Endoscope-assisted transscleral suture fixation of 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.

Endoscopy-guided in vivo evaluation of ciliary sulcus location in children with ectopia lentis

OBJECTIVE

To assess a new method to measure the distance of the needle passage from the ciliary sulcus to the corneal limbus anterior border (CTC) in eyes with ectopia lentis directly in vivo via endoscopy and to further evaluate the correlations among the CTC, age, automated horizontal white-to-white distance (WTW), and ocular axial length (AL).

METHODS

The WTW and AL were measured using an optical biometer. An intraocular endoscope was used during transscleral suture fixation of posterior chamber intraocular lenses to identify the true location of the ciliary sulcus. Linear regression analysis was used to assess the correlation between the CTC and other ocular biological parameters, including age, WTW, and AL.

RESULTS

Thirty eyes of 30 children with ectopia lentis were evaluated. A statistically significant correlation was found between age and the CTC. The CTC could be predicted by the equation CTC = 0.1313 × Age + 0.9666. No statistically significant correlations were found between CTC and WTW, CTC and AL, WTW and AL, or WTW and age.

CONCLUSION

Endoscopy is useful for precisely suturing intraocular lens haptics in the real ciliary sulcus. Age can be used as an equivalent parameter for prediction of the true ciliary sulcus location.

Intraocular endoscopy: A review

Optimal visualization is one of the most challenging aspects of performing vitreoretinal surgery. In situations where conventional microscopic techniques provide poor posterior visualization, the adjunctive skill set of endoscopic visualization may be needed. This allows for by-passing the opaque anterior segment media and getting access to the posterior segment pathology. Endoscopic vitrectomy is a useful and unique adjunct to microincision vitreoretinal surgery. The optical set-up of endoscopy allows for clinical approaches that are impossible with regular microscope viewing systems. These include the ability to observe across optically significant anterior segment opacities and directly visualize the posterior segment of the eye. It also allows for visualizing the difficult-to-access retroirideal, retrolental, and anterior retinal structures. Surgical access to anatomic spaces like the pars plana, pars plicata, ciliary sulcus, ciliary body, and peripheral lens is tedious. This is made simpler by endoscopy. In this review, we summarize and review the usage of the intraocular endoscope as a diagnostic and therapeutic armamentarium across a wide spectrum of ocular pathologies.

Endoscopy-assisted vitrectomy in the anterior vitreous

Endoscopy-assisted ocular surgery is a relatively old technique that is increasingly being recognized for its application in cases of vitreoretinal disease. This technique is especially useful when both the vitreous and retina are difficult to access because of media opacity, a small pupil, or a microcornea. In this context, the anterior vitreous is often difficult to dissect because of its complex pathological changes. This article reviews the common anatomical features and pathologies that are observed in the anterior vitreous, as well as the applications and indications of endoscopy-assisted vitrectomy in the anterior vitreous.

Posterior Chamber Lens Implantation Techniques in Posterior Capsular Rupture

Purpose

To evaluate posterior chamber lens implantation techniques and their results in patients in whom posterior capsular rupture and zonular dialysis arose during cataract operation.

METHODS

Forty-three cataractous eyes of 43 consecutive patients with complicated cataract operations such as posterior capsular rupture or zonular dialysis were accepted into this prospective study between November 1999 and January 2001. Intraocular lens implantation to ciliary sulcus was achieved without sutures in 19 cases (Group 1), with one suture from 12 o'clock quadrant in 14 cases (Group 2), and with two sutures from 3 to 9 o'clock quadrants in 10 cases (Group 3). Patients were followed up for 3 months after operation and evaluated for best-corrected visual acuity, refractive astigmatism, corneal edema, anterior chamber depth and inflammation, synechia at angle, intraocular pressure, lens tilt and decentration, intraocular hemorrhage, cystoid macular edema, and retinal detachment.

Results

There was no difference among groups in best-corrected visual acuity, refractive astigmatism, corneal edema, anterior chamber depth and inflammation, intraocular pressure, lens tilt and decentration, cystoid macular edema, or retinal detachment. Anterior chamber and vitreous hemorrhage and peripheral anterior synechia were significantly higher in Group 3 when compared with Group 1 (p=0.009, p=0.009, and p=0.004).

CONCLUSIONS

In all cases with posterior capsular rupture and zonular dialysis, different posterior chamber lens implantation techniques could be performed, beginning with the least invasive procedure suitable for the conditions with the least complications.

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 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.

Using endoscopy to teach cataract surgery

Current methods of teaching cataract surgery include lectures, wet-lab sessions, and participation in real surgery. We describe a new method using a microendoscopic cyclophotocoagulation device during phacoemulsification cataract extraction and posterior chamber intraocular lens (IOL) implantation in 4 eyes of 4 patients. Endoscopic visualization during surgery aided in construction of the corneal incision, location of the capsulorhexis edge, and estimation of the lens groove depth. It also demonstrated clinical findings not observable with the surgical microscope such as misplaced IOL haptics and residual lens cortex. Use of the endoscope enhanced the educational value of the surgery and the final surgical outcome.

New Endoscopic Technique to Analyze Various Modern Specialized Intraocular Lenses in Research Eyes and Human Eyes Obtained Postmortem

PURPOSE

To describe a new modification of the Miyake-Apple posterior video photographic technique and its 2 variations. We have developed a new endoscopic technique that is especially amenable for observation of modern specialized intraocular lenses (IOLs).

DESIGN

Laboratory study.

PARTICIPANT

Three cadaver eyes obtained postmortem.

METHODS

Human eyes obtained postmortem were prepared according to our modified preparation technique used for analyses of whole globes. An intraocular endoscope was utilized to demonstrate all aspects of the interior of an experimentally implanted IOL, with specialized reference to anterior segment structures, obtaining posterior, oblique, and side view images.

MAIN OUTCOME MEASURES

Different interior dynamic views of the anterior segment structures before and after implantation of an IOL.

RESULTS

High-magnification images of different intraocular structures both before and after device insertion as well as the device itself were obtained. Oblique and side view images from different locations were also available and informative. These images helped to create a 3-dimensional view of these objects and their relations to the surrounding structures.

CONCLUSION

The combination of the intraocular endoscope with the closed-system technique is a useful addition to our 3 previously described techniques: (1) the original Miyake-Apple posterior video/photograph technique and the (2) closed system and (3) side/oblique view (keyhole technique) modifications.

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.

Endoscope-assisted transscleral suture fixation to reduce the incidence of intraocular lens dislocation

PURPOSE

To examine the surgical complications of transscleral sulcus suture of posterior chamber intraocular lenses (IOLs) and to compare the rates of surgical complications between patients in the nonendoscope-assisted and endoscope-assisted groups.

SETTING

Kyoto University Hospital, Kyoto, Japan.

METHODS

This retrospective nonrandomized study comprised 121 eyes of 115 patients who had transscleral sulcus suture fixation of an IOL by the ab externo method. Typical 3-port vitrectomy was performed in 26 eyes in which the needle entry site and the haptic location were controlled using an endoscope.

RESULTS

During follow-up of at least 3 months, surgical complications in the nonendoscope-assisted group (95 eyes) included IOL dislocation in 22 eyes (23%), high astigmatism in 12 eyes (13%), transient ocular hypertension in 10 eyes (11%), vitreous hemorrhage in 5 eyes (5.3%), retinal detachment in 4 eyes (4.2%), and cystoid macular edema in 2 eyes (2.0%). In the endoscope-assisted group (26 eyes), the same complications were markedly decreased: there were no cases of IOL dislocation, high astigmatism, vitreous hemorrhage, retinal detachment, or cystoid macular edema; transient ocular hypertension occurred in 1 eye (3.8%). There was a statistically significant difference in the incidence of IOL dislocation between the 2 groups (P<.01).

CONCLUSION

Using an endoscope for transscleral sulcus suturing of an IOL can be an effective technique to reduce surgical complications, especially postoperative IOL dislocation.

Continuous curvilinear capsulorhexis with use of an endoscope

We describe a technique for creating a continuous curvilinear capsulorhexis (CCC) using an endoscope. Three 2.0 mm limbal incisions 120 degrees apart were made in 4 cadaver eyes. The anterior capsule was stained with trypan blue 0.1% (Vision Blue). Under endoscopic visualization, a CCC was attempted in each of the 4 globes. It was completed in 1 of them. Endoscopy provides a safe and effective tool to visualize the anterior chamber and perform a CCC when there is a poor view through the cornea.

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.

Lens implant selection with absence of capsular support

If contact lens or spectacle correction is not viable, little debate exists that the secondary placement of an intra-ocular lens (IOL) is the method of choice in the absence of capsular support. The choice of IOL mainly depends on the preoperative status of the eye (eg, aphakia in children) and the selected location for the implant. Theoretically, there are several IOL implantation approaches in cases without capsular support: an angle-supported anterior chamber (AC) IOL, an iris-fixated ACIOL, an iris-sutured or iris-fixated posterior chamber (PC) IOL and a transsclerally sutured PCIOL. No consensus exists, however, on the indications as well as on the relative safety and efficacy of these different options. Implantation of modern ACIOLs, like the refined open-loop or iris-fixated claw (toric) ACIOLs, have regained popularity and provide a valuable alternative to sutured PCIOLs. However, in the absence of capsular support, the transsclerally sutured PCIOLs offer numerous advantages for certain eyes. Because of its anatomic location, the sutured PCIOL is more appropriate for eyes with compromised cornea, peripheral anterior synechiae, shallow anterior chamber, or glaucoma. Moreover, sutured PCIOLs are appropriate if the patient with aphakia is young or has a life expectancy of 10 years or more. Recent technological advances, including PCIOL with iris diaphragm for aniridia, toric ACIOLs, and small-incision surgery with foldable, transsclerally sutured IOLs, seem to further improve clinical outcomes.

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.

Haptic design for continuous-loop, scleral fixation of posterior chamber lens

We describe a haptic design for continuous-loop fixation of posterior chamber intraocular lenses (IOLs) to sclera. The haptic ends are broadened to allow two perforations on each haptic through which the sutures are guided. In this manner (satured with continuous loops), a stable four-point fixation is achieved that resists torsional forces, depending only on the mechanical strength of the haptics. Tilt during suture placement can be avoided by inserting the surgical needles and the 27 gauge disposable needles through the sclera at similar angles and distances from the limbus. When tested in a simple experimental model (as well as clinically), the new IOL behaved as predicted. The advantage of this haptic design is a stable, tilt free fixation by a continuous loop that allows the knot to be buried; the disadvantage is that a sophisticated and meticulously executed surgical technique is essential.

Secondary implantation of scleral-fixated intraocular lenses

PURPOSE

To evaluate the results of a large series of secondary implantations using scleral-fixated posterior chamber intraocular lenses (IOLs).

SETTING

Bellevue Eye Hospital, Kiel, Germany.

METHODS

This retrospective review comprised 624 consecutive patients who had secondary implantation of a posterior chamber IOL with scleral fixation between 1988 and 1995. All patients had been aphakic for at least 1 year. An ab interno or ab externo suture technique through the ciliary sulcus was used. Visual outcome and complications 1 year after surgery were determined.

RESULTS

Best corrected visual acuity improved or remained unchanged in 92.0% of eyes; 8.0% lost one or two lines. Intraocular lens decentration of more than 1.5 mm occurred in 1.9% of eyes. Suture erosion was observed in 17.9%, cystoid macular edema in 5.8%, retinal detachment in 1.4%, and vitreous hemorrhage in 1.0%. Severe uveitis occurred in 0.5%.

CONCLUSION

Secondary IOL implantation with scleral fixation was a safe procedure. Although there was a small risk of significant complications, more than 90% of patients regained or improved their preoperative visual acuity.

Scleral suturing of intraocular lenses

This paper describes a simple, safe, and reproducible method for scleral suturing intraocular lenses. The method uses standard tools and equipment.