Histologic study of eyes with transsclerally sutured posterior chamber intraocular lenses

Endoscope-Assisted Carlevale Lens Implantation in Patients Without Capsular Support: A Novel Surgical Approach to Ensure Correct Lens Positioning

PURPOSE

To describe endoscope-assisted Carlevale intraocular lens (IOL) implantation.

METHODS

Twelve eyes underwent posterior vitrectomy combined with Carlevale IOL implantation and endoscopy in a single procedure, using a technique developed by the authors. Transscleral incisions were performed under direct visualization of the sulcus using the endoscope, and the final lens position was checked at the end of each intervention. The main outcome was to determine the exact position of all lens fixation points.

RESULTS

All plugs were correctly placed in the sulcus, but in seven eyes (58.3%), at least one of the closed-loop haptics was folded over the ciliary body. Repositioning was performed during the same procedure. Given that each IOL has four closed-loop haptics, the incidence of this complication was 23% (11/48).

CONCLUSION

Blind implantation of Carlevale IOL may cause a high incidence of haptic malpositioning. Because the sulcus and the ciliary body are not visible under the microscope, endoscopy is the only way to ensure correct lens implantation. This new technique ensures that all lens fixation points are correctly placed by the end of surgery, avoiding complications such as decentration or tilting of the IOL, damage to the iris or the ciliary body, and uveitis.

Scleral fixation of a novel modified, injected canine intraocular lens by haptic capture, in 17 dogs

INTRODUCTION

The aims of lens removal surgery are to re-establish or preserve both a clear visual axis and emmetropic vision. Trans-scleral intraocular lens (IOL) fixation has been described in cases where lens capsule instability precludes the insertion of a prosthetic intraocular lens into the lens capsule. Previous techniques have necessitated enlargement of the corneal incision to accommodate either a rigid polymethylmethacrylate IOL or an acrylic foldable IOL inserted using forceps. This paper reports the modification of an endocapsular IOL to be used as an injectable suture-fixated IOL introduced through a 2.8 mm corneal incision.

MATERIALS AND METHODS

All cases underwent lens extraction by phacoemulsification followed by removal of the unstable lens capsule. A PFI X4 IOL (Medicontur) was modified to create four open-loop haptics. The IOL was injected into the anterior chamber, each haptic was captured in a loop of suture introduced ab externo, and the lens was sutured with four-point fixation.

RESULTS

The results from 20 eyes in 17 dogs are reported. Over an average follow-up time of 14.5 months, vision was retained in 16/20 eyes. Vision was lost in four eyes due to corneal ulceration and ocular hypertension (1/20), retinal detachment (2/20), and Progressive Retinal Atrophy (1/20).

CONCLUSIONS

The modified PFI X4 proved suitable for injection and scleral fixation through a 2.8 mm corneal incision, with a success rate comparable to previously published techniques.

An innovative alternative for spherophakia

Objective: The aim of this case report is to report a new aphakic intraocular lens (IOL) that can be used for spherophakia. Methods: This is a single case report wherein the authors elaborate the technique of inserting the new IOL design in patients with spherophakia. Results: This new IOL design is very stable and is very promising in our follow-up of 6 months. Conclusion: The CM T-flex IOL can be a simple and alternate option for correcting aphakia.

Sutureless Intrascleral Posterior Chamber Intraocular Lens Fixation: Analysis of Clinical Outcomes and Postoperative Complications

Purpose

To report a technique for performing sutureless intrascleral fixation of a posterior chamber intraocular lens (PC-IOL) and analyzing the clinical outcomes and postoperative complications. Study Design. 68 eyes of 66 patients who received the technique were studied retrospectively.

Methods

The best-corrected visual acuity (BCVA), intraocular pressure (IOP), anterior chamber depth (ACD), IOL tilt and decentration, corneal topography (K1 and K2), and postoperative complications were determined at 3 months.

Results

The mean preoperative BCVA was 1.63 ± 1.24 logMAR units, and the mean postoperative BCVA was 0.74 ± 0.59 logMAR units at 3 months (P < 0.05). The mean preoperative IOP was 21.9 ± 12.6 mmHg, and the mean postoperative IOP was 16.9 ± 4.5 mmHg at 3 months (P = 0.001). The mean preoperative corneal topography (K1 and K2) was K1 = 42.14 ± 1.91 and K2 = 43.54 ± 1.51; the mean postoperative corneal topography (K1 and K2) was K1 = 43.03 ± 2.18 and K2 = 43.40 ± 1.71 at 3 months (P = 0.678 and 0.468, respectively). The mean preoperative spherical equivalent was +11.00 ± 13.19 diopters (D), and the mean postoperative spherical equivalent was +0.06 ± 0.86 D (P < 0.005). The mean IOL tilt was 2.4 ± 1.7°, and the mean decentration was 0.35 ± 0.21 mm. The mean ACD was 4.31 ± 0.29 mm.

Conclusions

The 27-gauge sutureless intrascleral PC-IOL implantation technique minimizes intraoperative injury, simplifies procedure, and provides good PC-IOL fixation with few postoperative complications.

Secondary intraocular lens implantation with absence of capsular support: Scleral versus iris fixation

PURPOSE

To assess the outcomes of iris fixated (IF) posterior chamber (PC) intraocular lens (IOL) versus scleral-fixated (SF) PC IOL implantation, and compare them with the results reviewed from the literature.

SETTING

The study took place in the ophthalmology department of the Eye and Ear Hospital (Lebanon).

DESIGN

This is a retrospective institutional study that collected the records of patients admitted for secondary IOL implantation between January 2007 and December 2016.

METHODS

A total of 28 eyes that underwent PC IOL fixation were included, 13 of which underwent trans-scleral PC IOL fixation and 15 of which underwent iris PC IOL fixation. Data were analyzed over a period of 3 years.

RESULTS

Of the 28 patients, 18 (64.3%) were male and 10 (35.7%) were female (mean age at intervention 36.78±23.47 [standard deviation, SD] years). There were no significant intergroup differences with regard to baseline values and demographic characteristics. Trauma was the most common etiology for posterior capsule insufficiency (82.1%). The mean preoperative baseline BCVA was 0.58±0.27 logMAR for SF and 0.27±0.20 logMAR for IF (P=0.07). Both groups had significant improvement in vision during the follow up period. No significant differences were noted regarding early or late postoperative complications between the two groups.

CONCLUSION

SF and IF techniques for PC IOL have similar outcomes and result in a significant improvement in BCVA. When compared to AC (anterior chamber) IOL, both techniques seem to yield fewer complications.

Sulcus Fixated Posterior Chamber Lenses with and without Suture in Cases Lacking Capsular Support

In a prospective study ten commercially available anterior chamber lenses with S-shaped haptics and multipoint support were implanted into the posterior chamber in cases of secondary lens implantation after intracapsular cataract operation. The lenses were trans-sclerally fixed by two sutures through the ciliary sulcus. They showed more immediate stability than ten C-loop posterior chamber lenses of a control group and remained firmly fixed without complications during a follow-up of up to 54 months. To overcome the disadvantages of suture fixation a sutureless sulcus self-fixation PCL was developed and implanted into six eyes with special indications. After more than one year of follow-up no late adverse reaction was noted.

Transscleral Suture-Fixated Versus Intrascleral Haptic-Fixated Intraocular Lens: A Comparative Study

PURPOSE

To compare the clinical outcomes between sutured transscleral-fixated and intrascleral haptic-fixated posterior chamber intraocular lens (IOL).

SETTING

Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi.

DESIGN

A comparative case series.

METHODS

Forty eyes of 40 patients were included; 20 in each group. Patients in group 1 underwent sutured transscleral-fixated IOL and those in group 2 underwent intrascleral haptic-fixated IOL augmented by fibrin glue. Parameters evaluated were uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), intraocular pressure (IOP), central macular thickness (CMT), IOL tilt on ultrasound biomicroscopy (UBM), and pseudophakodonesis on slitlamp and UBM.

RESULTS

The most common cause of aphakia was complicated cataract surgery (50%). The mean preoperative UCVA in logarithm of minimum angle of resolution (logMAR) was 1.59±0.24 and 1.63±0.26 in group 1 and 2, respectively (P=0.45). There was significant improvement in UCVA in both groups (P=0.001) at 6 months (group 1: 0.33±0.17; group 2: 0.22±0.10); the improvement being greater in group 2 (P<0.05). Mean percentage endothelial cell loss and IOP change were comparable. Mean CMT (μm) was 250.95±23.98 and 225.85±21.13 in group 1 and 2, respectively (P=0.009). Pseudophakodonesis was more in group 1 as assessed on slitlamp (P=0.037) and as assessed on UBM (P=0.046). Macular edema was the most common complication seen more in group 1.

CONCLUSIONS

Intrascleral haptic-fixated IOL provides more stable fixation, better visual outcome, and lesser complication in comparison with sutured transscleral-fixated IOL.

Clinical spectrum and surgical outcomes in spherophakia: a prospective interventional study

PurposeTo study the varied clinical presentations of patients with spherophakia, their management using surgical methods, and the clinical outcomes.Patients and methodsA prospective interventional study of 13 patients of spherophakia who presented to us from January 2014 and were followed up over the course of their treatment, and the data were documented for analysis.ResultsIn all, 26 eyes of 13 patients were reviewed and the median age of presentation was 12±12.05 years. All patients had a bilateral presentation with 22 eyes having lenticular myopia with a mean refractive error of -11.5±12.945 DS. Ten eyes presented with glaucoma of which six had raised intraocular pressure (IOP) >21 mm Hg. A total of 23 eyes underwent lens extraction for dislocation/subluxation. Lens extraction helped lower overall IOP. Refractive rehabilitation was done with ACIOL, posterior chamber intraocular lens (PCIOL) with capsular tension ring, and scleral-fixated intraocular lens (SFIOL) in respective cases with ACIOLs being the most commonly used option.ConclusionsSpherophakia is a rare condition, which exhibits a varying degree of lenticular myopia, glaucoma, and subluxation of the crystalline lens. Lensectomy with proper rehabilitation using ACIOL, PCIOL, or SFIOL is a method of managing subluxation and unacceptable myopia. Lensectomy may also be a viable option of controlling glaucoma alongside medications and glaucoma surgery for the management of glaucoma in such cases.

Complications of Scleral-Fixated Intraocular Lenses

INTRODUCTION

Understanding the evolution of complications after scleral-fixated lens placement demonstrates advantageous surgical techniques and suitable candidates.

MATERIALS/METHODS

A literature search in PubMed for several terms, including "scleral intraocular lens complication," yielded 17 relevant articles.

RESULTS

Reviewing complication trends over time, lens tilt and suture erosion have decreased, cystoid macular edema has increased, and retinal detachment has remained the same after scleral-fixated lens placement. The successful reduction in complications are attributed to several alterations in technique, including positioning sclerotomy sites 180 degrees apart and using scleral flaps or pockets to bury sutures. Possible reduction in retinal risks have been proposed by performing an anterior vitrectomy prior to lens placement in certain settings.

DISCUSSION

Complications after scleral-fixated lens placement should assist patient selection. Elderly patients with a history of hypertension should be counseled regarding risk of suprachoroidal hemorrhage, while young patients and postocular trauma patients should be considered for concurrent anterior vitrectomy.

Small-incision 4-point scleral suture fixation of a foldable hydrophilic acrylic intraocular lens in the absence of capsule support

PURPOSE

To determine the visual outcomes and complications of a new small-incision technique for 4-point fixation of a hydrophilic acrylic posterior chamber intraocular lens (IOL) in the absence of capsule support.

SETTING

Three North American tertiary referral centers and a private practice.

DESIGN

Retrospective case series.

METHODS

Secondary IOL placement was performed from 2011 to 2014. Indications for surgery, clinical results, and complications were analyzed. Primary outcomes included postoperative corrected distance visual acuity (CDVA) and surgical complications.

RESULTS

Charts of 35 patients (37 eyes) were reviewed. The mean age at surgery was 56 years, and the mean follow-up was 6 months (range 3 to 24 months). Clinical indications included a dislocated IOL (30%), ocular trauma (19%), crystalline lens subluxation (19%), uveitis-glaucoma-hyphema syndrome (5%), post-complicated cataract (8%), congenital cataract (8%), and decompensated cornea (3%). The mean CDVA improved from 20/80 preoperatively to 20/40 postoperatively (P < .01). Thirty-six eyes (97%) had an improved or unchanged CDVA, and 1 eye (3%) had a reduced CDVA because of worsening glaucoma. Postoperative complications included ocular hypertension (24%), iritis (5%), wound leakage (3%), transient corneal edema (3%), glaucoma requiring a tube shunt (3%), and IOL dislocation (3%).

CONCLUSION

Small-incision 4-point scleral fixation of the Akreos AO60 hydrophilic acrylic IOL in the absence of capsule support appears to be a safe and effective technique for secondary IOL placement.

FINANCIAL DISCLOSURES

Drs. Berdahl and Ayres are consultants to Bausch & Lomb, Inc. Drs. Ayres and Fram have received speaker fees from Bausch & Lomb. Dr. Terveen does not have a financial or proprietary interest in any material or methods mentioned.

Transscleral fixation of single-piece foldable acrylic lens with eyelets at the optic-haptic junction

OBJECTIVE

To report the clinical outcomes of transscleral fixation using a single-piece foldable acrylic intraocular lens (IOL) with eyelets at the optic-haptic junction (enVista; Bausch & Lomb).

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Sixty eyes of 60 patients who underwent transscleral fixation with an enVista IOL were reviewed.

METHODS

Preoperative patient status, postoperative visual and refractive outcomes, and postoperative complications were analyzed.

RESULTS

The study included 60 eyes of 60 patients (52 males, 8 females) with a mean age of 56.65 ± 15.57 years. At final follow-up visit, the mean follow-up was 11.40 ± 4.24 months. The mean uncorrected visual acuity (logMAR) improved from 1.95 ± 0.90 to 0.85 ± 0.77 (p < 0.001), and best corrected visual acuity (logMAR) improved from 1.11 ± 1.13 to 0.64 ± 0.70 (p = 0.006). The mean spherical equivalent improved significantly from 6.90 ± 6.10 to 0.21 ± 2.10 D postoperatively (p < 0.001). Complications included transient ocular hypertension (15%), transient hypotony (7%), and hyphema (5%), but no serious complications were observed. In all cases, the IOL remained stable and well centred.

CONCLUSIONS

Transscleral fixation using a foldable acrylic IOL with eyelets at the optic-haptic junction can be a safe and effective alternative technique to manage cases with broken capsular bag or weak zonular support.

Surgical management of non-traumatic pediatric ectopia lentis: A case series and review of the literature

PURPOSE

To report a small series of pediatric patients with ectopia lentis that underwent limbal-approach lensectomy and vitrectomy and scleral-fixated intraocular lens implantation and to review the literature on the topic of surgical management of ectopia lentis.

METHOD

A retrospective review of 13 eyes of seven patients that underwent lensectomy, vitrectomy, and scleral-fixated intraocular lens implantation and a review of the ophthalmic literature.

RESULTS

In our series, the average age at surgery was 70.3 ± 13.8 months and the average length of follow-up was 23.8 ± 5.9 months. The mean pre-operative visual acuity was 0.86 ± 0.17 which improved to 0.23 ± 0.09 post-operatively (p < 0.001). No complications were encountered in our series. A review of the literature found that amblyopia was the biggest vision-limiting factor. In general, the literature suggested that a higher percentage of eyes that were left aphakic achieved better vision than those implanted with a scleral-fixated intraocular lens. However, there may be selection bias in that more eyes receiving an intraocular lens may have pre-existing amblyopia. The complication rates for lensectomy or scleral-fixated intraocular lens implantation were low in the literature. In the latter group, suture breakage and resultant intraocular lens dislocation is a worrisome late complication.

CONCLUSION

Surgical intervention for ectopia lentis via vitrectomy techniques yields good result. In cases of unilateral aphakia or in settings where compliance with aphakic refractive correction is questionable and amblyopia is a constant threat, scleral-fixated intraocular lens implantation is highly encouraged. However, long-term follow-up is required due to the risk of suture breakage and resultant intraocular lens dislocation over time.

Feasibility and Complications between Phacoemulsification and Manual Small Incision Surgery in Subluxated Cataract

Purpose. To compare the feasibility of cataract surgery with implantation of endocapsular supporting devices and intraocular lens (IOL) in subluxated cataract in phacoemulsification and manual small incision cataract surgery (MSICS). Design. Prospective randomized intervention case series consisting of 60 eyes with visually significant subluxated cataract. Method. The patients were randomly distributed between the two groups equally. The main outcome measure was implantation of in-the-bag IOL, requirement of additional procedure and complications, if any. Results. Capsular bag retention in subluxated lenses is possible in 90% cases in phacoemulsification versus 76.67% cases in MSICS (P = 0.16). Both groups, achieved similar best corrected visual acuity (P = 0.73), although additional procedures, intraoperative, and postoperative complications were more common in MSICS. Conclusions. Achieving intact capsulorhexis and nuclear rotation in MSICS may be difficult in cases with large nucleus size and severe subluxation, but subluxated cataracts can be effectively managed by both phacoemuslification and MSICS.

Visual outcomes and complications of scleral-fixated posterior chamber intraocular lenses

PURPOSE

To report the long-term visual outcomes and complications after implantation of scleral-fixated posterior chamber intraocular lenses (PC IOLs).

SETTING

Princess Alexandra Hospital, Mater Hospital, and Queensland Eye Institute, Brisbane, Australia.

DESIGN

Case series.

METHODS

This study reviewed the records of patients who had anterior vitrectomy and scleral-fixated PC IOL implantation between 1993 and 2008 and had a minimum follow-up of 6 months.

RESULTS

The study comprised 82 eyes of 72 patients (47 men). The mean follow-up was 83.3 months (range 6.7 to 166.5 months) and the mean age at surgery, 62 years (range 15 to 97 years). The mean improvement in corrected distance visual acuity (CDVA) was 1.6 Snellen chart lines of vision, which was statistically significant; 59 eyes (72%) had an improved or unchanged CDVA, and 23 eyes (28%) had a reduced CDVA. The most common postoperative complication was ocular hypertension (25 eyes [30.5%]). Suture breakage occurred in 5 eyes (6%) after a mean of 4.9 years; 4 of these patients were younger than 40 years. Overall, 44 eyes (53.7%) had at least 1 complication, 36.4% within 1 week postoperatively and 63.6% after 1 week. Thirteen eyes (15.8%) required at least 1 further operation.

CONCLUSIONS

Scleral-fixated PC IOL insertion provided favorable visual outcomes in many cases. Complications were common, and suture rupture is an important long-term complication, particularly in young patients. These issues affect IOL choice for the surgical treatment of aphakia and should be discussed with patients during the consent process.

FINANCIAL DISCLOSURE

Neither author has a financial or proprietary interest in any material or method mentioned.

Visual rehabilitation by scleral fixation of posterior chamber intraocular lenses in Omani children with aphakia

BACKGROUND AND OBJECTIVE

To report indications and outcomes of scleral-fixated posterior chamber intraocular lenses (PC IOLs) in Omani children with aphakia.

PATIENTS AND METHODS

Patients with aphakia who were younger than 16 years, unsuitable for spectacle or contact lens correction, and without capsular support underwent an anterior vitrectomy and 10-0 polypropylene inside-out scleral fixation ofa PC IOL.

RESULTS

Scleral-fixated PC IOLs were implanted in 28 eyes of 24 patients. Group A comprised 10 (36%) eyes with congenital cataract and 3 (11%) eyes with ectopia lentis and group B comprised 15 (53%) eyes with traumatic cataract. The mean age at implantation was higher in group A (10.5 years) than in group B (7.3 years). Visual acuity improved in 17 of 28 (61%) eyes and remained at the preoperative levels in 11 of 28 (39%) eyes. Mean postoperative refraction was within +/- 2.0 diopters of the predicted refraction in 19 of 28 (68%) eyes. Complications included temporary intraocular pressure increase, vitreous hemorrhage, and iris capture with lens malposition.

CONCLUSION

Scleral-fixated PC IOLs are beneficial for children with aphakia without posterior capsular support who are lacking other means for visual rehabilitation. Patients with traumatic cataract and lens dislocation are more likely to experience an improvement in visual acuity postoperatively than patients with congenital cataract. However, this procedure is technically more difficult than routine PC IOL implantation and potentially carries greater risks.

Ultrasound biomicroscopic evaluation of the efficacy of a transillumination technique for ciliary sulcus localization in transscleral fixation of posterior chamber intraocular lenses

PURPOSE

To evaluate the efficacy of the transillumination technique for precisely locating the ciliary sulcus in transscleral fixation of posterior chamber intraocular lenses (PC IOLs) by determining the haptic positions with ultrasound biomicroscopy (UBM).

SETTING

Department of Ophthalmology, Numune Training and Research Hospital, Ankara, Turkey.

METHODS

Ultrasound biomicroscopy was used to determine the haptic positions in eyes with ab externo transsclerally fixated PC IOLs. Eyes were randomly assigned to a control group, in which transscleral fixation of a PC IOL was performed, or an endoilluminator-assisted group, in which transscleral fixation was combined with transillumination.

RESULTS

The study evaluated 33 eyes of 28 patients ranging in age from 16 to 81 years. The control group comprised 19 eyes (17 patients) and the endoilluminator-assisted group, 14 eyes (12 patients). All haptics were easily visualized with UBM. The UBM examination showed that the rate of haptics located in the sulcus was statistically significantly higher in the endoilluminator-assisted group (64%) than in the control group (24%) (P= .001). There was no significant difference in either group in the rate of precise sulcus location between the straight needle and the 28-gauge insulin needle (P> .05).

CONCLUSIONS

Ultrasound biomicroscopy showed the difficulty in reliably suturing the haptics in the ciliary sulcus, even with the use of a transillumination technique. However, the results suggest that the transillumination technique is a safe and easy procedure and helps the surgeon identify the ciliary sulcus during transscleral fixation of PC IOLs more precisely than without the use of transillumination.

Prevention of suture exposure in transscleral intraocular lens fixation: an original technique

BACKGROUND

In this retrospective study, we evaluated our surgical outcomes of transscleral intraocular lens (IOL) fixation and introduced a simple, quick, and effective method to fixate and bury the sutures in the sclera to avoid suture exposure.

METHODS

Eyes were divided into 3 groups according to surgical technique. Half-thickness scleral flaps were prepared, and polypropylene suture ends were cut short in group 1 (12 eyes). Suture ends were left long without flaps in group 2 (47 eyes) and were buried into the scleral tunnel in group 3 (21 eyes).

RESULTS

The suture exposure rate was significantly lower in group 3 (0%) compared with group 2 (p = 0.006) and group 1 (p = 0.040). There was no significant difference in group 1 (25%) compared with group 2 (27.6%) (p = 1.000).

INTERPRETATION

Burying the suture ends into the scleral tunnel is a simple, safe, and effective technique for avoiding suture exposure in scleral-fixated IOL implantation.

Safety of transscleral-sutured intraocular lenses in children

PURPOSE

To evaluate the long-term efficacy, safety, and advisability of transscleral-sutured posterior chamber intraocular lenses (IOLs) in pediatric patients with no capsular support and to determine whether a 10-0 polypropylene suture should be used for this purpose.

METHODS

A long-term retrospective interventional case series review of 33 eyes of 26 patients who had a sutured IOL at Duke University Eye Center. Cases were evaluated for the intraoperative surgical risks and the number, type, and severity of the postoperative complications. A survey of pediatric ophthalmologists' experience with suture breakage was performed.

RESULTS

Intraoperative and immediate postoperative complications were minimal and not sight-threatening for the patient. Four patients developed subluxation of the IOL secondary to spontaneous 10-0 polypropylene suture breakage at 3.5, 5, 6, and 8 years after surgery. A survey of pediatric ophthalmologists revealed 13 similar cases (mean, 5 years after surgery).

CONCLUSIONS

Caution should be exercised in the use of 10-0 polypropylene suture to fixate an IOL to the sclera in children, and an alternative material or size (such as 9-0 polypropylene) should be considered.

Visual rehabilitation by scleral fixation of posterior chamber intraocular lenses in amblyopic aphakic children

Background/Aims:

To report on the outcome of scleral fixated posterior chamber intraocular lens (S-IOL) implantation in aphakic amblyopic children after 1 year.

Methods:

Amblyopic children with aphakia after traumatic and congenital cataract surgery unsuitable for spectacle or contact lens correction were operated with an anterior vitrectomy and inside-out double thread scleral fixation of an Alcon CZ70BD pcIOL. Refraction and vision was compared after 12 months.

Results:

From 2001-2006, 23 S-IOLs were implanted in 16 children (19 unilateral, 4 bilateral) aged 2-16 years: 10 eyes with traumatic [Group A], and 13 eyes with congenital cataracts including 3 eyes with ectopia lentis [Group B]. Preoperative UCVA compared to postoperative UCVA improved in 9/10 eyes in group A and 12/13 eyes in group B. Preoperative BCVA compared to postoperative UCVA improved in 9/10 eyes (90 percent) in group A and 4/13 eyes (31 percent) in group B. Mean age at surgery in group A was 6.8 years (1.5-16yrs) and in group B 10.5 years (4-16 years). More than one year elapsed in 2/10 eyes of group A and 8/13 eyes in group B. Postoperative refraction was within 2.0D of target in 17/23 eyes. Complications included temporary IOP rise in 2, vitreous hemorrhage in 1, and iris capture in 3 eyes. Two eyes required revision surgery.

Conclusion:

S-IOL implantation may be beneficial for aphakic children lacking other means for visual rehabilitation to improve vision. Amblyopia may be improved in most trauma, but only few congenital cataract eyes.

Long-term results of scleral fixation of posterior chamber intraocular lenses in children

PURPOSE

To evaluate the long-term results of transsclerally fixated posterior chamber intraocular lenses (SF-PCIOLs) in children without adequate capsular support.

DESIGN

Noncomparative interventional case series.

PARTICIPANTS

Twenty-five eyes of 23 children who underwent primary (6 eyes) or secondary (19 eyes) implantation of SF-PCIOLs. The primary cases included those undergoing surgery for lens subluxation due to Marfan's syndrome, and secondary cases included those after surgery for congenital cataract (3 eyes) or traumatic cataract (16 eyes). All eyes lacked adequate capsular support and, in secondary cases, manifested contact lens intolerance.

INTERVENTION

Ab externo transscleral fixation of PCIOLs.

MAIN OUTCOME MEASURES

Visual acuity (VA), IOL position, and postoperative complications.

RESULTS

The mean age of patients at the time of SF-PCIOL implantation was 79+/-20.2 months (range, 33-120). The mean duration of follow-up after surgery was 81.1+/-46.2 months (range, 12-144). Best-corrected VA improved postoperatively in 12 eyes (48%) by >1 Snellen line. The main cause of reduced vision was corneal and retinal pathologies and amblyopia. Complications included transient intraocular hemorrhage in 13 eyes (52%), transient choroidal effusion in 2 eyes (8%), late endophthalmitis in 1 eye (4%), retinal detachment in 1 eye (4%), and late IOL dislocation due to breakage of polypropylene sutures after 7 to 10 years in 6 eyes (24%).

CONCLUSION

Scleral fixation of PCIOLs can be visually rewarding in selected cases, but there is a high rate of complications during a long-term follow-up.

Injection of an intraocular lens in an eye without capsular support

We describe a technique that can be used to facilitate posterior chamber intraocular lens (IOL) placement with iris fixation in cases with compromised capsular support. This procedure allows injection of an IOL through an unenlarged clear corneal incision. A safety net suture is temporarily fixed in the posterior chamber to act as a surrogate capsule. This suture supports the IOL while the surgeon injects it and secures it to the iris. The addition of this single step facilitates the remainder of the procedure and potentially makes it safer.

Long-term outcome of combined pars plana vitrectomy and scleral fixated sutured posterior chamber intraocular lens implantation

PURPOSE

To investigate the long-term visual outcome and the complication rate following transscleral suture fixation of posterior chamber intraocular lenses (sutured PC-IOLs).

DESIGN

A retrospective case-series descriptive study.

METHODS

Records of patients who underwent combined pars plana vitrectomy and sutured PC-IOLs at Moorfields Eye Hospital and who had at least 12 months of follow-up were examined for recorded complications.

RESULTS

Sixty-one eyes of 48 patients (33 males and 15 females) were identified and included in the analysis, with mean follow-up of 6 years. The mean final best-corrected visual acuity remained at preoperative levels (P=.211) and was largely determined by the underlying ocular pathology before sutured PC-IOL. Overall 30 of 61 (49%) eyes, two or more procedures were performed to reverse a significant peri- or postoperative complication. Breakage of polypropylene sutures was the main indication accounting for 17 of 30 (57%) of those reoperations. Subgroup analysis showed that younger patients were more likely to suffer the above complication (P=.009). The multivariate analysis also showed that longer follow-up was significantly associated with suture breakage (P=.014), with the mean time to breakage approximately 4 years after surgery.

CONCLUSIONS

Long-term follow-up of patients undergoing sutured PC-IOLs appears to be associated with a high rate of postoperative complications and significant need for further surgery, which should be discussed during their informed consent process.

Techniques of intraocular lens suspension in the absence of capsular/zonular support

Implantation of intraocular lenses has become the standard of care in the aphakic state. Ideally, the lens is placed in the capsular bag, which affords stable fixation at a position closest to the nodal point of the eye. However, there will always be instances where this will not be possible. Congenital weakness of the lens zonules in various conditions, trauma, and surgical complications of cataract surgery are just some examples. In this article, we review the methods that have been devised to allow intraocular lens implantation in the absence of capsular or zonular support. These include anterior chamber angle and iris-fixated lenses, as well as posterior chamber iris- and scleral-sutured lenses. The various lenses are described, and the techniques involved, advantages and disadvantages, complications, and results of each method are discussed. It is hoped that this article will provide a comprehensive overview of ways to deal with a problem that can still result in a very good visual outcome for the patient. This is particularly relevant given the many recent developments and refinements of methods in implanting intraocular lenses.

Late dislocation of scleral-sutured posterior chamber intraocular lenses

PURPOSE

To examine a recent series of late scleral-sutured posterior chamber intraocular lens (PCIOL) dislocations to identify possible causes and preventive measures.

SETTING

Price Vision Group, Indianapolis, Indiana, USA.

METHODS

In this retrospective non-comparative interventional case series, 5 consecutive patients received treatment for dislocated scleral-sutured PCIOLs between July 2002 and March 2004. Dislocated lenses were resutured or replaced with another scleral-sutured PCIOL.

RESULTS

Dislocation of scleral-sutured PCIOLs occurred 7 to 14 years after implantation. Four dislocations were spontaneous, and 1 was precipitated by trauma. In each case, the suture affixing 1 or both haptics failed. There was no evidence that the suture had eroded through the tissue or that the knot had untied. Microscopic analysis of an explanted IOL with remnants of the suture attached showed localized degradation and cracking of the polypropylene suture material where it had been embedded in the scleral tissue.

CONCLUSION

Suture-fixated PCIOLs can dislocate due to degradation of the suture material over time. The use of larger diameter (9-0 instead of 10-0) polypropylene suture material and placement of the haptic and sutures in the ciliary sulcus to promote attachment of scar tissue may enhance the long-term stability of scleral-fixated PCIOLs.

RECURRENT VITREOUS HEMORRHAGE AFTER SUTURED POSTERIOR CHAMBER INTRAOCULAR LENSES

PURPOSE

To describe the clinical course and management of patients with late vitreous hemorrhage after scleral suturing of posterior chamber intraocular lenses (PCIOL).

METHODS

The authors reviewed patient demographics, ocular findings, and clinical course of six patients with late (>3 weeks) vitreous hemorrhage after sclera-sutured PCIOL. Intraoperative endoscopy was performed on two patients to better assess the haptic sulcus interaction.

RESULTS

Patient age ranged from 39 to 84 years (median 77 years). The interval between scleral suturing of the PCIOL and vitreous hemorrhage ranged from 3 weeks to 68 months (median 5 months). The number of hemorrhages ranged from one to four. The hemorrhage cleared spontaneously in three eyes. Three patients underwent surgery after the hemorrhages including sutured PCIOL removal with concurrent placement of an anterior chamber IOL (ACIOL) (two patients) and resuturing of a PCIOL in a different meridian (one patient). Follow-up ranged from 4 to 36 months, median 19.5 months, starting from the time of the initial postsuturing vitreous hemorrhage. Final vision ranged from 20/20 to hand motions, with four eyes having 20/40 or better vision. Endoscopy revealed a haptic embedded into the pars plicata in one eye but no evidence of neovascularization.

CONCLUSION

Recurrent vitreous hemorrhage may occur as a complication of scleral suturing of PCIOL. The etiology of these hemorrhages does not appear to be related to neovascular proliferation at the haptic suture site, but may be secondary to erosion of the haptic into uveal structures. Not all eyes require reoperation after these hemorrhages; however, good visual results may be achieved by replacing the sutured PCIOL with an ACIOL or by suturing the PCIOL in a different meridian.

Pars plana suture fixation for intraocular lenses dislocated into the vitreous cavity using a closed-eye cow-hitch technique

We describe a modified intraocular cow-hitch technique for pars plana suture fixation of intraocular lenses (IOLs) that dislocated into the vitreous cavity in 3 patients who had a 3-port vitrectomy and IOL implantation because of retinal disease. To reposition the dislocated IOL after the residual vitreous was removed, 2 additional sclerotomies for suture fixation were made 3.0 mm posterior to the limbus. A loop (cow-hitch knot) was made with 10-0 polypropylene for suture fixation. After the neck of the cow-hitch loop was grasped with an intraocular forceps, the loop was used to lasso a haptic of the dislocated IOL, which was then pulled forward to the sclerotomy. The same procedure was used for the other haptic, and both sutures were secured to the sclera under scleral flaps. In all patients, the dislocated IOLs were repositioned without the need for extraction. The procedures were uneventful. Pars plana suture fixation with the intraocular cow-hitch technique can be used to reposition an IOL that has dislocated into the vitreous cavity.

Subluxation of transscleral sutured posterior chamber intraocular lens (TSIOL)

PURPOSE

To evaluate factors related to late-onset transscleral sutured posterior chamber intraocular lens (TSIOL) subluxation.

METHODS

Retrospective observational case series. Analysis of subluxated TSIOLs in seven eyes from seven patients treated between May 1999 and May 2001.

RESULTS

Mean age at the time of TSIOL surgery was 33 +/- 6 years. Mean time from TSIOL surgery to its subluxation was 78 +/- 19 months. Initial diagnoses requiring TSIOL surgeries were previous history of trauma and Marfan syndrome. Subluxation of TSIOLs was associated with blunt trauma in three eyes, whereas the other four eyes experienced spontaneous lens dislocation.

CONCLUSION

Subluxation of TSIOL is not uncommon in younger patients with history of trauma or Marfan syndrome.

A new technique for suture fixation of posterior chamber intraocular lenses that eliminates intraocular knots

PURPOSE

The aim of this study was to describe a new technique for transscleral suturing of posterior chamber intraocular lenses (PCIOLs) without intraocular knots.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Twenty-four eyes underwent implantation of PCIOLs with this new technique.

METHODS

Suture fixation of PCIOLs was performed in eyes without capsular support.

MAIN OUTCOME MEASURES

The anatomic and functional outcome of surgery was determined during a follow-up of 2 to 40 months.

RESULTS

The PCIOL remained well centered without tilt in 22 of 24 (92%) eyes. The PCIOL was well centered in 16 of 17 (94%) eyes followed for > or =6 months. Complications related to lens suturing were minimal and resolved spontaneously. Final visual outcome depended almost entirely on the underlying health of the retina and optic nerve.

CONCLUSION

This technique eliminates intraocular knots, minimizes operating time with an open globe, and provides excellent lens centration in the absence of capsular support.

Sutureless ciliary sulcus supported intraocular lens with transiridal anchoring haptics

We report a technique for implanting intraocular lenses (IOLs) in the ciliary sulcus in eyes without capsule support. The IOL design allows it to be implanted without fixation sutures. The lens was implanted in 3 aphakic eyes without capsule support.

Intraocular lens implantation in the absence of capsular support: a report by the American Academy of Ophthalmology

OBJECTIVE

This review was conducted to determine the safety and efficacy of open-loop anterior chamber, scleral-sutured posterior chamber, and iris-sutured posterior chamber intraocular lenses (IOLs) in eyes with inadequate capsular support for posterior chamber implantation in the capsular bag or ciliary sulcus. It also attempted to determine whether there is a preferred IOL or fixation site of choice in eyes with inadequate capsular support.

METHODS

A literature search conducted for the years 1980 to 2001 yielded 189 citations related to IOL implantation in the absence of capsular support. An update search, conducted in March 2002, yielded an additional 28 articles. The Anterior Segment Panel members reviewed these abstracts and selected 148 articles of possible clinical relevance for review. Of these, 89 were considered sufficiently clinically relevant for the panel methodologist to review and rate according to the strength of evidence. A level I rating was assigned to properly conducted, well-designed, randomized clinical trials; a level II rating was assigned to well-designed cohort and case-control studies; and a level III rating was assigned to case series. Articles comparing the safety and efficacy of the IOL type and fixation site were further evaluated for the quality of the statistical methods used in the study. Studies with a rating of A or B were considered acceptable, C was borderline, and D and F were considered unacceptable as medical evidence.

RESULTS

Forty-three articles with data concerning outcome of IOL insertion in eyes with inadequate capsular support had an evidence rating of level III or higher and were used in the final review of the safety and efficacy of one or more lens types and/or fixation sites. Seven articles had data about more than one lens type. Six had a statistical method rating of C or higher and were used to evaluate differences in visual outcomes and complication rates between lens types and fixation sites.

CONCLUSIONS

The literature supports the safe and effective use of open-loop anterior chamber, scleral-sutured posterior chamber, and iris-sutured posterior chamber IOLs for the correction of aphakia in eyes without adequate capsular support for placement of a posterior chamber lens in the capsular bag or ciliary sulcus. At this time, there is insufficient evidence to demonstrate the superiority of one lens type or fixation site. Precise determination of small differences in visual outcome or complication rates will require a large prospective, randomized clinical trial.

Histopathologic findings in a transsclerally sutured posterior chamber intraocular lens

A 77-year-old woman had penetrating keratoplasty (PKP), removal of an anterior chamber intraocular lens (IOL), and implantation of a transsclerally sutured posterior chamber IOL for painful pseudophakic bullous keratopathy. Postoperatively, preexisting anterior synechias led to painful secondary angle-closure glaucoma and the eye was enucleated 8 months after the PKP. Light microscopy of the eye revealed that the haptics of the IOL were surrounded by a variably dense fibrous membrane consisting of connective tissue and fibroblasts. In some areas, the haptics had eroded into the superficial stroma of the ciliary body. Except for rare foreign-body giant cells, no inflammatory cells were present near the haptics. This case illustrates that haptics of transsclerally sutured posterior chamber IOLs may be stabilized by fibrous membranes and/or by erosion into the ciliary body relatively soon after implantation. This should be considered if surgical centration, removal, or exchange of such a lens is planned.

Ultrasound biomicroscopy of haptic position after transscleral fixation of posterior chamber intraocular lenses

PURPOSE

To determine the haptic position of ab externo transsclerally fixated posterior chamber intraocular lenses (PC IOLs) by ultrasound biomicroscopy (UBM).

SETTING

Mansoura Ophthalmic Center, Mansoura University, Mansoura, Egypt.

METHODS

Ultrasound biomicroscopy was used to determine the haptic position in relation to the ciliary sulcus, iris, and ciliary body in 20 patients with transsclerally fixated PC IOLs. The patients ranged in age from 10 to 65 years.

RESULTS

All IOL haptics were easily visualized and imaged by UBM. Of the 40 IOL haptics, 22 (55.0%) were located in the sulcus, 11 (27.5%) anterior to the sulcus, and 7 (17.5%) posterior to the sulcus region.

CONCLUSIONS

Ab externo scleral fixation of PC IOLs is a blind procedure in most cases. Ultrasound biomicroscopy showed the difficulty in reliably placing the haptics in the ciliary sulcus using this technique. Thus, endoscopic visualization of the iridociliary angle during surgery is recommended.

Pars plana vitrectomy and sutured posterior chamber lens implantation

Transcleral suturing of posterior chamber intraocular lenses (IOLs) was developed to extend the benefits of IOL visual rehabilitation to eyes lacking capsular support and to avoid the complications of closed loop interior chamber IOLs. Although most frequently implanted after complicated cataract surgery or penetrating keratoplasty, they are indicated in several situations following pars plana vitrectomy. The surgical techniques have evolved to minimize the risk of complications, but the surgery remains technically more demanding and time-consuming than insertion of a modern open loop anterior chamber IOL. No randomized trials have compared the relative risks of each lens type, which leaves surgeon preference as the major determinant of what lens is implanted. It is likely, however, that in eyes with extensive anterior chamber angle damage or large iris defects, sutured posterior chamber IOLs will remain the first choice for surgical rehabilitation.

Tilt and decentration after primary and secondary transsclerally sutured posterior chamber intraocular lens implantation

PURPOSE

To evaluate tilt and decentration after primary and secondary implantation of transsclerally sutured posterior chamber intraocular lenses (PC IOLs).

SETTING

Dokuz Eylül University Medical School, Department of Ophthalmology, Izmir, Turkey.

METHODS

Fifty-six consecutive eyes of 53 patients who had implantation of transsclerally sutured PC IOLs were prospectively included in the study. Intraocular lens tilt and decentration after primary (14 eyes) and secondary (42 eyes) implantation were compared quantitatively using Purkinje images.

RESULTS

The mean IOL tilt was 6.09 degrees +/- 3.80 (SD) in all eyes, 5.71 +/- 3.41 degrees in the primary implantation group, and 6.22 +/- 3.94 degrees in the secondary implantation group. The mean IOL decentration was 0.67 +/- 0.43 mm (range 0 to 2.5 mm), 0.59 +/- 0.38 mm, and 0.69 +/- 0.45 mm, respectively. There were no statistically significant differences between the primary and secondary implantation groups in decentration or tilt. Decentration greater than 1.0 mm was present in 7 eyes (16.7%) after secondary implantation and in 1 eye (7.1%) after primary implantation. Tilting of more than 10 degrees was present in 7 eyes (16.7%) and 2 eyes (14.2%), respectively. There were no statistically significant differences between the 2 groups in decentration greater than 1.0 mm (chi square = 0.194, P =.834) or in tilting greater than 10 degrees (chi square = 0.834, P =.659).

CONCLUSIONS

Clinically significant IOL tilt or decentration was rare after transscleral implantation. There were no differences in tilt or decentration between primary and secondary implantation.

Sutured posterior chamber intraocular lenses: indications and procedure

Intraocular lens (IOL) implantation is the standard of care for treating aphakia when spectacle or contact lens correction is not viable. There is considerable controversy about the relative efficacy and safety of the different IOL implantation approaches, as well as their indications. Since the development of the modern, open-loop anterior chamber IOL (ACIOL) and the re-emergence of the iris-fixated claw IOL, ACIOL implantation for aphakia has regained popularity. However, the posterior chamber IOL (PCIOL)--namely, the capsular-supported PCIOL and, in the absence of capsular support, the iris-sutured or transsclerally sutured PCIOL--offers numerous advantages for certain patients. By virtue of their anatomic location in the eye, capsular-supported or sutured PCIOLs are appropriate for patients with glaucoma, diabetes, cornea guttata or low endothelial cell count, peripheral anterior synechiae, or known or suspected cystoid macular edema. They may also be appropriate when the patient with aphakia is young and has a relatively long life expectancy. The sutured PCIOL procedure--specifically, the transsclerally sutured PCIOL procedure--is far from benign, however, and surgical expertise is an important consideration. Recent surgical and technological advances, including the technique of burying the suture knot in sclera, use of an ab externo suturing approach in the normotonic eye, and the use of intraoperative endoscopy, have improved the accuracy of the transsclerally sutured PCIOL technique. Additional advances, including diagnostic ultrasound biomicroscopy and small-incision surgery with foldable, transsclerally sutured IOLs, may further improve patient management and clinical outcomes.

Endoscopic technique for suturing posterior chamber intraocular lenses

A challenge of the sutured posterior chamber intraocular lens (IOL) technique is to perform blind actions behind the iris. To avoid imprecise transscleral sutures and complications, we use an endoscopic procedure with 2 goals: to control the entry site of the needle penetration and of the haptic location. The endoscopic technique allows retroiris control during transscleral suturing and iridociliary IOL implantation. It is a safe, precise method that avoids the risks of blind procedures behind the iris.

Scleral-fixated intraocular lens implantation in unilateral aphakic children

OBJECTIVE

To assess the feasibility of scleral-fixated intraocular lens (IOL) implantation as an alternative form of optical correction in aphakic children intolerant of contact lenses and whose anterior segments lack capsular support.

DESIGN

Prospective, noncomparative case series.

PARTICIPANTS

A total of 11 eyes of 11 unilateral aphakic children in the age group 4 to 9 years (mean, 6.45 years) were included in the study.

INTERVENTION

Secondary scleral-fixated IOL implantation was performed in all cases. The patients underwent anterior vitrectomy at the time of IOL implantation. Amblyopia therapy in the form of patching was given post-IOL surgery. The follow-up ranged from 4 to 18 months (mean, 10.90 months).

MAIN OUTCOME MEASURES

Postoperative best-corrected visual acuity (BCVA) in comparison to preoperative visual status and complications from the procedure were analyzed.

RESULTS

Postoperative BCVA remained within 1 Snellen line of the preoperative visual status in six eyes, or 54.5% of patients; it improved by more than 1 Snellen line in three eyes, or 27.2% of patients, and decreased by more than 1 Snellen line in two eyes, or 18.1% of patients. The complications encountered were suture erosion through the conjunctiva in two eyes (18.18%), marked postoperative anterior chamber reaction in two eyes (18.18%), IOL decentration in one eye (9.09%), glaucoma in one eye (9.09%), and cystoid macular edema in one eye (9.09%).

CONCLUSION

Secondary scleral-fixated IOL implantation was successful in achieving BCVA comparable to preoperative BCVA. However, a longer follow-up is required to document any further complications.

Scleral fixated (sutured) posterior chamber intraocular lens implantation in children

BACKGROUND

Optical rehabilitation of unilateral aphakia in eyes with no capsular support is problematic in pediatric patients who cannot tolerate contact lenses. Possible options include a unilateral aphakic spectacle, an anterior chamber intraocular lens (IOL), or a scleral fixated posterior chamber IOL. Of these choices the posterior chamber IOL is the most physiologic. Experience in adults shows increased complications with this technique.

OBJECTIVE

The objective of this study was to report the short-term results and complications of unilateral scleral fixated posterior chamber IOLs in the pediatric population.

METHODS

All patients with scleral fixated lenses younger than 16 years were retrospectively reviewed. Nine patients aged 12 months to 15 years underwent unilateral scleral fixated posterior chamber lens implantation using buried polypropylene fixation sutures. Follow-up averaged 24 months.

RESULTS

Postoperative visual acuity improved in all patients. Refractive goals were achieved in all but 1 patient. Complications included elevated intraocular pressure controlled with medications (1 patient), anterior uveitis (1 patient), and mild IOL decentration (1 patient).

CONCLUSIONS

Although short-term visual results appear encouraging, this procedure is technically more difficult and has an increased incidence of postoperative complications when compared with secondary sulcus-fixated IOLs supported by capsular remnants. Caution should be exercised when recommending this procedure for pediatric patients because long-term risks are unknown.

Intraocular lens tilt and decentration, anterior chamber depth, and refractive error after trans-scleral suture fixation surgery

OBJECTIVES

To compare the extent of intraocular lens (IOL) tilt and decentration, as well as the anterior chamber depth after trans-scleral suture IOL fixation after either secondary out-of-the-bag or primary in-the-bag IOL implantation.

DESIGN

Retrospective, comparative, nonrandomized, interventional study.

PARTICIPANTS

Fifty-two eyes that underwent scleral suture fixation were compared with 51 eyes that underwent secondary out-of-the-bag implantation and 50 eyes that underwent in-the-bag implantation.

INTERVENTION

One-piece polymethyl methacrylate IOL implantation by three different techniques.

MAIN OUTCOME MEASURES

The tilt angle and decentration length of the IOL, as well as the anterior chamber depth, were measured by the Scheimpflug videophotography system. The spherical equivalent error from the predicted value was also examined.

RESULTS

The mean tilt angle in the scleral suture fixation group was significantly greater than that in either the out-of-the-bag or the in-the-bag implantation group (P<0.0001). The mean decentration length was also largest in the suture group, followed by the out-of-the-bag group and the in-the-bag group (P<0.0001). The anterior chamber depth in the suture group and the out-of-the-bag group was significantly smaller than that in the in-the-bag group (P<0.0001). The spherical equivalent error in the suture group and the out-of-the-bag group was also greater than that in the in-the-bag group (P<0.0001).

CONCLUSIONS

The extent of both tilt and decentration after scleral suture fixation was greater than that observed after either out-of-the-bag or in-the-bag implantation. The anterior chamber depth with the sutured or out-of-the-bag fixated IOL was shallower than that with the in-the-bag fixated IOL, which resulted in a significant myopic shift.