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

Ultrasound biomicroscopy in the management of complex cataract and intraocular lens: A review

Ultrasound biomicroscopy (UBM) is an invaluable investigation for imaging anterior segment structures. Although it is operator-dependent and time consuming, unlike optical-based imaging techniques, it is able to image structures posterior to the iris, such as the zonules, ciliary body and part of the pars plana. It is especially useful in advanced cataracts, traumatic cataracts, subluxed lenses, posterior polar cataracts, and congenital and developmental anomalies affecting the anterior segment. It provides diagnostic information in eyes with complex cataracts or intraocular lens (IOL)-related pathology, and aids in surgical planning in order to minimise complications. In this review, we describe the UBM features of various lenticular pathologies and demonstrate its application in the diagnosis and surgical management of lens and IOL-related pathologies.

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 Suture Intraocular Lens Fixation Under Microscope-Intraoperative Optical Coherence Tomography

PURPOSE

The aim of this study was to evaluate the accessibility and potential value of intraoperative optical coherence tomography (iOCT) during scleral suture intraocular lens (IOL) fixation.

METHODS

This was a prospective cohort study in the Department of Ophthalmology, Eye and ENT Hospital, Fudan University, China. Seven eyes with insufficient capsular support and undergoing two-point scleral suture IOL fixation were included. The potential value of iOCT was evaluated, as well as the safety and efficacy of the surgery.

RESULTS

Seven eyes were included. With a tailor-made iOCT, the structure of the anterior segment could be clearly visualized during the surgery. Intraoperatively, iOCT helped locate the proper place for fixation and access the position of the IOL. After an average 4.43-month follow-up, the spherical equivalent changed significantly ( P < 0.001), but the intraocular pressure, best-corrected visual acuity, and endothelial cell density remained unchanged ( P > 0.05). The IOL was well-centered with a horizontal and a vertical tilt of 0.74 ± 0.60° and 1.13 ± 0.65°, and decentration of 0.28 ± 0.12 mm and 0.30 ± 0.13 mm. The estimated IOL-induced astigmatism was -0.11 diopters (D) ± 0.46 D.

CONCLUSION

Real-time high-resolution images of the anterior segment acquired by the iOCT helped the surgeon to achieve satisfactory results in scleral suture IOL fixation.

Intraocular lens implantation with flattened flanged intrascleral fixation technique in pediatric aphakia

PURPOSE

To evaluate the clinical outcomes of flattened flanged intrascleral fixation of the intraocular lens (IOL) in cases of pediatric aphakia without adequate capsular support.

METHODS

The medical records of children who underwent flattened flanged intrascleral IOL implantation for aphakia with insufficient capsular support, subluxated cataract, ectopia lentis, and dislocated IOL were reviewed retrospectively. Best-corrected visual acuity, astigmatism, corneal endothelial cell loss, IOL tilt, and intra- and postoperative complications were evaluated.

RESULTS

A total of 21 eyes of 16 patients were included. Mean patient age at time of surgery was 7.1 ± 3.8 years (range, 2-15). Mean follow-up time after surgery was 2.0 years. The mean pre- and postoperative best-corrected visual acuities were 1.03 ± 0.49 logMAR and 0.33 ±0.44 logMAR, respectively (P < 0.001). The mean preoperative astigmatism was 2.2 ± 0.9 D; and the mean postoperative astigmatism, 1.8 ± 0.8 D. The mean IOL tilt was 3.2° ± 3.1° (range, 0°-10°). The mean endothelial loss was 4.8%. Postoperatively, one of the haptics was partially visible in the scleral tunnel in one eye of a patient with Marfan syndrome.

CONCLUSIONS

In our study cohort, the flattened flanged IOL fixation technique provided good IOL fixation, with firm haptic fixation, without use of sutures or glue.

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

PURPOSE

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

SETTING

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

DESIGN

Retrospective observational case series.

METHODS

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

RESULTS

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

CONCLUSIONS

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

A systematic review of ultrasound biomicroscopy use in pediatric ophthalmology

Ultrasound biomicroscopy (UBM) is the only available option for noninvasive, high-resolution imaging of the intricate iridociliary complex, and for anterior segment imaging with corneal haze or opacity. While these unique features render UBM essential for specific types of trauma, congenital anomalies, and anterior segment tumors, UBM imaging has found clinical utility in a broad spectrum of diseases for structural assessments not limited to the anterior intraocular anatomy, but also for eyelid and orbit anatomy. This imaging tool has a very specific niche in the pediatric population where anterior segment disease can be accompanied by corneal opacity or clouding, and anomalies posterior to the iris may be present. Pediatric patients present additional diagnostic challenges. They are often unable to offer detailed histories or fully cooperate with examination, thus amplifying the need for high-resolution imaging. This purpose of this systematic review is to identify and synthesize the body of literature involving use of UBM to describe, evaluate, diagnose, or optimize treatment of pediatric ocular disease. The collated peer-reviewed research details the utility of this imaging modality, clarifies the structures and diseases most relevant for this tool, and describes quantitative and qualitative features of UBM imaging among pediatric subjects. This summary will include information about the specific applications available to enhance clinical care for pediatric eye disease.

Transscleral sutureless intraocular lens versus retropupillary iris-claw lens fixation for paediatric aphakia without capsular support: a randomized study

PURPOSE

To compare results of sutureless transscleral intraocular lens (IOL) fixation to retropupillary iris-claw lens implantation in cases of paediatric aphakia without capsular support.

METHODS

Thirty eyes of children with insufficient capsular support for IOL implantation were randomized to undergo sutureless transscleral IOL fixation or iris-claw lens fixation. The primary outcome was best-corrected visual acuity (BCVA). Secondary outcomes included operative time, astigmatism, central corneal thickness, endothelial cell count (ECC), IOL decentration and tilt, central foveal thickness and complications.

RESULTS

There was a significant improvement in BCVA at all follow-up visits, with no significant difference between both groups. 53.3% in the transscleral-fixated IOL group and 80% in the iris-claw IOL group had a final BCVA ≥0.3. The operative time was significantly shorter in the iris-claw IOL group (p = 0.001). IOL decentration and tilt were higher in the transscleral-fixated IOL group, but the difference was not significant. The ECC was reduced by 14.6% in the transscleral-fixated IOL group and 11% in the iris-claw group at 6 months, with no significant difference between both groups (p = 0.5). In the transscleral-fixated IOL group, two eyes developed ocular hypertension and two eyes had IOL decentration, while in the iris-claw IOL group, 1 eye developed glaucoma, three eyes had haptic disenclavation, and one eye had retinal detachment.

CONCLUSION

Both techniques yielded a comparable visual outcome. Retropupillary iris-claw lens fixation is a shorter procedure and technically easier than sutureless transscleral fixation, but the risk of disenclavation should be considered especially in younger age groups. Scleral fixation is the only option in case of severe iris damage, but may be associated with more endothelial cell loss.

Observational study of intraocular lens tilt in sutureless intrascleral fixation versus standard transscleral suture fixation determined by ultrasound biomicroscopy

Background

The position of the intraocular lens (IOL) is a major factor that affects the final visual acuity after cataract surgery. However, no prospective study has compared the IOL positions associated with the sutureless intrascleral technique and the standard transscleral suturing technique. The current study compared the IOL positions in the two techniques using ultrasound biomicroscopy (UBM) in vivo.

Methods

Twenty-one eyes of 21 patients were included in this observational study conducted between February and May 2015. Eleven patients underwent the sutureless intrascleral technique, and 10 patients underwent transscleral fixation with suturing. Ophthalmologic examination and UBM were performed in all patients. Optic tilt was measured in relation to the iris plane. The haptic location was defined. Mann-Whitney test and multiple linear regression were used to analyze the vertical and horizontal gradients. Significant differences were considered when p ≤ 0.05.

Results

The most common indication for scleral fixation was a complication during phacoemulsification (81.81% in the sutureless group and 60% in the suture group). The mean vertical and horizontal tilts were, respectively, 0.24 ± 0.21 and 0.25 ± 0.19 mm in the sutureless group and 0.14 ± 0.17 and 0.23 ± 0.16 mm in the suture group. No significant differences were seen in the vertical tilt and horizontal tilt (p = 0.888 and p = 0.148, respectively) between the groups. Gender (p = 0.835), age (p = 0.888), follow-up time (p = 0.915), and surgical duration (p = 0.094) were not associated with optic tilt. Of the 22 haptics in the sutureless group, 21 (95.45%) were in the intrascleral tunnel; of the 20 haptics in the suture group, 13 (65%) were posterior to the ciliary body, four (20%) anterior to the ciliary body, and three (15%) in the ciliary sulcus.

Conclusion

This study showed that there are no significant differences in the IOL positions between the two techniques.

Recommendations for ultrasound examination in ophthalmology. Part I: Ultrabiomicroscopic examination

Range of ultrasounds used in medical imaging is between 2 and 80 MHz. The highest frequencies are applied in medical imaging of an anterior segment of an eyeball. This paper covers the newest method of ultrasound imaging - an ultrabiomicroscopic examination. Its name reflects resolution which has so far been unavailable, and which allows for imaging a structure of the examined tissues. The article includes basic information about the structure and principles of operation of ultrabiomicroscopic examination tools. Moreover, its position among other methods for echographic examination of an eyeball was determined. Examination techniques and the role of standards of conduct at each stage of a diagnostic procedure were discussed. A role of insufficient cooperation between constructors of new ultrasonographic diagnostic tools and software IT specialist with the users of these tools, which results in the lack of consistency between the components of these sets was emphasized. Based on long term experience in ultrabiomicroscopic examinations, the authors shared observations on practical aspects of this method. Finally, indications and contraindications for ultrabiomicroscopic diagnostics were listed. Introduction of an ultrahigh frequency ultrasound probe allowed for the visualization of an post-iridial area of an anterior segment of an eyeball - an area whose diagnosis is impossible with other diagnostic methods. A wide spectrum of diagnostic indications, which covers both diseases and development anomalies of an anterior segment of an eyeball, confirms a special meaning of this method.

Range of ultrasounds used in medical imaging is between 2 and 80 MHz. The highest frequencies are applied in medical imaging of an anterior segment of an eyeball. This paper covers the newest method of ultrasound imaging – an ultrabiomicroscopic examination. Its name reflects resolution which has so far been unavailable, and which allows for imaging a structure of the examined tissues. The article includes basic information about the structure and principles of operation of ultrabiomicroscopic examination tools. Moreover, its position among other methods for echographic examination of an eyeball was determined. Examination techniques and the role of standards of conduct at each stage of a diagnostic procedure were discussed. A role of insufficient cooperation between constructors of new ultrasonographic diagnostic tools and software IT specialist with the users of these tools, which results in the lack of consistency between the components of these sets was emphasized. Based on long term experience in ultrabiomicroscopic examinations, the authors shared observations on practical aspects of this method. Finally, indications and contraindications for ultrabiomicroscopic diagnostics were listed. Introduction of an ultrahigh frequency ultrasound probe allowed for the visualization of an post-iridial area of an anterior segment of an eyeball – an area whose diagnosis is impossible with other diagnostic methods. A wide spectrum of diagnostic indications, which covers both diseases and development anomalies of an anterior segment of an eyeball, confirms a special meaning of this method.

Glued intrascleral haptic fixation of an intraocular lens

Glued intrascleral haptic fixation of an intraocular lens (glued IOL) has evolved as a technique with various modifications that are adopted and practiced by several surgeons. With adequate and appropriate haptic tuck, glued IOL imparts a stable IOL fixation and is a secured method of secondary IOL placement with no pseudophacodonesis.

Endoscopic-Assisted Scleral Fixated IOL in the Management of Secondary Aphakia in Children

Purpose. To evaluate the short-term postoperative outcomes in endoscopic-assisted sclera fixation intraocular lens (IOL) for the management of secondary aphakia in children. Methods. This is a prospective study, whereas 40 aphakic eyes with absence of a good capsular support were implanted by endoscopy-assisted sclera fixation technique. Results. No major intraoperative complications were recorded. All cases were followed up for 6 months. Only transient ocular hypertension occurred in 10 (25%) eyes. Lens decentration and/or tilting were clinically detected in 2 eyes (5%). Ultrasonic biomicroscopic (UBM) examination revealed lens tilting in 2 (5%) of the operated eyes, despite the proper haptics positioning in the ciliary sulcus. Postoperative vitreous hemorrhage was reported in 5 eyes (12.5%) in the early postoperative period and retinal detachment in one eye. A postoperative refractive astigmatism ranging from 0.75 D to 3.75 D (mean 1.7 D ± 0.79) was recorded, as compared to mean preoperative values of 2.00 D, with no statistically significant differences being recorded (p ≥ 0.05). An improvement of BCVA, 1-2 lines on Snellen chart at the end of the follow-up period, was detected in 23 eyes (57.5%) with a mean of 0.6 ± 0.08 SD, as compared to a preoperative mean values of 0.5 ± 0.07 SD (p ≥ 0.05). Conclusion. Using an endoscope for transscleral suturing of intraocular lenses in aphakic pediatric eyes might be considered as being an effective technique that can reduce surgical complications, especially postoperative lens decentration.

Laser iridotomy to treat uveitis-glaucoma-hyphema syndrome secondary to reverse pupillary block in sulcus-placed intraocular lenses: Case series

PURPOSE

To present cases of uveitis-glaucoma-hyphema (UGH) syndrome due to reverse pupillary block in sulcus-placed posterior chamber intraocular lenses (PC IOLs) that were managed with laser peripheral iridotomy (LPI).

SETTING

Community-based subspecialty clinics.

DESIGN

Retrospective interventional case series.

METHODS

A chart review of patients with a sulcus-placed PC IOLs presenting with UGH syndrome and reverse pupillary block with posterior iris bowing as diagnosed by gonioscopy and anterior segment optical coherence tomography was carried out. Laser peripheral iridotomy was performed in the eyes included in the study. The main outcome measure was clinical resolution of UGH syndrome.

RESULTS

The study included 6 eyes of 6 patients with a mean age of 59.8 years (range 43.0 to 66.0 years) who presented with unilateral UGH syndrome a mean of 28.7 months (range 0.3 to 84.0 months) after PC IOL implantation. All patients were previously myopic, with 5 (83.3%) having a history of vitrectomy. The mean axial length was 27.0 mm ± 1.4 (SD). An LPI was used to treat the reverse pupillary block with resultant improvement in iris profile and resolution of UGH syndrome in all eyes. The mean intraocular pressure decreased from 30.5 ± 10.0 mm Hg on 0.5 ± 0.8 glaucoma medications to 15.5 ± 3.2 mm Hg postoperatively on 0.7 ± 1.2 medications.

CONCLUSIONS

The UGH syndrome due to reverse pupillary block occurred after sulcus-placed PC IOLs in susceptible patients, those with axial myopia, and post-vitrectomized eyes. The cases were managed with LPIs.

FINANCIAL DISCLOSURE

Dr. Ahmed is a consultant to Alcon Laboratories, Inc. and Abbott Medical Optics, Inc. No author has a financial or proprietary interest in any material or method mentioned.

Ultrasound Biomicroscopy Comparison of Ab Interno and Ab Externo Intraocular Lens Scleral Fixation

Purpose. To compare ab interno and ab externo scleral fixation of posterior chamber intraocular lenses (PCIOL) using ultrasound biomicroscopy (UBM). Methods. Randomized patients underwent ab externo or ab interno scleral fixation of a PCIOL. Ultrasound biomicroscopy was performed 3 to 6 months postoperatively, to determine PCIOL centration, IOL distance to the iris at 12, 3, 6, and 9 hours, and haptics placement in relation to the ciliary sulcus. Results. Fifteen patients were enrolled in the study. The ab externo technique was used in 7 eyes (46.6%) and the ab interno in 8 eyes (53.3%). In the ab externo technique, 14 haptics were located: 4 (28.57%) in the ciliary sulcus; 2 (14.28%) anterior to the sulcus; and 8 (57.14%) posterior to the sulcus, 6 in the ciliary body and 2 posterior to the ciliary body. In the ab interno group, 4 haptics (25.0%) were in the ciliary sulcus, 2 (12.50%) anterior to the sulcus, and 10 (75.0%) posterior to the sulcus, 4 in the ciliary body and 6 posterior to the ciliary body. Conclusions. Ab externo and ab interno scleral fixation techniques presented similar results in haptic placement. Ab externo technique presented higher vertical tilt when compared to the ab interno.

Sulcus Fixation of Foldable Intraocular Lenses Guided by Ultrasound Biomicroscopy

Background. To evaluate the clinical efficacy of suture fixation of foldable intraocular lens (IOL) in ciliary sulcus guided by ultrasound biomicroscopy (UBM). Methods. Thirty-five eyes of 32 cases needing suture fixation of foldable IOL in ciliary sulcus in our hospital were collected and divided into two groups: group A and group B. In group A, UBM was performed on 19 eyes of 17 cases before surgery to locate the projection position of ciliary sulcus in iris surface. In group B, the traditional sulcus fixation of IOL was performed on 16 eyes of 15 cases. The inserting position of needles, the haptics position of IOL and the IOL tilt, and decentration were observed by UBM examination 3 months after the surgery. Meanwhile, the vision and contrast sensitivity were analysed. Results. The differences in inserting position of the needle, the IOL tilt and decentration, the ratio of IOL haptics in sulcus, and uncorrected visual acuity were statistically significant (P < 0.05). The differences in best corrected visual acuity (BCVA) and contrast sensitivity were not statistically significant (P > 0.05). Conclusions. Sulcus fixation of foldable IOL aided by UBM can increase the accuracy of IOL haptics implanted into ciliary sulcus and reduce the IOL tilt and decentration.

Ultrasound biomicroscopy in chronic pseudophakic ocular inflammation associated with misplaced intraocular lens haptics

PURPOSE

To evaluate the usefulness of ultrasound biomicroscopy in confirming intraocular lens haptic-induced ocular irritation and in the management of these patients.

DESIGN

A retrospective review of patient data.

METHODS

Twenty pseudophakic patients who underwent ultrasound biomicroscopy examination between May 2009 and February 2011 to confirm the clinical suspicion of misplacement of intraocular lens haptics were reviewed. Ophthalmic findings at the time of presentation and at each follow-up visit, and management of each patient, were recorded.

RESULTS

Intraocular lens haptic misplacement was confirmed by ultrasound biomicroscopy in all suspected cases. In 75% of the eyes 1 haptic was embedded in the iris; it extended into the ciliary body process in 35% and into the pars plana in 10%. Focal iris thinning/atrophy was detected by ultrasound biomicroscopy in 15% of cases and focal angle closure in 25%. Intraocular lens exchange was performed in 40% of patients. The remaining 60% were kept under observation, with the addition of topical steroids and/or cycloplegics in eyes that demonstrated anterior chamber inflammation and intraocular pressure-lowering medications in eyes with persistent elevated intraocular pressure or glaucoma.

CONCLUSIONS

Ultrasound biomicroscopy appears to be a valuable tool in confirming the presence of haptic-induced ocular irritation and in assisting the management of these patients.

Explaining The Current Role Of High Frequency Ultrasound In Ophthalmic Diagnosis (Ophthalmic Ultrasound)

Ultrasound has become as indispensable as indirect ophthalmoscopy or slit lamp in evaluation of the eye. It is an important adjuvant for the clinical assessment of a variety of ocular and orbital diseases. Advances in instrumentation, higher frequencies and more sensitivity and resolution have resulted in continuous improvement in image quality.Very high frequency ultrasound uses frequencies in the range of 35 to 100 MHz to show greater detail of the anterior segment. Penetration is limited for these higher frequencies to only a few millimeters and thus only the anterior vitreous behind the ciliary body and lens can be imaged. High frequency ultrasound in the range of 20 to 30 MHz has a penetration of about 10 mm and can be used for posterior pole evaluation of the retina and choroid.

In vivo analysis of glued intraocular lens position with ultrasound biomicroscopy

PURPOSE

To report ultrasound biomicroscopic (UBM) findings of glued transscleral-fixated posterior chamber intraocular lenses (IOLs) in eyes with inadequate capsules.

SETTING

Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India.

DESIGN

Case series.

METHODS

Eyes with glued IOLs for inadequate capsule support were examined with UBM. Optic tilt was measured in relation to the iris plane. Haptic location, iris-IOL contact, vitreous incarceration, and central anterior chamber depth (ACD) were measured and correlated clinically with vision and refractive error.

RESULTS

The mean follow-up was 24.6 months ± 14.3 (SD). Of the 46 eyes, 8 (17.4%) showed optic tilt and 38 (82.6%) showed no optic tilt. Of 92 haptics examined, 85 (92.4%) were in the ciliary sulcus and 7 (7.6%) in the pars plicata. There was no significant association between the presence of optic tilt and haptic location (P=.585, chi-square test). The mean ocular residual astigmatism (ORA) was 0.5 ± 0.2 diopter (D). There was no significant difference in ORA between eyes with tilt and eyes without tilt (P=.079). There was no significant correlation between ORA and IOL position. There was no correlation of optic tilt and postoperative vision or cylinder. Other features included iris-IOL contact (6.5%), vitreous incarceration (5.4%), and ACD difference (P=.002).

CONCLUSIONS

No significant IOL optic tilt affecting the postoperative vision was detected with glued transscleral-fixated IOLs. The technique reliability was good, with the haptics located in the intended position in more than 90% of eyes.

FINANCIAL DISCLOSURE

Dr. Amar Agarwal is a paid consultant to Staar Surgical Co. No other author has a financial or proprietary interest in any material or method mentioned.

[Treatment of pediatric cataracts. Part 2: IOL implantation, postoperative complications, aphakia management and postoperative development]

There is a lot of uncertainty concerning intraocular lens (IOL) implantation for pediatric cataracts. The appropriate age which ocular abnormalities are contraindications and according to which formula IOL should be calculated are controversial. In addition to the imperative of identifying postoperative complications, such as secondary cataract formation and secondary glaucoma in a sufficiently timely manner, a modern management of aphakia with refractive compensation and occlusion is necessary. Some easy rules can help prevent pitfalls.

Glued intrascleral fixation of posterior chamber intraocular lens in children

PURPOSE

To evaluate the short-term results of glued intrascleral fixation of posterior chamber intraocular lens (glued IOL) in children without adequate capsular support.

DESIGN

Noncomparative retrospective observational case series.

PATIENTS

SETTING

Institutional practice.

METHODS

Forty-one eyes of 33 children who underwent glued IOL implantation were retrospectively evaluated. The indications were postsurgical aphakia, subluxated cataract, ectopia lentis, traumatic subluxation, and decentered IOL.

MAIN OUTCOME MEASURES

Visual acuity (VA), endothelial cell changes, intraoperative and postoperative complications.

RESULTS

The mean age at the time of glued IOL was 10.7±3.6 years (range 5-15). The mean duration of follow-up after surgery was 17.5±8.5 months (range 12-36). The mean postoperative best spectacle-corrected visual acuity (BCVA in decimal equivalent) was 0.43±0.33 and there was significant change noted (P<0.001). Postoperatively, 20/20 and >20/60 BCVA was obtained in 17.1% and 46.3% of eyes respectively. BCVA improvement more than 1 line was seen in 22 eyes (53.6%). The mean postoperative refraction was myopic (-1.19±0.7 diopters [D]) in 19 eyes and hyperopic (+1.02±0.7 D) in 22 eyes. The mean endothelial loss was 4.13% (range 1.3%-5.94%). The 3 causes of reduced BCVA were the preexisting corneal, retinal pathology, and amblyopia. Postoperative complications included optic capture in 1 eye (2.4%), macular edema in 2 eyes (4.8%), and clinical decentration in 2 eyes (4.8%). There was no postoperative retinal detachment, IOL dislocation, endophthalmitis, or glaucoma.

CONCLUSION

Short-term results in children after glued IOL were favorable, with a low rate of complications. However, regular follow-ups are required since long-term risks are unknown.

Pars plana vitrectomy with endoscope-guided sutured posterior chamber intraocular lens implantation in children and adults

PURPOSE

To describe a novel method for placement of a sulcus-fixated, sutured posterior chamber intraocular lens (sf-SPC-IOL) using endoscopic guidance during pars plana vitrectomy surgery.

DESIGN

A retrospective case-series by a single surgeon in both pediatric and adult patients undergoing sf-SPC-IOL in the setting of posterior segment surgery.

METHODS

Seventy-four eyes of 71 patients had pars plana vitrectomy and placement of an sf-SPC-IOL in an academic, outpatient setting. Preoperative diagnosis included trauma (42%), subluxated lenses with no capsular support (24%), uveitis (15%), congenital cataract (11%), Marfan syndrome or ectopia lentis (6%), and other (2%). Fifty-one adults and 20 children (<18 years of age) were reviewed from cases performed from 1999 through 2007. The sf-SPC-IOL sutures were placed using endoscopic visualization of ab interno scleral fixation.

RESULTS

The mean follow-up time was nearly 3 years (3 months to 9 years) and most patients experienced an improvement in visual function. Many eyes had advanced posterior segment disorders. Only 2 broken sutures occurred, both attributable to repeat trauma. Advantages of this technique include: excellent visualization and haptic localization, optimal lens centration, buried knots, broad scleral imbrication, and minimal vitreous- and hemorrhage-related complications. Disadvantages include the learning curve, increased operative time, long-term suture stability issues, and limited availability of intraocular endoscopes.

CONCLUSIONS

Endoscopic-guided sf-SPC-IOL using this approach, in the setting of posterior segment disease, is a reasonable option for visual rehabilitation in both pediatric and adult patients.

Ultrasound biomicroscopic analysis of iris-sutured foldable posterior chamber intraocular lenses

PURPOSE

To report ultrasound biomicroscopic (UBM) findings of iris-sutured foldable posterior chamber intraocular lenses (PCIOLs).

DESIGN

Prospective, noninterventional consecutive case series.

METHODS

Fifteen eyes with foldable acrylic IOL implantation using peripheral iris suture fixation in the absence of capsular support were included. UBM was used to determinate the haptic position in relation to the ciliary sulcus and ciliary body in these eyes. Additionally, anterior chamber depth, lens tilt, site of suture fixation, focal iris or angle abnormalities, and relationship of iris to lens were determined. Main outcome measures were haptic position, anterior chamber depth, and iris anatomic changes.

RESULTS

Of the 30 haptics imaged, 16 (53.3%) were positioned in the ciliary sulcus. Nine (30%) haptics were found over the ciliary processes, and 5 (16.7%) were over pars plana. No patients were found to have peripheral anterior synechiae present at the haptic position. The mean (+/- standard deviation) depth of the anterior chamber was 3.84 +/- 0.36 mm. The iris profile was altered in all patients at the iris-haptic suture fixation site. No angle abnormalities or tilted lenses were found.

CONCLUSIONS

Iris-sutured PCIOL haptics were found to be in the ciliary sulcus or over the ciliary body with no significant tilt on UBM analysis. The procedure respects the angle anatomy, and no evidence of angle closure was found. The anterior chamber was deeper than has been reported previously for scleral sutured PCIOLs and was similar to that of pseudophakic eyes. This may have implications for surgical technique, IOL power calculations, and postoperative complications.

Complications of sulcus placement of single-piece acrylic intraocular lenses: recommendations for backup IOL implantation following posterior capsule rupture

PURPOSE

To describe complications arising from sulcus placement of single-piece acrylic (SPA) intraocular lenses (IOLs), evaluate IOL options for eyes that lack adequate capsule support, and examine the appropriateness of various IOL designs for sulcus placement.

SETTING

University and private anterior segment surgery practices.

METHODS

Patients referred for complications of SPA IOLs in the ciliary sulcus from 2006 and 2008 were identified. Demographic information, examination findings, and complications of the initial surgery were recorded. Details of surgical interventions and the most recent corrected distance visual acuity (CDVA) were noted. A thorough review of the literature was undertaken to analyze options for IOL placement.

RESULTS

Complications of sulcus SPA IOLs included pigment dispersion, iris transillumination defects, dysphotopsia, elevated intraocular pressure, intraocular hemorrhage, and cystoid macular edema. Two patients in the series of 30 patients experienced 1 complication; 8 experienced 2 complications; 13 experienced 3 complications; 4 experienced 4 complications; and 2 experienced 5 complications. Twenty-eight eyes (93%) required surgical intervention; IOL exchange was performed in 25 (83%). Postoperatively, the mean CDVA improved, with most eyes attaining 20/20.

CONCLUSIONS

Intraocular lenses designed solely for the capsular bag should not be placed in the ciliary sulcus. Backup IOLs in appropriate powers, sizes, and designs should be available for every cataract procedure. The development, investigation, and supply of IOLs specifically designed for placement in eyes that lack adequate capsule support represent clinically important endeavors for ophthalmology and the ophthalmic industry.

Ultrasound biomicroscopy comparison of ab interno and ab externo scleral fixation of posterior chamber intraocular lenses

PURPOSE

To compare ab interno and ab externo scleral fixation of posterior chamber intraocular lenses (PC IOLs) using ultrasound biomicroscopy (UBM) to determine the centration of IOL optic and the position of the haptics in relation to the sulcus.

SETTING

Kasr Eleini Hospital, Cairo University, Cairo, Egypt.

METHODS

Consecutive patients with aphakia had ab externo or ab interno scleral fixation of a PC IOL. Ultrasound biomicroscopy was used preoperatively to determine whether the eyes were unsuitable for capsule fixation and 3 and 6 months postoperatively, determine the position of the haptics in relation to the ciliary sulcus, and evaluate centration of the optic.

RESULTS

Fifteen eyes of 14 patients were studied. Eight patients had ab externo fixation, and 7 had ab interno fixation. The haptics were located in the sulcus in 31% of cases with ab externo fixation and 29% with ab interno fixation. The difference was not statistically significant.

CONCLUSION

Ab interno and ab externo scleral fixation, which are both blind procedures, resulted in comparable low rates of sulcus fixation.

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.

Ultrasound biomicroscopy characterization of acrylic, silicone, and polymethyl methacrylate lenses in vitro

BACKGROUND

This study aims to characterize the reflective properties of some commonly used intraocular lenses (IOLs) in vitro, with a particular focus on lens haptics.

METHODS

Six different types of IOLs, representative of silicone, acrylic, and polymethyl methacrylate (PMMA), single, multipiece, and multifocal were imaged using high-resolution ultrasound biomicroscopy (UBM).

RESULTS

Reflectivity patterns were distinct to the material that was being imaged irrespective of whether the part being imaged was the haptic or optic. Acrylic haptics demonstrated a single "tram-track" reduplication echo, whereas PMMA haptics showed multiple reverberation echoes off the posterior surface. The optics of various PMMA and acrylic lenses demonstrated a reflectivity pattern similar to the respective haptics made of the same material. Silicone optics displayed clear delineation with no reverberation. Both acrylic and silicone material was relatively less reflective when compared with PMMA.

INTERPRETATION

With UBM imaging, the haptics of acrylic and PMMA IOLs demonstrate unique reflective patterns, depending on the material being studied. Prior knowledge of what the lens haptics and optics look like in vitro provides information that may assist in identifying and localizing misplaced intraocular lenses in vivo.

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.

Ab Externo Technique for Accurate Haptic Placement of Transscleral Sutured Posterior Chamber Intraocular Lenses

A modified technique is presented for transscleral suture fixation of posterior chamber intraocular lenses for aphakic correction in cases with inadequate capsular support. An ab externo approach for suture externalization is described that minimizes intraocular manipulation and facilitates accurate placement of haptics in the ciliary sulcus, thereby reducing the risk of lens tilt and decentration. This technique eliminates intraocular suture knots and reduces the amount of time the globe is open during surgery by creating two intraocular suture loops in preparation for posterior chamber intraocular lens placement before creating a limbal incision.

Iris fixation of foldable intraocular lenses for ectopia lentis in children

PURPOSE

To describe a technique for iris fixation of acrylic intraocular lenses (IOLs) in ectopia lentis and evaluate the medium-term anatomical and functional results in children.

SETTING

Pediatric Ophthalmology Department, Fondation Rothschild, Paris, France.

METHODS

This retrospective study included 17 eyes of 9 children. The technique consisted of lens ablation, leaving in place the capsule in the zone of nonruptured zonule, and an IOL placement in the remaining sulcus with 2 iris sutures. The age of patients, postoperative complications, follow-up, anatomical results, final refraction, and visual acuity were noted.

RESULTS

Median age was 4.8 years. One case of postoperative hyphema and 1 case of aseptic endophthalmitis occurred and resolved after treatment. The anatomical outcome was favorable in all cases, with centered IOLs and round pupils. Mean follow-up was 16.3 months. Mean final refraction was +0.18 diopter, and mean final best corrected visual acuity was 20/32 (range 20/50 to 20/20).

CONCLUSIONS

The results suggest that iris fixation of foldable IOLs for ectopia lentis in children can lead to good anatomical and functional results. The use of the remaining part of the sulcus is helpful in reaching correct positioning of the IOL. The complication rate is similar to that with other techniques described in the literature, whereas the small incision and the absence of transscleral sutures could simplify the short-term and long-term evolution.

Preoperative assessment of secondary intraocular lens implantation for aphakia: a comparison of 2 techniques

PURPOSE

To compare the preoperative evaluation of secondary intraocular lens (IOL) implantation in aphakic adults following cataract extraction in childhood using slitlamp examination and high-frequency ultrasound (HFU).

METHODS

In a prospective case series, patients who had had lensectomies for congenital cataracts without primary implantation IOL were evaluated for secondary IOL insertion. Slitlamp examination and HFU were performed to study the degree of ciliary sulcus support and iridocapsular adhesions. The choice of IOL (posterior sulcus supported or anterior chamber) was compared using the 2 techniques.

RESULTS

Nine eyes of 5 patients (3 men and 2 women aged 15 to 40 years) were assessed for secondary IOL insertion. Clinical slitlamp examination suggested that 3 of 9 eyes had inadequate sulcociliary support, but HFU of these eyes revealed more than adequate capsular remnants. In all 9 eyes, sulcus-supported posterior chamber IOLs were implanted. No postoperative complications were observed, and no patients required surgery for dislocated IOL.

CONCLUSIONS

High-frequency ultrasound is a useful adjunct for the preoperative assessment of secondary ciliary sulcus-supported IOL implantation in aphakic patients who had congenital cataract extraction without IOL implantation. In patients in whom inadequate dilation precludes the detection of capsular support, posterior ciliary sulcus-supported secondary IOL implantation should be considered preoperatively. Although the technique enhances surgical planning and informed patient consent, the final decision occurs at the time of surgery with direct visualization of the ciliary sulcus support.

Anterior segment imaging: ultrasound biomicroscopy

Ultrasound biomicroscopy technology has become an indispensable tool in qualitative and quantitative assessment of the anterior segment. Advances in soft-ware design and algorithms will improve theoretical understanding of the pathophysiology of anterior segment disorders. Future applications of quantitative techniques will yield important information regarding mechanisms of angle closure, improving understanding of the dynamic functions of the iris,accommodation, presbyopia, and other aspects of anterior segment physiology and pathophysiology.

Suture fixation technique for posterior chamber intraocular lenses

We describe a modified method for scleral fixation of posterior chamber intraocular lenses (IOLs). A double-armed, 10-0 polypropylene (Prolene) suture on a curved long needle is passed through a groove in the sclera and retrieved within the barrel of a bent 25-gauge needle through the opposite groove. Double transscleral passages enable 4-point fixation and provide better stability and centration. Knots are buried completely in the scleral groove. In a series of 10 cases, the IOLs were well centered, no sutures protruded from the scleral groove, and the vision in all eyes improved. In 1 case, a ciliary hemorrhage occurred during insertion of the 25-gauge needle, but the bleeding stopped after ocular pressure reform. This technique is easy to perform, improves centration and stability of the IOL, and avoids suture exposure.