fragments of 6-0 polypropylene monofilament, the ends of which were brought out through the sclera and cauterized. The astigmatic axis of a TIOL was adjusted according to the corneal astigmatic axis of the patient. The surgery was performed in the 5 eyes of 5 patients without capsular support. The method was safe and effective in fixing the lens to the sclera, and it ensured good centration of TIOL with predictable refractive outcomes. No conjunctival sutures, glue, or flap formation was required during the surgery. There were no relevant complications related to the procedure.

Longer axial length is associated with better prediction for refractive error after sutureless flanged intrascleral fixation of intraocular lens

OBJECTIVE

To investigate refractive outcomes and associated factors after sutureless flanged intrascleral fixation of intraocular lens (SFIF-IOL).

METHODS

We retrospectively reviewed the medical records of consecutive patients who underwent SFIF-IOL at a single centre. The prediction error (PE; difference between the achieved and target refractive error) and absolute PE (APE) were analysed. Risk factors associated with refractive surprise, defined as APE > +0.5 D, were investigated using multivariable logistic regression analysis.

RESULTS

Ninety-one eyes were included. At the final follow-up, the mean PE and APE were +0.07 ± 0.88 and +0.68 ± 0.56 D, respectively. Refractive surprise was observed in 44 eyes (54.3%) and was associated with a shorter axial length (AL) [odds ratio, 0.825; 95% confidence interval, 0.688-0.991; P = 0.039]. APE showed a significant correlation with AL at the final visit (⍴ = -0.269, P = 0.010), and eyes with AL ≥ 26 mm had significantly lower APE than did those with AL of 24-26 mm (P = 0.021) and AL < 24 mm (P = 0.0059).

CONCLUSIONS

The refractive outcome after SFIF-IOL using manufacturer's A constant was favourable on average. Eyes with a longer AL were more likely to show a smaller deviation from the target refraction.

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.

Comparison of three techniques for simultaneous intraocular lens implantation in subluxated cataract surgery: Transconjunctival intrascleral, Z-suture knotless transscleral, and Cionni capsular tension ring assisted

PURPOSE

To evaluate and compare the clinical outcomes of three different methods of intraocular lens (IOL) implantation in the surgery of subluxated cataracts.

METHODS

In this retrospective, comparative, clinical interventional study, the medical records of patients who underwent IOL implantation with sutureless 27-gauge needle-assisted transconjunctival intrascleral (Group 1), Z-suture knotless transscleral (Group 2), and Cionni capsular tension ring (Cionni-CTR) assisted (Group 3) simultaneously with subluxated cataract extraction between June 2010 and June 2022 were evaluated. Demographic characteristics, follow-up times, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical and cylindrical refractive values, and spherical equivalent (SE) values of three groups were compared. Intraoperative and postoperative complications were recorded.

RESULTS

There were 20 eyes in Group 1, 35 eyes in Group 2, and 40 eyes in Group 3. In all groups, statistically significant improvement was observed in postoperative UDVA and CDVA compared to preoperative values (each p < 0.05). There was no statistical difference between the groups in postoperative UDVA and CDVA values. (p = 0.130, p = 0.167 respectively). No significant difference was observed between the groups in terms of postoperative spherical, cylindrical, and SE values (each p > 0.05).

CONCLUSION

The study suggests that three different IOL implantation techniques for simultaneous IOL implantation in subluxated cataract surgery have similar effects on visual and refractive outcomes.

Repositioned versus exchanged flanged intraocular lens fixation for intraocular lens dislocation

This study aimed to compare the outcomes of flanged intraocular lens (IOL) fixation with new IOL exchange after dislocated IOL removal and repositioned dislocated IOL in patients with IOL dislocation. Eighty-nine eyes that underwent flanged IOL fixation were retrospectively included, with 51 eyes in the exchanged IOL group and 38 eyes in the repositioned IOL group. In both groups, best-corrected visual acuity (BCVA) improved at 1, 3, 6, and 12 months postoperatively and did not differ between the two groups at any of these time points. However, at 1 week postoperatively, BCVA in the repositioned IOL group improved compared with baseline, whereas that in the exchanged IOL group did not. Moreover, there were lesser changes in the corneal endothelial cell density (ECD) and corneal astigmatism in the repositioned IOL group than in the exchanged IOL group. The IOL positions, including IOL tilt and IOL decentration, were not different between the groups. Flanged IOL fixation with new IOL exchange and with repositioned dislocated IOL for patients with IOL dislocation had similar visual outcomes and IOL position. However, the latter had a smaller corneal ECD decrease and astigmatic change. This technique was effective in treating IOL dislocation while minimizing corneal injury.

Dislocation force of scleral flange-fixated intraocular lens haptics

PURPOSE

To measure the dislocation forces in relation to haptic material, flange size and needle used.

SETTING

Hanusch Hospital, Vienna, Austria.

DESIGN

Laboratory Investigation.

METHODS, MAIN OUTCOME MEASURES

30 G (gauge) thin wall and 27 G standard needles were used for a 2 mm tangential scleral tunnel in combination with different PVDF (polyvinylidene fluoride) and PMMA (polymethylmethacrylate haptics). Flanges were created by heating 1 mm of the haptic end, non-forceps assisted in PVDF and forceps assisted in PMMA haptics. The dislocation force was measured in non-preserved cadaver sclera using a tensiometer device.

RESULTS

PVDF flanges achieved were of a mushroom-like shape and PMMA flanges were of a conic shape. For 30 G needle tunnels the dislocation forces for PVDF and PMMA haptic flanges were 1.58 ± 0.68 N (n = 10) and 0.70 ± 0.14 N (n = 9) (p = 0.003) respectively. For 27 G needle tunnels the dislocation forces for PVDF and PMMA haptic flanges were 0.31 ± 0.35 N (n = 3) and 0.0 N (n = 4), respectively. The flange size correlated with the occurring dislocation force in experiments with 30 G needle tunnels (r = 0.92), when flanges were bigger than 384 micrometres.

CONCLUSIONS

The highest dislocation forces were found for PVDF haptic flanges and their characteristic mushroom-like shape for 30 G thin wall needle scleral tunnels. Forceps assisted flange creation in PMMA haptics did not compensate the disadvantage of PMMA haptics with their characteristic conic shape flange.

RELAY INTRASCLERAL 6-0 POLYPROPYLENE-ASSISTED INTRAOCULAR LENS FIXATION: A Retrospective Comparison With Modified Yamane Technique

PURPOSE

To describe a new surgical technique that uses a relay suture to optimize sutureless scleral fixation of intraocular lens in eyes with capsular insufficiency and to evaluate the outcomes of this technique versus Flanged, double needle-guided, scleral fixation of intraocular lens with haptic trimming (modified Yamane approach).

METHODS

Relay intrascleral 6-0 polypropylene sutures with flanges generated at the intraocular ends were used to fixate and securely hold a rigid intraocular lens with haptic eyelets against the inner scleral wall. The results were analyzed at 3-, 6-, and 12-month follow-up.

RESULTS

This retrospective cohort study found that compared with the control group (n = 27), the relay-sutured group (n = 26) had greater mean changes in corneal astigmatism (0.44 vs. -0.52 diopters [D]) and fewer mean degrees of intraocular lens astigmatism (0.62 vs. 1.1 D). The mean intraocular lens decentration was comparable between both the groups; however, in the control group, there was a significant increase in intraocular lens tilt degrees from 3 to 12 months. Moreover, significantly higher proportions of patients with persistent macular edema and iris-optic capture were seen in the control group.

CONCLUSION

The relay-sutured technique may be an alternative to flapless scleral fixation of intraocular lens and provides a stable intraocular lens position with acceptable complication rates.

Bilaterally subluxed diffractive intraocular lenses: big expectations and even bigger comorbidities

A 78-year-old woman with an ocular history of cataract surgery with a diffractive intraocular lens (IOL) in each eye has developed fluctuating vision, greater in the right eye than the left eye, after 4 years. She has a history of inactive central serous retinopathy and a vision potential of 20/25 + 2 in the right eye and 20/25 in the left eye. She has well-controlled diabetes, hypertension, and hypercholesterolemia. She has enjoyed her spectacle independence for some time and wishes to have her vision restored. On examination, her uncorrected distance visual acuity (UDVA) was 20/50 in the right eye and 20/25 in the left eye and her uncorrected near visual acuity (UNVA) was J3 in the right eye and J1 in the left eye. Intraocular pressures (IOPs) measured 22 mm Hg in the right eye and 18 mm Hg in the left eye. Pupils had limited reactivity with irregularity in the right eye but no obvious relative afferent pupillary defect. Motility and confrontation visual fields were unremarkable in both eyes. Retinal acuity meter was 20/20 in both eyes, and manifest refraction was plano -1.25 × 105 20/40, J3 in the right eye and +0.50 × 20/25, J1 in the left eye. Pertinent findings on slitlamp examination included temporal iris atrophy and transillumination defects greater in the right eye than the left eye, peripupillary pseudoexfoliative changes in both eyes, significant inferior subluxation of a diffractive 3-piece posterior chamber IOL in the capsular bag with lens-pitting peripherally and few central, moderate pseudophacodonesis, and an open posterior capsule in the right eye. In the left eye, she had mild inferior subluxation of a single-piece acrylic diffractive IOL in the capsular bag with moderate pseudophacodonesis and an open posterior capsule (Figure 1JOURNAL/jcrs/04.03/02158034-202403000-00019/figure1/v/2024-02-20T193212Z/r/image-tiff). All other anterior segment findings were unremarkable. On dilated posterior examination, she had a cup-to-disc ratio of 0.50 in the right eye and 0.65 in the left eye without edema hemorrhage or pallor. There were attenuated vessels in both eyes, posterior vitreous detachment in both eyes, and a few small drusen peripherally in both eyes. There was retinal pigment epithelium irregularity and dropout parafoveal in the right eye and subfoveal in the left eye (Figure 2). There was no evidence of macular edema, subretinal fluid, choroidal thickening, or neovascular membranes. The periphery was unremarkable in both eyes.JOURNAL/jcrs/04.03/02158034-202403000-00019/figure2/v/2024-02-20T193212Z/r/image-tiff What testing would you obtain preoperatively to help guide your decision-making? How would you counsel the patient regarding comorbid conditions and expectations?

[Intraoperative Complications in Cataract Surgery]

Cataract surgery is frequently and successfully performed in the developed world. The indications for the operation have shifted on one hand towards healthier patients seeking freedom from glasses and on the other hand towards more complex cases. How should the patient be informed? What complications can occur intraoperatively, and what treatment options are available for these complications?This article offers a focus on conditions such as zonulopathy and pseudoexfoliation that can pose challenges to cataract surgery. It discusses the use of specialized tools such as capsular tension rings and capsular hooks and precise maneuvers to minimize stress on weakened zonules in order to ensure in-the-bag fixation of the IOL.Furthermore, the article addresses appropriate actions towards intraoperative complications such as anterior or posterior capsule ruptures and loss of nuclear fragments into the vitreous cavity.Exploring innovative advancements, this article presents the latest alternatives for intracapsular lens fixation, such as sutureless scleral fixation and emerging lens designs in cases where there is insufficient capsular support.Ultimately, the primary objective remains delivering optimal outcomes even for complex cases, and minimizing post-surgical issues. Numerous tools and techniques are available.

Case report: Management of recurrent pupillary optic capture with sutureless surgical technique using 7-0 polypropylene flange

Background

To report a novel surgical technique for recurrent pupillary optic capture after flanged intraocular lens (IOL) fixation.

Methods

In this retrospective case series, we detail our use of two parallel 7-0 polypropylene sutures passed between the iris plane and the optic of scleral-fixated IOL to address pupillary optic capture. Flanges were created using ophthalmic cautery to secure it to the sclera without suture.

Results

Two eyes with pupillary optic capture underwent a sutureless surgical technique using 7-0 polypropylene flanges. No recurrences of pupillary optic capture were observed during the 1-year follow-up.

Conclusion

Our sutureless surgical technique using a 7-0 polypropylene flange was an effective, efficient, and less invasive approach for treating recurrent pupillary optic capture.

Z-suture scleral fixation intraocular lenses: A refractive and safety report

PURPOSE

Scleral fixation of intraocular lenses constitutes a surgical option in cases where there is inadequate capsular support or zonular insufficiency. Knotless techniques, such as the z-suture technique, avoid suture-related complications, such as conjunctival erosion or exposure. The purpose of this study was to evaluate the visual outcomes and postoperative complications of patients who underwent scleral z-suture fixation of the Akreos AO® intraocular lenses.

METHODS

A retrospective, observational study was conducted, including 22 eyes of 20 patients who underwent Akreos AO® intraocular lenses using the z- suture scleral fixation technique.

RESULTS

The mean age of the patients was 55,64 ± 28,47 years old, and the mean follow-up time was 25,64 months. The most common indication for surgery was previous complicated cataract surgey. The mean postoperative spherical equivalent was +0,058D ± 0,79D, with values ranging from - 1,50D to +1,00D. Mean best-corrected visual acuity was 0,178 ± 0,15 logMAR. Intraocular pressure was 15,07 ± 2,56 mmHg on the day after surgery, and 16 ± 2,15 mmHg 1 month after. No suture-related complications were observed in any patient postoperatively. One patient had a slight inferonasal lens dislocation and another patient had a severe case of herpetic keratitis posoperatively.

DISCUSSION

The knotless z-suture technique appears to be a reliable and safe way to fix an intraocular lens in the sclera, regardless of the patient's age. Our results show good visual results and predictable refractive outcomes. Decades of follow-up may be necessary to assess the long-term risk of lens dislocation.

CONTRIBUTION FACTORS OF EFFECTIVE LENS POSITION, TILT, AND DECENTRATION DURING FLANGED SCLERAL FIXATION OF INTRAOCULAR LENS: A Model Eye Study

PURPOSE

The authors aimed to elucidate the factors related to effective lens position, tilt, and decentration of scleral fixed intraocular lenses (IOLs) with a flanged haptic technique in an artificial eye model using anterior segment optical coherence tomography.

METHODS

Two bent 27-gauge needles were passed through a 1.0- or 2.0-mm scleral tunnel, 2.0 mm posterior to the limbus and 180° apart. Both haptics of a three-piece IOL were docked with guide needles and externalized. Factors related to the IOL position were analyzed using anterior segment optical coherence tomography and a stereomicroscope.

RESULTS

The 1.0-mm scleral tunnel induced a significantly longer effective lens position than the 2.0-mm tunnel and suture fixation ( P < 0.05 and P < 0.01, respectively). Discrepancy in scleral tunnel length induced higher decentration of the optic to the opposite side of the haptic-embedded shorter tunnel and tilt perpendicular to the fixed axis than that in the scleral tunnel of the same length ( P < 0.001 and P < 0.05, respectively). If the scleral fixation points of both haptics are not exactly 180° apart, the IOL may become decentered and tilted ( P < 0.01 and P < 0.05, respectively).

CONCLUSION

In the flanged haptic technique, the length, balance, and position of both scleral tunnels determine IOL effective lens position, tilt, and decentration.

Sutureless intrascleral intraocular lens fixation and modified iris cerclage pupilloplasty for aphakia and traumatic mydriasis

PURPOSE

To evaluate the safety and efficacy of sutureless intrascleral intraocular lens (IOL) fixation combined with modified iris cerclage pupilloplasty for treating aphakia and traumatic mydriasis.

METHODS

Five patients with aphakia and traumatic mydriasis were operated on by the same surgeon. All patients underwent sutureless intrascleral IOL fixation combined with modified iris cerclage pupilloplasty and were followed up for ≥6 months. Best-corrected visual acuity (BCVA) was measured using the logarithm of the minimum angle of resolution (logMAR). BCVA, intraocular pressure (IOP), pupil diameter, and corneal endothelial cell count (CECC) preoperatively and postoperatively were statistically analyzed. The pupil shape, photophobia, IOL position, and surgical complications were evaluated.

RESULTS

The mean BCVA was significantly improved 6 months postoperatively (0.26 ± 0.17 logMAR, P = 0.042) than preoperatively (0.50 ± 0.30 logMAR). No significant difference was observed between the preoperative and postoperative IOP (P = 0.138). The mean pupil diameter significantly reduced postoperatively than preoperatively (3.44 ± 0.35 mm vs. 7.28 ± 0.35 mm, P = 0.043). There was no significant decrease in CECC postoperatively (P = 0.225). The pupil shape was round-like, and photophobia disappeared in all patients. No intraoperative or postoperative complications occurred.

CONCLUSION

Sutureless intrascleral IOL fixation combined with modified iris cerclage pupilloplasty is a safe and efficient procedure for treating aphakia traumatic mydriasis patients without sufficient capsular support.

LONG-TERM OUTCOMES OF SUTURELESS INTRASCLERAL INTRAOCULAR LENS FIXATION IN CHILDREN AND ADULTS: Single-Surgeon Case Series With and Without Haptic Flanging With Up to 11 Years of Follow-Up

PURPOSE

Report and compare long-term outcomes and complications of sutureless scleral tunnel (SST) and flanged haptic (FH) scleral-fixated intraocular lens, with spontaneous intraocular lens (IOL) dislocation as primary outcome measure.

METHODS

Retrospective single-surgeon case series of 95 SST and 458 FH eyes from 2011 to 2022 (553 total eyes). Demographics, surgical indications, ocular history, visual acuity, and complication rates were collected.

RESULTS

Reoperation-requiring spontaneous IOL dislocation rate was significantly different ( P = 0.0167) between FH (3.7%) and SST (10.5%). Mean follow-up was 3.31 ± 0.30 versus 1.58 ± 0.07 years for SST and FH, respectively. There was no significant difference between preoperative (20/305 vs. 20/300) or final postoperative (20/77 vs. 20/62) visual acuity. Other complications included any cystoid macular edema (20.0% vs. 25.3%), elevated intraocular pressure (16.8% vs. 9.6%), IOL tilt requiring reoperation (5.3 vs. 0%), haptic exposure (2.1% vs. 3.3%), and reverse pupillary block (4.2% vs. 1.1%).

CONCLUSION

Haptic flanging resulted in fewer eyes meeting the primary end point of IOL dislocation. We reported the longest-to-date follow-up of both nonflanged SST IOL fixation and our FH-modified Yamane technique. Our FH-modified Yamane technique represents a safe, durable, and potentially superior option for scleral-fixated intraocular lens.

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 meta-analysis of sutureless scleral-fixated intraocular lens versus retropupillary iris claw intraocular lens for the management of aphakia

This study compared the visual outcomes and complications between sutureless scleral-fixated intraocular lens and iris claw intraocular lens implantation in aphakia without adequate capsule and/or zonule support. Studies comparing the clinical outcomes of scleral-fixated intraocular lens and iris claw intraocular lens implantation published until April 2022 were retrieved from the PubMed, EMBASE, Cochrane Library, and Google Scholar databases. The outcomes included postoperative final visual acuity, surgical time, surgery-induced astigmatism, and complications. The weighted mean difference and odds ratio were calculated. Two randomized controlled trials and five cohort studies, including 244 and 290 eyes in the scleral-fixated intraocular lens group and iris claw group, respectively, were included. Scleral-fixated intraocular lens implantation results in a better postoperative final corrected distance visual acuity compared with iris claw intraocular lens implantation; however, it is more time-consuming. Scleral-fixated intraocular lens implantation seems to have lesser incidences of surgery-induced astigmatism. Furthermore, both procedures have a similar complication rate. Therefore, based on current best evidence, these two procedures should be considered according to patient's conditions.

Management of complications of sutureless intrascleral intraocular lens fixation

PURPOSE

The purpose of the study was to report the complications of sutureless intrascleral (SIS) intraocular lens (IOL) fixation and its management.

MATERIALS AND METHODS

A multicenter, retrospective, consecutive interventional case series of patients with intra or postoperative complications after SIS IOL fixation during the technical learning curve of vitreoretinal surgeons from three Taiwanese referral hospitals. The used surgical techniques were the Scharioth technique for intrascleral tunnel fixation, Yamane technique (double-needle scleral fixation), and modified Yamane technique (double-needle flanged haptic scleral fixation). The IOL models and surgical instruments used as well as each patient's ocular characteristics and complication management were recorded.

RESULTS

Of the eight included patients, the complications of 3 (37.5%) and 5 (62.5%) were noted intraoperatively and postoperatively, respectively. Haptic-related complications, including haptic breakage, slippage, and haptic disinsertion, occurred in six eyes. Other complications included uveitis-glaucoma-hyphema syndrome, retinal detachment, and IOL tilt. For the two patients with haptic slippage, repositioning was achieved using a modified cow-hitch technique that resulted in favorable IOL centration and restored visual acuity.

CONCLUSION

Most complications surgeons encountered during their early exposure to SIS IOL fixation were haptic related. Surgeons should be aware of such complications to prevent and manage them during surgery. Our modified cow-hitch technique could be used to reposition IOLs with unilateral haptic slippage.

In-Office Lens Repositioning for Anterior Crystalline Lens Dislocation

BACKGROUND AND OBJECTIVE

We describe an in-office lens repositioning technique for anterior crystalline lens dislocation.

PATIENTS AND METHODS

We present a case series of four patients with spontaneous or traumatic anterior crystalline lens dislocation.

RESULTS

The technique included supine patient positioning, gentle pressure with a cotton swab on the peripheral cornea to guide the lens into the posterior chamber, and the use of a miotic agent afterward to prevent subsequent subluxation. In the four cases described, the in-office technique successfully restored the lens to the posterior chamber, improved vision, and decreased intraocular pressure in most instances by resolving the angle closure secondary to pupillary block.

CONCLUSIONS

The in-office lens repositioning technique is appropriate as an acute non-surgical intervention or temporizing measure for anterior crystalline lens dislocation. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Effect of sutureless scleral fixed intraocular lens implantation on aphakic eyes: a system review and meta-analysis

BACKGROUND

Sutureless scleral fixed intraocular lens implantation (SF-IOL) has become one of the mainstream schemes in clinical treatment of aphakic eyes because of its advantages, such as avoiding dislocation of intraocular lens or subluxation caused by suture degradation or fracture and significant improvement of postoperative visual acuity. However, a consensus on the relative effectiveness and safety of this operation and other methods is still lacking. This study aimed to compare the efficacy and safety of sutureless SF-IOL with other methods. Aphakia means that the lens leaves the normal position and loses its original function, including absence or complete dislocation and subluxation of the lens which could cause anisometropic amblyopia, strabismus, and loss of binocular function in children and adolescents. For adults, the loss of the lens could lead to high hyperopia and affect vision. Above all this disease can seriously affect the quality of life of patients.

METHODS

Literature about sutureless SF-IOL in PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, China Technical Journal VIP database, and Wanfang database published from 2000 to 2022 was reviewed. The weighted average difference was calculated by RevMan5.3 software for analysis. Two researchers independently selected the study and used the Cochrane collaboration tool to assess the risk of errors. Cochrane bias risk tool was used to evaluate the quality of evidence. This study is registered on PROSPERO (CRD42022363282).

RESULTS

The postoperative IOL-related astigmatism of sutureless SF-IOL was lower than that of suture SF-IOL, and there was statistical difference when we compared the absolute postoperative spherical equivalent after sutureless SF-IOL and suture SF-IOL. Indicating that the degree of refractive error after sutureless SF-IOL was lower. Meanwhile, the operation time of sutureless SF-IOL was shorter than that of suture SF-IOL. The subgroup analysis showed that the absolute postoperative spherical equivalent and astigmatism values in Yamane technique were lower than those in suture SF-IOL.

CONCLUSION

Sutureless SF-IOL has the advantages of stable refraction, short operation time, and less postoperative complications. However, high-quality literature to compare these technologies is lacking. Some long-term follow-up longitudinal prospective studies are needed to confirm the findings.

Four-Point Scleral Fixation of An Akreos Adapt AO Intraocular Lens Using Double-Strand 9-0 Polypropylene Suture

PURPOSE

To report the results of a novel surgical four-point transscleral suture fixation of intraocular lens (IOL) with four hollow haptics using the double-suture technique.

METHODS

We retrospectively reviewed the medical records of 15 eyes of 15 patients who underwent 4-point transscleral suture fixation of a foldable IOL using the double-suture technique. Preoperative data and follow-up data for at least 4 months were collected for all patients.

RESULTS

The IOLs were fixed and centered well. The mean preoperative corrected distance visual acuity was 0.70 ± 0.54 logarithm of the minimum angle of resolution (Snellen 20/102), and it improved to 0.29 ± 0.26 logarithm of the minimum angle of resolution (Snellen 20/39) at the final follow-up ( P = 0.001). No vitreous hemorrhage, hypotony, suture breakage, retinal detachment, IOL dislocation, and iris capture was detected during the follow-up period in any of the patients.

CONCLUSION

We have developed a novel technique for 4-point transscleral suture fixation of IOL using the double-suture technique with 9-0 polypropylene suture. This technique seemed to be safe and it may not require the surgeon to learn any new technique.

Intraocular Suture Technique for Flapless Two-Point Fixation of Four Fenestrated Haptics Intraocular Lenses

PURPOSE

To describe a flapless technique for two-point fixation of intraocular lens (IOL) with four fenestrated haptics.

METHODS

A transconjunctival puncture of 1-mL syringe needle was used to guide the suture needle out of the eye. The suture was taken out of the eye through the corneal incision, passed through the pair of fenestrated haptics of the IOL and then securely tied with overhand knots. The folded IOL was implanted into the posterior chamber. The anchor knots were created by both ends of the thread approximately 4 mm to 5 mm apart from the transconjunctival puncture and was intrasclerally buried.

RESULTS

The technique was used in 18 eyes (18 patients). The mean postoperative follow-up period was 17.22 ± 8.82 months. The IOLs of all the eyes remained well positioned and stable at the final follow-up. The visual acuities of all the eyes were improved postoperatively. No suture loosening, suture erosion, hypotony, scleral atrophy, chronic inflammation, retinal tears, and/or detachments were observed in any of the patients.

CONCLUSION

The present technique provides minimal trauma and reliable stability for the two-point transscleral fixation of four fenestrated haptics IOL.

Peripheral Intravascular Catheter-Assisted Sutureless Scleral Fixation of Three-Piece Intraocular Lenses: A Novel Technique

PURPOSE

To describe and report the anatomical and functional outcomes of a novel sutureless peripheral intravascular catheter (PIVC)-assisted scleral fixation of three-piece IOL.

METHODS

A retrospective chart review of all patients who underwent scleral fixation surgery performed by a single surgeon was conducted. In all cases, a novel scleral fixation technique of three-piece IOL was performed with the aid of a 24-gauge PIVC cannula. Patients were followed up at postoperative months 1, 3, and 6.

RESULTS

Thirteen eyes of 12 patients were included in the analysis. Preoperatively, mean best-corrected visual acuity was 1.26 ± 0.82 LogMar (20/364 Snellen Equivalent), and it improved significantly at all follow-up endpoints being of 0.52 ± 0.25 LogMar at 1 month (20/66 Snellen Equivalent, P = 0.02), 0.4 ± 0.22 LogMar at 3 months (20/50 Snellen Equivalent, P = 0.007) and 0.37 ± 0.2 LogMar (20/47 Snellen Equivalent, P = 0.008) at 6 months postoperatively. No serious intraoperative or postoperative complications were registered. Postoperatively, there were no cases of conjunctival erosions. Over the follow-up period, in all the included cases, the IOL remained centered and stable.

CONCLUSION

The PIVC-assisted scleral fixation technique may be a safe and reliable surgical option for secondary IOL placement in cases of insufficient capsular support.

Double-Needle Haptic Repositioning: A Troubleshooting Technique for Flanged Intraocular Lens Fixation

PURPOSE

Haptic repositioning during flanged intraocular lens (IOL) fixation can be difficult, and the haptic requiring repositioning may be at increased risk of excessive bending or breakage. This study aimed to report double-needle haptic repositioning technique outcomes for the aforementioned difficulty during flanged IOL fixation.

METHODS

This retrospective case series included seven eyes requiring haptic repositioning during flanged IOL fixation. The method features reinsertion of an already externalized haptic into the needle lumen followed by a needle-haptic complex internalized through the original tract into the eyeball. Thus, an adequate configuration for contralateral haptic can be achieved for insertion into the needle lumen to create a double-needle condition before both haptics are successfully externalized.

RESULTS

The median follow-up duration was 24 months (range, 4-24 months). Postoperatively, the IOL was well-centered, and corrected distance visual acuity improved from 20/320 (20/4,000-20/70) to 20/50 (20/250-20/20). No intraoperative or postoperative complications were noted.

CONCLUSION

The technique produced encouraging results in patients undergoing haptic repositioning during flanged IOL fixation. This technique could potentially reduce haptic overbending risk and facilitate haptic adjustment. Further studies are needed to confirm the feasibility of the technique.

Clinical Outcomes of Transscleral-Sutured Intraocular Lens Combined With Descemet Membrane Endothelial Keratoplasty

PURPOSE

The aim of the study was to report clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) combined with transscleral-sutured intraocular lens (IOL) compared with DMEK combined with phacoemulsification and posterior chamber IOL (Phaco-DMEK).

METHODS

A retrospective chart review of all patients who underwent DMEK combined with transscleral-sutured intraocular lens fixation or combined with phacoemulsification for Fuchs endothelial corneal dystrophy from 2016 to 2021 at the Toronto Western Hospital or the Kensington Eye Institute (Toronto, ON, Canada) and had at least 18 months of follow-up was performed. Main outcomes were postoperative distance-corrected visual acuity, rebubbling rate, graft survival rate, and complications.

RESULTS

Twenty-one cases of DMEK combined with transscleral-sutured IOL (DMEK-TSS-IOL) and 44 cases of Phaco-DMEK were evaluated. Twelve eyes (57.15%) had a foldable acrylic 3-piece IOL (AR40E) and 9 (42.85%) had a single-piece polymethylmethacrylate (PMMA) IOL (CZ70BD). LogMAR distance-corrected visual acuity improved significantly from 1.48 ± 0.62 (SD) to 0.86 ± 0.82 ( P = 0.01) 12 months after DMEK-TSS-IOL and from 0.41 ± 0.29 logMAR to 0.11 ± 0.11 logMAR ( P < 0.0001) after Phaco-DMEK. No statistically significant differences were observed in donor ( P = 0.97) or 1-year postoperative endothelial cell density ( P = 0.11) between the groups. Rebubbling was necessary in 33.33% of eyes in DMEK-TSS-IOL compared with 25% of Phaco-DMEK eyes ( P = 0.55). Graft survival rate was 76.19% in the DMEK-TSS-IOL group compared with 90.90% in the Phaco-DMEK group ( P = 0.13).

CONCLUSIONS

Transscleral-sutured IOL combined with DMEK is an option for the management of endothelial diseases in aphakic eyes or those which require IOL exchange for the experienced surgeon. However, when compared with routine Phaco-DMEK, there are higher complication and lower survival rates at 18 months.

Comparison of three different intraocular lens implantation techniques in the absence of capsular support: sutured scleral, haptic flanged intrascleral, and four flanged intrascleral fixations

INTRODUCTION

After lens extraction, if the capsular bag insufficiency occurs, there are different IOL implantation techniques. IOL implantation in the posterior chamber is safer in eyes with low endothelial cell count, peripheral anterior synechiae, shallow anterior chamber, and glaucoma. Alternative approaches for scleral fixation techniques, both with and without sutures, continue to undergo development. In this study, we aimed to compare the postoperative outcomes of the sutured scleral fixation (SSF), haptic flanged intrascleral fixation (HFISF) and four flanged intrascleral fixation (FFISF) IOL implantation techniques in eyes with the absence of capsular support.

MATERIALS AND METHODS

A hundred and thirty-seven aphakic eyes with the absence of capsular support were included in the study. The patients were divided into three groups: group 1-SSF, group 2-HFISF (Yamane technique), and group 3-FFISF. Surgical time in minutes, preoperative and postoperative parameters such as best corrected visual acuity (BCVA), corneal astigmatism, lenticular astigmatism, intraocular pressure (IOP), specular microscopy, central macular thickness (CMT) were recorded. Pseudophacodonesis was assessed at 6 months postoperatively using a slit lamp, and early and late complications were recorded.

RESULTS

Of the 137 eyes, 69 eyes were included in the SSF group, 41 eyes in the HFISF group, and 27 eyes in the FFISF group. No statistically significant differences were observed among the three groups in terms of age, gender, preoperative mean BCVA, corneal astigmatism, IOP, endothelial cell density, and CMT. It was observed that the mean BCVA significantly improved compared to the preoperative visual acuity in all three groups. Postoperative lenticular astigmatism, pseudophacodonesis score, percentage of the endothelial cell loss were found to be higher in FFISF groups. The surgical time was found to be shorter in the HFISF group. IOL decentration was observed in 1.44% of the SSF group and 7.40% of the FFISF group. Cystoid macular edema was observed in 5.79% of the SSF group, 4.87% of the HFISF group, and 7.40% of the FFISF group. Retinal detachment was observed in 1.44% of the SSF group and 7.31% of the HFISF group.

CONCLUSIONS

The optimal technique for treating aphakia without capsular support remains uncertain. Surgeons are tasked with a complex decision, aiming for both excellent vision and minimal risk. This decision is based on their expertise, the distinctive ocular condition of the patient, and the availability of essential operating room equipment. In this study, the following findings were observed: in the HFISF technique, the average surgical time was found to be shorter, the SSF technique demonstrated greater stability in terms of astigmatism and pseudophacodonesis and the FFISF technique was recognized for its relatively straightforward application method. It is important to note that the three IOL implantation techniques yielded comparable outcomes in terms of postoperative BCVA, as well as early and late complications.

Two-way adjustable double-knots intrascleral fixation and single sclerotomy looping technique: a novel minimal invasive adjustable intraocular lens fixation technique

BACKGROUND

IOL fixation without capsular support presents challenges for surgeons. Although innovative techniques were developed to address subluxated IOLs, adjustable IOL fixation methods are seldom reported. We introduce a novel two-way adjustable double-knots intrascleral fixation combined with single sclerotomy looping technique for fixing intraocular lenses (IOL) or IOL-capsular bags.

METHODS

A bent 30-gauge needle threaded with 8 - 0 polypropylene was introduced into the eye. A gripping forceps assisted the haptic looping. Two overhand knots were made with 8 - 0 polypropylene thread. The knots were incarcerated into a scleral tunnel made by a 30-gauge needle, with two ends of the thread left at each side of the tunnel. The IOL was adjusted to the premium position with adequate tension by pulling either end of the threads. The study included 19 eyes with aphakia, subluxated IOL-capsular bags, or subluxated crystalline lenses. The mean followed up period was 18.9 ± 7.1 months with evaluations of uncorrected visual acuity (UCVA), intraocular pressure, slit-lamp examination, and swept-source optical coherence tomography of the anterior segment.

RESULTS

UCVA increased from 1.28 ± 0.74 at baseline to 0.44 ± 0.51 (logMAR) at final visit (P < 0.001). All IOLs were fixed well-centered. The mean IOL tilt was 3.5°±1.1°. Postoperative complications included transient IOP elevation (15.8%), hypotony (10.5%), and cystoid edema (5.3%) which resolved within 4 weeks.

CONCLUSIONS

We presented a novel adjustable technique for IOL fixation, which stabilize IOLs by using an intrascleral double-knots structure. This technique minimized surgical manipulations by using a single sclerotomy looping technique without large conjunctival dissection and scleral flap creation. The technique offers a reliable and optimal IOL positioning and improved visual outcomes in patients undergoing scleral fixed IOL implantation.

Use of Yamane technique for secondary intraocular lens implantation following open globe injury

A woman in her 50s presented with suspected open globe injury (OGI) of the right eye after being hit with a high velocity piece of plastic. Visual acuity at the time of presentation was counting fingers in the affected eye. Slit lamp examination revealed a full thickness laceration of the cornea and a traumatic cataract. Primary corneal repair was performed and the patient was left aphakic after cataract removal. Secondary intraocular lens placement was deferred for 2 years, after which time a scleral-fixated intraocular lens was implanted using the Yamane technique. Postoperative visual acuity of 20/50 was achieved, with the vision limited by persistent diabetic macular oedema. Thus, this case of successful implantation of a secondary lens using the Yamane technique in a patient with prior corneal laceration and traumatic cataract highlights that the Yamane technique can result in visual improvement in patients with prior OGI.

Vitreous management in Yamane's technique for crystalline lens dislocation: anterior vitrectomy or PPV?

OBJECTIVE

To study the postoperative visual outcomes and surgical complications of anterior/pars plana vitrectomy and concurrent Yamane's IOL fixation for crystalline lens dislocation.

METHODS

Fifty-three patients (56 eyes) with crystalline lens subluxation/dislocation were enrolled in this retrospective interventional study. Patients received anterior/pars plana vitrectomy and concurrent Yamane's IOL fixation. Main outcome measures were postoperative BCVA and surgical complications. Proportion of spontaneous PVD and preoperative undetected retinal holes/degeneration (PURH/D) were recorded.

RESULTS

Twenty-four eyes were treated with anterior vitrectomy (Group AnV) and 32 eyes with pars plana vitrectomy (Group PPV). Overall incidence of PURH/D was 10.7% (6/56). Spontaneous PVD occurred in 68.8% (24/32) in Group PPV. During six months follow-up, one case of postoperative RRD and one case of choroidal detachment occurred in Group AnV. There was no significant difference between anterior vitrectomy and PPV in the final BCVA and postoperative complications.

CONCLUSION

Anterior or pars plana vitrectomy, which are both applicable in YAMANE technique for crystalline lens dislocation, exhibit similar surgical outcomes. Patient's age, PVD status and PURH helps to determine the route of vitrectomy. Pediatric patients might be potential candidates for transcorneal vitreolensectomy. For adult, PURH managed with total vitrectomy and intraoperative lase retinopexy might be beneficial to decrease the incidence of postoperative RRD.

Visual Outcomes of Traumatic Lens Dislocations and Subluxations Managed by Pars Plana Vitrectomy and Lensectomy

AIM

The aim of this study was to evaluate the visual outcome of lens dislocation and subluxation managed by pars plana vitrectomy (PPV) and lensectomy in patients with open (OGIs) or closed globe injuries (CGIs).

METHODS

Medical records of 70 consecutive patients treated by PPV and lensectomy over a period of 11 years (1 January 2010-31 December 2020) were retrospectively reviewed. We collected demographic data, best corrected visual acuity (BCVA) using a Snellen Chart pre- and postoperatively, associated ocular injuries and treatment strategy. Visual outcome was evaluated according to the final BCVA which was defined as poor <0.1 or good ≥0.1.

RESULTS

The mean age was 57.9 ± 17.6 years. CGIs were present in 49 (70.0%) cases and open OGIs in 21 (30.0%) cases. The dislocation mechanism was zonular lysis in 59 cases (84.3%) and capsular rupture in 11 cases (15.7%). The intraocular lens implant (IOL) was sutured to the sclera in 51 (72.9%) cases or positioned in the capsular bag or in the sulcus in 3 (4.3%) cases and 1 (1.4%) case, respectively, whereas 15 (21.4%) patients remained aphakic. A good BCVA ≥ 0.1 was achieved in 45.71% of the eyes. The presence of retinal detachment (RD) (p = 0.014), iridodonesis (p = 0.011) and initial BCVA (p = 0.000) achieved statistical significance in predicting visual outcome. After treatment, 45.71% of patients achieved a final BCVA ≥ 0.1.

CONCLUSION

RD, iridodonesis and initial BCVA were risk factors for poor visual outcome in our series.

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.

Optic inversion of scleral-fixated intraocular lens after vitrectomy with fluid-air exchange: case series and review of the literature

Lens dislocation is a significant complication after cataract surgery. Scleral fixation of 3-piece intraocular lens provides favorable visual outcome and can spare patients the need for lens exchange. Two patients presented with dislocated 3-piece lenses implanted over 10 years earlier. Both patients underwent pars plana vitrectomy and dropped lens rescue with scleral fixation. Postoperatively, the lens optic was found flipped nearly 90° at the optic-haptic junctions secondary to fluid-air exchange performed during vitrectomy. Both patients underwent intraocular lens exchange with a four point sclera fixated lens. Our study found that air tamponade is better avoided during rescue of old dislocated 3-piece lens implants. Intraocular lens exchange is preferred, when possible, to avoid complications associated with old dislocated lenses. Larger studies are needed to determine the effect of time on dislocated lens implants materials.

IMPACT OF GAS/AIR TAMPONADE ON REFRACTIVE OUTCOMES AFTER FLANGED INTRASCLERAL INTRAOCULAR LENS FIXATION

PURPOSE

This study aims to investigate the postoperative refractive outcomes in eyes that underwent the flanged intrascleral intraocular lens (IOL) fixation combined with vitrectomy with or without gas/air tamponade.

METHODS

The eyes were divided into two groups (Group A; eyes that underwent flanged intrascleral IOL fixation with gas/air tamponade, and Group B; eyes that underwent flanged intrascleral IOL fixation without gas/air tamponade). The predicted spherical equivalent (SE) refraction values were calculated using the Sander-Retzlaff-Kraff Theoretical formula. Then, the prediction error was calculated by subtracting the predicted SE refraction from the postoperative objective SE refraction and the absolute prediction error was calculated as the absolute value of the prediction error for each eye.

RESULTS

A total of 68 eyes were included in the current study. There was a significant correlation between the predicted and postoperative SE refraction in both groups (Group A, r = 0.968, P < 0.0001, Group B, r = 0.943, P < 0.0001, linear regression analysis). The prediction error demonstrated a mild myopic shift after the flanged intrascleral IOL fixation in both groups (Group A, -0.40 ± 0.96 diopter, Group B, -0.59 ± 0.95 diopter). There was no significant difference in prediction error and absolute prediction error between the two groups ( P = 0.44, P = 0.70, Wilcoxon rank sum test).

CONCLUSION

The postoperative SE refraction after flanged intrascleral IOL fixation was not influenced by gas/air tamponade.

MODIFIED SUTURELESS INTRASCLERAL FIXATION TECHNIQUE FOR SECONDARY INTRAOCULAR LENS IMPLANTATION: A Pilot Study

BACKGROUND/PURPOSE

To demonstrate possible complications of a new intraocular lens for sutureless secondary scleral implantation and modifications of the surgical technique to optimize outcomes.

METHODS

A retrospective study of 16 eyes (16 patients) who underwent a secondary intraocular lens implantation using the Carlevale intraocular lens (Soleko, Italy) with two anchor haptics for intrascleral implantation (mean follow-up 2.2 months).

RESULTS

The visual acuity did not improve statistically significantly postoperatively ( P = 0.601). Seven (44%) patients suffered from postoperative hypotonia (intraocular pressure <5 mmHg) during the first three postoperative days.

CONCLUSION

Owing to the early postoperative hypotony, we decided to modify the surgical technique. We present several suggestions to optimize the technique and outcome such as positioning the sclerotomies at the 2 and 8 o'clock positions, using 27 G trocars alone and suturing the frown incisions using self-resorbing sutures.

SCLERAL FIXATION OF CARLEVALE INTRAOCULAR LENS: A Systematic Review and Meta-Analysis

PURPOSE

The mean change in best-corrected visual acuity (BCVA), intraocular pressure, and endothelial cell counts after intraocular lens (IOL) implantation and the incidence rate of postoperative complications were estimated by systematic review and meta-analysis to assess the surgical and refractive outcomes of the sutureless scleral fixation Carlevale IOL.

METHODS

A literature search was conducted using PubMed, Embase, and Scopus. The weighted mean difference (WMD) was used to present the mean change in BCVA, intraocular pressure, and endothelial cell count after IOL implantation, whereas a proportional meta-analysis was used to estimate the pooled incidence rate of postoperative complications.

RESULTS

In the meta-analysis of 13 studies involving 550 eyes, the pooled WMD of the mean change in BCVA showed a significant improvement in BCVA in patients who underwent Carlevale IOL implantation (WMD = 0.38, 95% confidence interval: 0.30-0.46, P < 0.001; heterogeneity [I 2 ] = 52.02%). The subgroup analyses indicated that the mean change in BCVA was not significantly higher according to the last follow-up visit, with no statistically significant subgroup effect ( P = 0.21) (WMD up to 6 months: 0.34, 95% confidence interval: 0.23-0.45, I 2 = 58.32%, WMD up to 24 months: 0.42, 95% confidence interval: 0.34-0.51, I 2 = 38.08%). In the meta-analysis of 16 studies involving 608 eyes, the pooled incidence rate of postoperative complications was equal to 0.22 (95% confidence interval: 0.13-0.32, I 2 = 84.87, P ≤ 0.001).

CONCLUSION

Carlevale IOL implantation represents a reliable method of restoring vision in eyes with missing capsular or zonular support.

Four-flanged polypropylene optic piercing technique for scleral fixation of multifocal intraocular lens

BACKGROUND

To evaluate the feasibility of creating flanges using an optic piercing technique with a 6 - 0 polypropylene monofilament for scleral fixation of dislocated one-piece diffractive multifocal intraocular lenses (IOLs).

STUDY DESIGN

Experimental study and case series.

SUBJECTS

Optical bench test and eyes with IOL dislocation.

METHODS

Two separate 6 - 0 polypropylenes were penetrated twice at the opposite peripheral optic of the TECNIS Synergy IOL (Johnson & Johnson Vision). The root mean square of the modulation transfer function (MTFRMS), at between + 1.00 and - 4.00 D of defocus, was measured in the TECNIS Synergy IOL both with and without optic piercing in the optical bench study. This case series included three eyes from two patients who underwent scleral-fixation of multifocal IOLs using the four-flanged polypropylene optic piercing technique. The postoperative corrected distance visual acuity (CDVA) at 4 m, the uncorrected near visual acuity (UNVA) at 40 cm, and IOL centration were evaluated.

RESULTS

The optical bench test showed no differences in MTFRMS values measured in the TECNIS Synergy IOL, either with or without optic piercing at all defocuses. In all three case series, the postoperative CDVA at 4 m was 20/20 and UNVA at 40 cm was J1. Postoperative anterior segment photographs showed good centration of IOLs in all cases.

CONCLUSION

The four-flanged polypropylene optic piercing technique for multifocal IOL scleral fixation can provide excellent clinical outcomes and IOL stability after surgery without diminishing the performance of the multifocal IOLs.

FIL SSF intraocular lens opacification after pars plana vitrectomy with gas tamponade for traumatic lens luxation and retinal detachment: a case report and literature review

BACKGROUND

To report a case of sutureless scleral-fixated hydrophilic intraocular lens (FIL SSF IOL, Soleko, Italy) opacification following pars plana vitrectomy surgery using sulfur hexafluoride (SF6) for traumatic lens luxation associated with retinal detachment.

CASE PRESENTATION

A 77-year-old woman was referred to our emergency department after blunt trauma in her right eye. At the ophthalmic evaluation, visual acuity was hand movement, biomicroscopy showed pseudoexfoliation syndrome and a traumatic lens luxation in the vitreous chamber. The patient underwent pars plana vitrectomy, subluxated cataract explantation, and FIL SSF IOL implant. During surgery, an inferior retinal detachment was encountered, requiring 20% SF6 gas tamponade. No adverse events were encountered. One month postoperatively, visual acuity (BCVA) improved to 0,3 logMAR. At the 3-month follow-up, the patient presented with BCVA of 0,5 logMAR, and biomicroscopy showed a minimal IOL opacification. Six months postoperatively, BCVA decreased to 1.0 logMAR, and diffuse, IOL opacification was noted at slit lamp examination. The patient refused any other surgical intervention for IOL exchange.

CONCLUSIONS

Although hydrophilic IOL opacification gas related is known, to the best of our knowledge, this is the first case reported in the literature of FIL SSF IOL opacification after pars plana vitrectomy with gas tamponade for retinal detachment.