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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Technique of Phacoemulsification and Intraocular Lens Implantation in Subluxated Cataract Surgery

The purpose of this study was to investigate the effectiveness and practicability of phacoemulsification and intraocular lens implantation for subluxated cataracts. A retrospective review of subluxated cataract surgeries of 19 eyes performed in Kunhua Hospital Affiliated with Kunming University of Science and Technology between January 2017 and June 2021 was conducted. We choose to use the rotate-and-chop phacoemulsification techniques described when the crystal nucleus is rotated out of the capsular bag and simultaneously perform horizontal chops over the capsule. The viscoelastic agent was the important material that filled the capsule to support the capsular bag, and capsular hooks were used in 10 eyes necessarily. Anterior vitrectomy was undergone in 15 eyes. Single-piece intraocular lenses (IOL) were implanted in the capsular bag in 12 eyes including 8 capsular tension ring (CTR) implantation. Three-piece IOLs were fixed scleral layer in 7 eyes. Follow-up was 6 months to 2 years, and all eyes were successfully implanted with centered IOL. The best corrected visual acuity (BCVA) increased from 0.06 ± 0.04 to 0.62 ± 0.15. The cornea of all patients was clear, the intraocular lens was centered, the pupil was round, and the intraocular pressure was normal. Subluxated cataracts are a challenging surgery. The technique of phacoemulsification in subluxated cataract surgery is a key procedure to rotate and remove the lens from the capsule and at the same time horizontal chops and emulsification over the capsular bag to be performed. Viscoelastic agents and capsular hooks were important choices to support the capsule to reduce the incidence of complications related to the vitreous and retina and prevent the range enlarging of the zonular dialysis. A capsular tension ring was also an effective device to maintain capsular stability. Double-needle-guided scleral interlamellar fixation is an effective and practical method for IOL. Overall, the incision technique explored in this study and the surgical technique to support capsular stabilization provide a safe approach and satisfactory results in cataract surgery for subluxation.