Epidemiology, Etiology, and Prevention of Late IOL-Capsular Bag Complex Dislocation: Review of the Literature

[Incidence and risk factors of late intraocular lens dislocation]

BACKGROUND

Late intraocular lens (IOL) dislocation is the second most common late complication after successful cataract surgery. It also represents the most common cause of IOL explantations. An increasing incidence of this complication has already been described in the literature since 1995. The aim of this study is to observe the development of the incidence of IOL dislocation within our department over the last 10 years and to identify and evaluate possible risk factors.

MATERIALS AND METHODS

In this retrospective monocentric analysis, a total of 578 eyes of 544 patients, who had undergone surgery for an IOL dislocation within the last 10 years, were included. The presence of myopia, pseudoexfoliation, prior vitrectomy or intravitreal injection (IVI), traumatic events and use of topical prostaglandin therapy were analyzed as possible risk factors.

RESULTS

Since 2017, there has been an increase in the incidence of IOL dislocations (R2 = 0.45). On average, the dislocations occurred 11.7 years after cataract surgery, at an age of 75.6 ± 11 years. Myopia was present in 62% of the patients, of which 40.6% had high myopia. Pseudoexfoliation was documented in 38% of cases. No clear correlations were found for the further analyzed factors, such as prior prostaglandin therapy, IVI or trauma.

CONCLUSION

Due to the increasing number of cataract surgeries, a further increase in the incidence of IOL dislocations is to be expected in the future. The presence of possible risk factors for IOL dislocation and the age of the patient should therefore be taken into consideration prior to indication of cataract surgery and IOL selection.

Comparative Cost Analysis of Secondary Intraocular Lens Surgeries Using Time-Driven Activity-Based Costing

OBJECTIVE

To assess the economics of secondary intraocular lens (IOL) surgeries, with a focus on variations in day-of-surgery costs based on surgical approach and number of surgeons involved.

DESIGN

Retrospective, time-driven, activity-based costing study analyzing costs and reimbursement rates.

SETTING

University of Michigan Kellogg Eye Center, analyzing procedures performed between January 1, 2014, and December 31, 2023.

PARTICIPANTS

Patients undergoing secondary IOL surgeries, including both single- and multi-surgeon cases and procedures without vitrectomy, with anterior vitrectomy, and with pars plana vitrectomy (PPV).

METHODS

Data were obtained from the institution's Electronic Health Record and Revenue Department secondary IOL surgeries (Current Procedural Terminology [CPT] codes 66985 and 66986) performed over 10 years at a single academic institution. Time-driven activity-based costing was applied to calculate the costs associated with each procedure. Primary outcomes were the total cost, reimbursement, and net margins for secondary IOL surgeries. Secondary outcomes were surgical times, time-related costs, and material costs.

RESULTS

A total of 391 cases were included in this analysis over a 10-year period, including 145 without vitrectomy, 56 with anterior vitrectomy, and 190 with PPV. There was no difference in primary or secondary outcome measures between IOL insertion (CPT 66985) and IOL exchange (CPT 66986). The total day-of-surgery costs were $4248.40 to $4447.15 for secondary IOL without vitrectomy, $4245.05 to $4600.36 for secondary IOL with anterior vitrectomy, $5518.52 to $5272.21 for single-surgeon secondary IOL with PPV, and $7769.22 to $8609.39 for multiple-surgeon secondary IOL with PPV. The calculated Medicare reimbursements were $2771.67 to $2901.81 for secondary IOL without vitrectomy, $3005.66 to $3155.75 for secondary IOL with anterior vitrectomy, and $4813.26 to $4861.62 for secondary IOL with PPV. Therefore, the net margins were -($1675.48-$1347.59) for secondary IOL without vitrectomy, -($1444.60-$1239.39) for secondary IOL with anterior vitrectomy, -($704.26-$410.59) for single-surgeon secondary IOL with PPV, and -($3796.13-$2907.60) for multiple-surgeon secondary IOL with PPV.

CONCLUSIONS

All secondary IOL surgeries result in net negative margins with single-surgeon PPV cases having the most favorable reimbursement that covers 87% to 92% of day-of-surgery costs and multiple-surgeon PPV surgeries having the least favorable with only 56% to 63% of costs reimbursed. Identifying these cost-intensive procedures offers insights for potential cost-reduction strategies, supporting both economic viability and patient access to necessary eye care.

Clinical Features, Risk Factors, and Outcomes Following Surgery for Late Intraocular Lens Decentration in the Dead Bag Syndrome

PURPOSE

To evaluate demographic profile, risk factors, and outcomes following intraocular lens (IOL) exchange surgery for late decentration of IOLs in dead bag syndrome DESIGN: Prospective, interventional case series METHODS: This was a study conducted at Raghudeep Eye Hospital, India. Explantation of the decentered/dislocated IOL along with pars plana vitrectomy and intrascleral fixation of a 3-piece foldable IOL using the Yamane technique was performed for all eyes. A total of 46 eyes (43 patients) with late decentration/dislocation of IOLs and spontaneous posterior capsule rupture in a clear and relatively intact capsular bag were treated. None of the eyes had significant zonular weakness. The main outcome measures were demographic profile, associated risk factors, visual outcomes and postoperative complications following IOL exchange in dead bag syndrome.

RESULTS

A total of 30 eyes had in-the-bag IOL decentration and 16 had total dislocation of the IOL into the vitreous cavity. The mean (SD) age was 68.7 ± 8.9 years, and 91% patients were male. Of the patients, 36 had unilateral IOL disease, whereas 7 had bilateral dead bag syndrome, with or without clinically significant IOL decentration. The mean duration from primary cataract surgery to re-operation was 16.8 years. More than 50% eyes had axial myopia (axial length >24 mm). Only 4 eyes (9.3%) had associated pseudoexfoliation. Mean (SD) follow-up after IOL exchange surgery was 10.9 ± 9.8 months. The single-piece hydrophobic acrylic IOL was the most commonly explanted IOL. Intraoperatively, a Soemmering ring was seen in 71.7% (31) eyes. Of the eyes, 87% had an improvement in corrected-distance visual acuity (CDVA) following surgery, with 95% of eyes having a CDVA of ≤0.3 logMAR. Postoperative complications were a transient IOP spike in 8 (17%) eyes and cystoid macular edema in 6 eyes (13%). Three eyes had pre-existing glaucoma, which remained controlled at final follow-up.

CONCLUSIONS

The major risk factors for dead bag syndrome were male sex, axial myopia, and duration of posterior capsule rupture event from the cataract surgery. Bilaterality and presence of the Soemmering ring in the majority of cases were new observations warranting further research. Outcomes following surgery were satisfactory.

Clinical Outcomes Following Suture Fixation of Intraocular Lenses at the University Eye Clinic Freiburg: A Retrospective Analysis

Background: Suture fixation of intraocular lenses (IOLs) is a rare but essential procedure for patients with inadequate capsular support, offering crucial therapeutic benefits. This study analyzes a large cohort of patients undergoing IOL suture fixation, focusing on demographics, risk factors, and clinical outcomes. Methods: In this retrospective analysis of 332 eyes treated at the Eye Center of the University Hospital Freiburg (2008-2022), we evaluated immediate and long-term postoperative outcomes, including visual acuity and refraction. The follow-up averaged 2.5 years. A detailed analysis of the IOL positioning was performed in 111 patients. Results: The most common indications were pseudoexfoliation syndrome (33%), trauma (17%), and prior complicated cataract surgery (11%). The Zeiss CT27SF lens was used most frequently (91%). The mean spherical equivalent deviation from target refraction was -0.375 diopters overall. According to the detailed analysis, IOL tilt occurred in 6.3% of patients, and decentration occurred in 7.2%. Only three patients (3.6%) required additional ocular procedures specifically for IOL repositioning. Risk factors for further surgery included underlying systemic conditions or multiple previous surgeries. Conclusions: Suture fixation of IOLs proves to be an adequate and effective intervention for visual rehabilitation in patients with compromised capsular support, demonstrating good refractive outcomes and low complication rates. Even in cases where the postoperative visual acuity was comparable to the best-corrected preoperative acuity, the procedure improved refractive correction by reducing the need for extensive refractive aids, such as contact lenses required for aphakia.

Levitation of posteriorly dislocated intraocular lens: I.V. catheter connected to the vitreotome aspiration

Background

To introduce a new, simple, and affordable technique that uses a 22G intravenous (I.V.) catheter connected to the vitreotome aspiration to lift the intraocular lens (IOLs) off the retina.

Methods

This retrospective, non-comparative, single surgeon, interventional, consecutive case series examined 4 patients (4 eyes) who underwent the surgical procedure from March 12 and October 22, 2023. Reliability, reproducibility, and intraoperative and postoperative complications of the technique were analyzed.

Results

Four patients presenting with posteriorly dislocated IOLs were included. After a complete 23G vitrectomy under wide-angle viewing system or high magnification contact lens, the 22G I.V. catheter was connected to the vitreotome aspiration and active aspiration was applied. When the IOLs were lifted towards the posterior chamber by continuous vacuum aspiration, they were be safely grasped using intraocular forceps and reposited with scleral fixation suturing or removed through a limbal incision. None of the IOLs fell during active aspiration.

Conclusion

Connection of I.V. catheter with vitreotome aspiration to lift the IOLs off the retina was a new, simple, safe, and affordable technique.

Ocular shape of cataract with retinitis pigmentosa: case-control study

PURPOSE

To investigate the anterior segment morphology in cataracts with retinitis pigmentosa (RP).

SETTING

The Jikei University Hospital.

DESIGN

Retrospective matched case-control study.

METHODS

The analysis included 28 eyes of 28 patients with cataracts and RP and 28 eyes of 28 patients with cataracts but without RP, matched for age and sex. Lens thickness, anterior lens curvature (Front R), posterior lens curvature, anterior chamber depth (ACD), anterior chamber width, central corneal thickness (CCT), white-to-white (WTW) distance, corneal curvature, and axial length (AL) were compared between the groups. Data were obtained from preoperative evaluations conducted before cataract surgery. The same set of comparisons was also conducted for 18 eyes of 18 patients with cataracts and RP and 18 eyes of 18 patients with cataracts but without RP, matched for age, sex, and AL. Cases with missing data, categorized as Emery-Little classification grade 4 or above, or those with a history of acute angle closure were excluded.

RESULTS

In the age and sex-matched analysis, cataracts with RP showed a significantly thicker lens, steeper Front R, shallower ACD, thinner CCT, and shorter AL. In the analysis matched by age, sex, and AL, cataracts with RP had a thicker lens, steeper Front R, and larger WTW distance.

CONCLUSIONS

Cataracts with RP demonstrated centripetal swelling of the lens, centrifugal corneal thinning, and AL shortening. A decrease in tension between the lens and eyeball wall because of zonular weakness in the RP may lead to swelling of the lens and horizontal flattening of the eyeball.

Comparative Functional and Morphological Data of Different IOL Dislocation Treatment Methods

Background: This study compared the visual and morphological outcomes between iris fixation and anterior chamber intraocular lens (ACIOL) implantation for late spontaneously dislocated intraocular lens (IOL)-capsular bag complexes in a tertiary reference center in Lithuania. Methods: A prospective observational study was conducted between 2017 and 2019 involving 80 patients (83 eyes) with late spontaneous IOL-capsular bag dislocation. Patients underwent repositioning and fixation of the dislocated IOL to the iris (IF group) or IOL exchange with an ACIOL implant (ACIOL group). Pre- and postoperative assessments included best-corrected distance visual acuity (BCDVA), intraocular pressure (IOP), corneal endothelial cell density (ECD) and macular thickness (evaluating whether cystoid macular edema (CME) had occurred). Results: Both groups showed a significant improvement in BCDVA, with a more remarkable improvement in the IF group (median: 0.1 logMAR) than in the ACIOL group (median: 0.3 logMAR), p = 0.001. Corneal astigmatism increased significantly in the ACIOL group (p < 0.001) but remained stable in the IF group. IOP management outcomes were better in the IF group as fewer eyes required additional glaucoma treatment. ECD decreased in both groups, but the decrease was significantly greater in the ACIOL group (p < 0.001). Postoperative CME occurred in 4.4% of IF eyes and 39% of ACIOL eyes (p = 0.01). Conclusions: The iris fixation of late dislocated IOL-capsular bag complexes is a safe and minimally invasive technique that offers better visual outcomes, less astigmatism and fewer complications than ACIOL exchange.

Complication rates in cataract surgery before and during the COVID-19 pandemic

OBJECTIVE

To assess the cataract surgery (CS) complication rates before and during the COVID-19 pandemic.

DESIGN

Retrospective, cross sectional study.

METHODS

Medical records of patients undergoing CS at two surgery centers in Winnipeg from January 2018 to April 2022 were reviewed. The study periods were pre-COVID-19 (January 1, 2018 to March 31, 2020) and COVID-19 (April 1, 2020 to April 30, 2022). Complication rates for endophthalmitis, sulcus-positioned intraocular lens (IOL) implant, anterior chamber IOL (ACIOL) implant, capsular tension ring (CTR) insertion, cumulative dissipated phacoemulsification energy (CDE), posterior capsular rupture (PCR), unplanned anterior vitrectomy, and return to the OR within one month of surgery were compared.

RESULTS

45,559 patients were included. Pre-COVID-19 rates were compared to COVID-19 rates and stated as per 100 cataract surgeries. Endophthalmitis rates increased from 0.008 to 0.028 (RR 0.27, p=0.09). Sulcus IOL implant rates increased from 0.61 to 1.00 (RR 0.61, p<0.0001). ACIOL implant rates increased from 0.53 to 0.68 (RR 0.78, p=0.05). CTR usage rates increased from 0.48 to 0.75 (RR 0.63, p=0.001). Average CDE increased from 4.6 to 6.7 (p=0.0030). PCR rates decreased from 0.49 to 0.38 (RR 1.3, p=0.14). Unplanned anterior vitrectomy rates decreased from 0.43 to 0.36 (RR 1.18, p=0.35). Return to OR rates remained unchanged at 0.59 and 0.58 (RR 1.01, p=0.93).

CONCLUSIONS

Our study found significant increases in some CS complication rates when comparing the defined pre-COVID interval to the COVID interval.

Risk and protective factors of late in-the-bag intraocular lens dislocations: systematic review

TOPIC

To identify and review published articles addressing risk and protective factors of late in-the-bag (ITB) intraocular lens (IOL) dislocations.

CLINICAL RELEVANCE

Prevention of this complication is of great importance considering the great number of cataract cases and its vision-threatening capacity.

METHODS

A structured search on PubMed (MEDLINE) using both Medical Subject Headings and key words was conducted. In addition, the reference lists of the resulting articles were screened for further publications. Articles were eligible if they included 20 or more patients. Hazard and odds ratios were analyzed if they were calculated in the original study. The relative frequency of risk factors was recorded if hazard or odds ratios were not available. The threshold for clinical significance was set at 10%. Risk-of-bias in individual studies was evaluated using the revised Cochrane risk-of-bias tool in randomized trials (RoB 2.0) and the Cochrane risk-of-bias in nonrandomized studies of intervention tool.

RESULTS

Database search identified 3474 records, and no further records were obtained from the reference lists. After exclusion of records not related to the topic, 177 articles were assessed for eligibility. Of these, 39 were considered eligible and read in full. 3 studies were prospective, while all other investigations were retrospective. In total, 18 614 cases of late ITB dislocations were analyzed across all studies. The risk of bias within studies was considerable because only 3 studies were prospective and statistical significance of risk factors was assessed in only 5 studies.

CONCLUSIONS

Typical patient age of this condition is between 70 and 85 years, and there seems to be a slight male predominance. Risk factors with a good level of evidence include preoperative trauma and zonular dehiscence, previous vitrectomy, retinitis pigmentosa, pseudoexfoliation, high myopia, glaucoma/previous glaucoma surgery, corneal endothelial damage, and uveitis. Hydrophilic, quadripode, and haptic-angulation IOLs are further risk factors. Capsular tension rings, Nd:YAG capsulotomy, 3-piece IOLs, and IOLs with large optic diameters protect from ITB dislocations. Typically, no risk factors can be identified in approximately one-fourth of patients.

Gonioscopy-assisted transluminal trabeculotomy (GATT) with scleral or iris fixation for subluxated intraocular lenses and glaucoma

INTRODUCTION

This retrospective chart review aims to report a combined surgical approach of intraocular lens (IOL) fixation and gonioscopy-assisted transluminal trabeculotomy (GATT) for the treatment of subluxated IOLs and glaucoma or ocular hypertension.

METHODS

Charts of patients who underwent IOL fixation combined with GATT between November 2019 and July 2023 were reviewed. The main outcome measure was surgical success, defined as a well-centered IOL and an IOP of 18 mmHg or lower and either a 30% IOP reduction or a reduction in medications as compared to baseline. Complications and the need for reoperation were recorded.

RESULTS

Eleven patients who underwent GATT with IOL fixation were included. The mean age was 80.45 years (range: 73-90). IOL subluxation was associated with pseudoexfoliation in all cases. Seven patients underwent scleral fixation, and four underwent iris fixation. The mean follow-up was 15.36 (range: 2.7-26.6) months. The success rate was 72.73%. The mean baseline IOP was 20.63 ± 6.56 mmHg on 2.81 ± 1.53 medications. Four patients were on oral carbonic-anhydrase inhibitor (CAI) before surgery. The mean IOP at the end of the follow-up was 13.86 ± 3.5 mmHg on 1.36 ± 1.57 medications, and none were on oral CAIs. No intraoperative complications occurred, and transient hyphema and vitreous hemorrhage were the most common postoperative complications. All patients had a well-centered IOL. No patients needed additional surgery for IOL position or IOP control. The mean corrected distance visual acuity was 0.634 ± 0.62 logMAR at baseline and 0.36 ± 0.38 at the end of follow-up.

CONCLUSIONS

GATT can be combined with IOL fixation to the sclera or iris to effectively reduce IOP and medication usage.

Factors predicting redislocation or suture break in eyes after scleral-fixated intraocular lens

PURPOSE

To investigate predictive factors for redislocation in patients with recurrent intraocular lens (IOL) dislocation after secondary scleral-fixated IOL (SF IOL) surgery.

SETTING

2 tertiary referral hospitals.

DESIGN

Retrospective case series.

METHODS

Patients undergoing SF IOL surgery were grouped into redislocation and no-redislocation groups. Medical records of consecutive patients who underwent SF IOL surgery between June 2014 and December 2019 at 2 tertiary referral centers were reviewed. Data regarding patient demographics, treatment factors, anatomical and functional outcomes, and postoperative complications were recorded.

RESULTS

237 eyes of 225 patients (169 [75.1%] men) were included. The redislocation group was more likely to have a younger mean age at the initial SF IOL surgery (redislocation vs no-redislocation, 55.4 vs 62.0 years, respectively; P = .008), have a prior history of a previous suture break (23 eyes, 52.3% vs 1 eye, 0.5%; P < .001), and have undergone the initial SF IOL surgery using <1 mm-sized side-port incisions (17 eyes, 38.6% vs 32 eyes, 16.5%; P = .002) than was the no-redislocation group. In addition, the redislocation group had a higher occurrence of complications ( P < .001). Multivariate regression revealed that younger age, left eye involvement, aphakic status before the surgery, unremarkable primary IOL dislocation cause, need for ocular hypertension treatment and glaucoma surgery, and no large incision during the initial surgery were significantly (all P < .05) associated with redislocation.

CONCLUSIONS

Younger age, left eye involvement, postoperative complications such as ocular hypertension and glaucoma, and techniques without large incisions increase the risk of redislocation. Conversely, lower risk factors include unremarkable surgery causes and a history of aphakic conditions.

Effectiveness of prophylactic capsular tension ring implantation during cataract surgery in highly myopic eyes

PURPOSE

To assess the effectiveness of prophylactic capsular tension ring (CTR) implantation during cataract surgery in highly myopic eyes.

SETTING

Eye and Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China.

DESIGN

Prospective cohort study.

METHODS

Consecutive highly myopic patients treated with cataract surgery were recruited and randomized to undergo CTR implantation or not. The outcomes compared between the 2 groups included axial lens position (ALP), intraocular lens (IOL) decentration and tilt, area of anterior capsule opening, severity of anterior capsular opacification (ACO), and posterior capsular opacification (PCO) at 1 year postoperatively.

RESULTS

A total of 55 highly myopic eyes with CTRs implanted and 55 without were included in the analysis. At 1 year postoperatively, no significant differences were detected between the CTR and non-CTR groups for the mean ALP, IOL decentration, or tilt (all P > .05). However, the CTR group had a significantly larger area of anterior capsule opening (23.62 ± 3.30 mm2 vs 21.85 ± 2.30 mm2, P = .003), and less severe ACO (P = .033) and PCO (PCO-3 mm: 0.06 ± 0.13 vs 0.13 ± 0.20, P = .038; PCO-C: 0.15 ± 0.18 vs 0.25 ± 0.26, P = .026) than the non-CTR group. The corrected distance visual acuity, prediction error, and higher-order aberrations did not differ between the 2 groups (all P > .05).

CONCLUSIONS

In highly myopic eyes, although prophylactic CTR implantation can reduce the severity of capsular contraction and opacification, it does not significantly affect postoperative IOL stability or visual outcomes.

Clinical outcomes of iris fixation and sutureless scleral fixation of dislocated foldable posterior chamber intraocular lenses

PURPOSE

Explore the visual outcome and complications of iris fixation intraocular lenses (IFIOL) and sutureless scleral-fixated intraocular lenses (SSFIOL) in the surgical management of patients without exchanging dislocated posterior chamber intraocular lenses (PCIOLs) in the vitreous.

METHODS

Retrospectively, 14 IFIOL and 15 SSFIOL reimplantations for dislocated PCIOLs were analyzed. Mean follow-up of reIFIOL group and reSSFIOL group: 11.3±2.0 (range: 9-15) months and 11.8±2.2 (range: 9-16) months, respectively. Preoperative and postoperative outcomes, operative indications, and complications were evaluated.

RESULTS

Primary surgical indications were pseudoexfoliation (PXE) (21.4%), post-cataract surgery (PCS) (35.7%), trauma (42.8%) in the reIFIOL group, and PXE (26.6%), PCS (40%) trauma (33.3%) in reSSFIOL group, respectively. At the latest follow-up, there was an improvement in best-corrected visual acuity (BCVA) (0.053±0.051 to 0.53±0.13, P<0.0001) in reIFIOL group and (0.05±0.02 to 0.64±0.16, P<0.0001) in reSSFIOL group. Postoperative complications of reIFIOL group and reSSFIOL group included corneal edema (14.2%; nil), IOP elevation (21.4%; 7.1%), bullous keratopathy (14.2%; nil), anterior uveitis (35.7%; 13.3%), cystoid macular edema (CME) (21.4%; 7.1%), pupil ovalization (21.4%; nil), broken haptic (none; 13.3%), IOL exchange (nil; 13.3%), and vitreous hemorrhage (nil; 14.2%).

CONCLUSIONS

Self-dislocated IOL reimplantation may enable much earlier visual rehabilitation in the reSSFIOL group than in the reIFIOL group. Moreover, the 27G trocar-assisted reSSFIOL technique takes a shorter operation time and relatively lower complication rates. However, further prospective studies with larger series and longer follow-up periods are required.

Complications of high myopia: An update from clinical manifestations to underlying mechanisms

Background

High myopia is one of the major causes of visual impairment and has an ever-increasing prevalence, especially in East Asia. It is characterized by excessive axial elongation, leading to various blinding complications that extend beyond mere refractive errors and persist immovably after refractive surgery, presenting substantial public health challenge.

Main text

High myopia-related complications include lens pathologies, atrophic and tractional maculopathy, choroidal neovascularization, peripheral retinal degenerations and retinal detachment, and glaucoma and heightened susceptibility to intraocular pressure (IOP) elevation. Pathological lens changes characteristic of high myopia include early cataractogenesis, overgrowth of lens, weakened zonules, and postoperative capsular contraction syndrome, possibly driven by inflammatory pathogenesis, etc. Dome-shaped macula and cilioretinal arteries are two newly identified protective factors for central vision of highly myopic patients. These patients also face risks of open-angle glaucoma and IOP spike following intraocular surgery. Morphologic alternations of optic nerve in high myopia can complicate early glaucoma detection, necessitating comprehensive examinations and close follow-up. Anatomically, thinner trabecular meshwork increases this risk; conversely lamina cribrosa defects may offer a fluid outlet, potentially mitigating the pressure. Notably, anxiety has emerged as the first recognized extra-ocular complication in high myopia, with an underlying inflammatory pathogenesis that connects visual stimulus, blood and brain.

Conclusions

High myopia induces multiple ocular and potential mental health complications, underscoring the need to develop more effective strategies to improve both physical and emotional well-being of these patients, among which anti-inflammation might possibly represent a promising new target.

Short-term outcomes of implanting a retropupillary iris-claw intraocular lens in patients with lens and intraocular lens drops

Lens drop and intraocular lens (IOL) drop can occur after cataract or phacoemulsification surgery, where the IOL is dislocated from the capsular bag into the vitreous cavity. The aim of this study was to investigate the short-term outcomes of implanting a retropupillary iris-claw in patients with IOL drop and lens drop after phacoemulsification. A cross-sectional study was conducted at Santosa Hospital, Bandung, West Java, Indonesia, from January 2020 to December 2023. Patients were divided into two groups: IOL drop and lens drop groups. Total sampling was used, involving 51 patients in the present study, with 27 patients in the IOL drop group and 24 patients in the lens drop group. Data collected included age, sex, eye laterality, the onset of IOL drop or lens drop, intraocular pressure (IOP), uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), record of astigmatism change preoperative and postoperative, and postoperative pars plana vitrectomy (PPV) complications. Our data indicated that the UDVA significantly improved in both IOL drop and lens drop groups after PPV surgery (p<0.001). However, there were no significant changes in IOP or astigmatism following the surgery in either group. Over one month, both groups showed improved UDVA, decreased IOP, and changes in astigmatism, with no significant differences between groups. Similarly, there was no significant difference in CDVA between IOL drop and lens drop groups. Only four complications were recorded in the present study. Comparing IOL drop and lens drop groups, only an increase in IOP showed a significant difference (p=0.018). Corneal edema, IOL decentration, and pupil ovalization were not significantly different. In conclusion, retropupillary iris-claw IOL implantation is safe and effective for aphakic patients with complications from phacoemulsification, regardless of whether it is lens drop or IOL drop.

Dislocated 4-haptic intraocular lens rescue with Gore-tex suture scleral re-fixation

BACKGROUND

Dislocated IOL exchange conventionally involves manipulation within the anterior chamber which risks secondary injury to anterior chamber structures. We describe and evaluate a 4-haptic IOL rescue technique that avoids entering the anterior chamber and thus minimizes post operative inflammation, astigmatism and recovery time relative to conventional IOL explantation and replacement techniques.

METHODS

Retrospective, non-randomized, interventional study of all patients undergoing 4-haptic IOL rescue performed by two independent vitreoretinal surgeons at a single UK centre over two years.

SURGICAL TECHNIQUE

A limited peritomy is performed with four 25-gauge scleral ports placed to enable use of two forceps, an infusion and a chandelier. A further four 27-gauge sclerotomies are symmetrically placed on the nasal and temporal sclera at 3 mm from the limbus with a 5 mm vertical separation on either side. A pars plana vitrectomy is performed followed by chandelier illuminated, bimanual cleaning of the dislocated IOL using 27-gauge serrated forceps. Gore-tex sutures are threaded through the IOL islets within the vitreous cavity and externalized through the sclerotomies for scleral re-fixation followed by conjunctival closure.

RESULTS

Seven patients underwent IOL recycling with Gore-Tex suture scleral re-fixation. All procedures were successful in repositioning the IOLs, with all patients satisfied with post-operative outcome. Mean (standard deviation) time to IOL dislocation was 13 (3) years. Median visual acuity significantly improved post-operatively from 0.85 logMAR (Interquartile Range [IQR]: 0.2-2.1) to 0.07 (0.02-0.60) logMAR (p = 0.02). No significant post-operative complications were noted apart from persistent cystoid macular oedema in one patient non-compliant with post-operative treatment.

CONCLUSIONS

Transscleral refixation using Gore-Tex suture is an effective, safe and practical approach in the management of dislocated 4-piece IOLs.

Background factors determining the time to intraocular lens dislocation

PURPOSE

To clarify the characteristics of intraocular lens (IOL) dislocation requiring IOL suture or intraocular scleral fixation.

METHODS

This retrospective consecutive case series included 21 eyes (21 patients) who required sutured or sutureless intrascleral IOL fixation following IOL extraction owing to IOL dislocation at the outpatient clinic in the Department of Ophthalmology, Saitama Red Cross Hospital, Japan, between January and December 2019. Medical records were retrospectively reviewed for background diseases, location of the dislocated IOL (intracapsular/extracapsular), insertion of a capsular tension ring (CTR), and the period from IOL insertion to dislocation.

RESULTS

We included 21 eyes of 21 patients who required IOL suture or intrascleral fixation for IOL dislocation at our clinic from January to December 2019 were included. The most common background disease was pseudoexfoliation syndrome (four cases), followed by atopic dermatitis, dysplasia/dehiscence of the zonule, post-retinal detachment surgery, high myopia, and uveitis (three cases each). At the time of dislocation, the IOLs were either intracapsular (16 cases, including 3 cases with CTR insertion) or extracapsular (5 cases). The time from IOL insertion to IOL dislocation was 13.7 ± 8.1 years (maximum: 31.3 years, minimum: 1.7 years).

CONCLUSIONS

In this study, all 21 cases represented late IOL dislocations occurring after 3 months postoperatively. Among these late IOL dislocation cases, IOL dislocation occurred in a short-medium period of time, especially in those with CTR insertion and weakness/dehiscence of the zonule, with an average of 3 to 5 years postoperatively. We propose referring to these cases as intermediate-term IOL dislocation.

Clinical and anatomic correlates of objectively measured zonular dehiscence in 427 postmortem pseudophakic eyes

OBJECTIVE

This study aims to objectively measure the degree of zonular dehiscence in postmortem eyes and to assess for clinical and anatomic correlates.

DESIGN

Cross-sectional study.

MATERIALS

Four hundred and twenty-seven postmortem pseudophakic human eyes.

METHODS

Eyes were obtained from the Lions Gift of Sight Eye Bank. Microscope photographs were taken of the eyes in Miyake-Apple view, and region-of-interest analysis was performed using ImageJ to measure the area, circumference, and diameter of the capsular bag, the ciliary ring, and the capsulorhexis. Clinical and anatomic parameters were assessed using simple linear regression analysis and one-way analysis of variance with post hoc Bonferroni testing. Zonular dehiscence was measured via 2 surrogates: capsule area over ciliary ring area ratio (CCR) and capsule-ciliary ring decentration (CCD). Low CCR and high CCD indicate more zonular dehiscence.

RESULTS

CCR was significantly inversely correlated with smaller capsulorhexi (p = 0.012), lower intraocular lens power (p < 0.00001), younger age at death (p = 0.00002), and a longer cataract-to-death time (p = 0.00786). CCR also was significantly lower in glaucomatous cases (p = 0.0291). CCD was significantly correlated with longer cataract-to-death time (p = 0.000864), larger ciliary ring area (p = 0.001), more posterior capsule opacification (p = 0.0234), and higher Soemmering's ring opacity (p = 0.0003). There was also significantly more decentration in male eyes than in female eyes (p = 0.00852).

CONCLUSIONS

CCR and CCD are novel measures of zonular dehiscence in postmortem eyes, with many interesting correlates. An enlarged ciliary ring area is possibly associated with zonular dehiscence in pseudophakic eyes and may be a quantifiable surrogate in vivo.

Impact of anterior capsule polishing on capsule opacification and capsule bend after age-related cataract surgery

PURPOSE

To investigate the effect of anterior capsule polishing on postoperative capsule opacification and capsular bend in patients with age-related cataract displaying normal axial length.

SETTING

Eye Hospital of Wenzhou Medical University at Hangzhou.

DESIGN

Prospective self-controlled trial.

METHODS

Patients with age-related cataracts aged 56 to 84 years displaying normal axial length were enrolled. Before surgery, a coin-toss method was used to randomly select 1 eye for intraoperative 360 degrees anterior capsule polishing (polishing group); the contralateral eye received no treatment (control group). Capsular bend index (CBI), anterior capsule opacification (ACO), posterior capsule opacification (PCO), and anterior capsule opening area (ACOA) were recorded at 1 week, 1 month, 3 months, 6 months, and 12 months postoperatively using swept-source optical coherence tomography and slitlamp examination.

RESULTS

21 patients (42 eyes) were enrolled. Within-group comparisons showed that both groups had significant differences in CBI between 1 week and 1 month postoperatively, and between 6 months and 12 months postoperatively ( P < .05). Between-group comparisons revealed a significant difference in CBI at 1 week postoperatively ( P < .05); at 12 months postoperatively, there was a significant difference in ACOA ( P < .05). There were no significant between-group differences regarding ACO or PCO at any timepoint ( P > .05).

CONCLUSIONS

For patients with age-related cataracts and normal axial length, 360 degrees anterior capsule polishing can delay early capsular bag deformation without increasing the risks of ACO and PCO. This approach can also limit contraction of the anterior capsule opening.

Clinical Outcomes in Scleral Fixation Secondary Intraocular Lens with Yamane versus Suture Techniques: A Systematic Review and Meta-Analysis

Background: The purpose of the study is to compare the visual outcomes and complications of sutured scleral fixation (SSF), a traditional and conservative surgical approach, and the newer and faster Yamane technique for secondary intraocular lens placement. Methods: A literature search was performed on PubMed, Embase, and Scopus on studies published between 1 July 2017 to 29 September 2023. Outcomes analyzed included the final best corrected visual acuity (BCVA) between 3 and 12 months to assess the effectiveness of the procedure, post-operative month (POM) 1 BCVA to assess the speed of visual recovery, endothelial cell count (ECC), absolute refractive error, surgical duration, and complication rates. Additional subgroup analyses were performed based on surgeon experience with the technique. Single-surgeon studies had an average of 26 procedures performed, whereas multiple-surgeon studies averaged only 9 procedures performed; these were then used to delineate surgeon experience. A sample-size weighted mean difference (MD) meta-analysis was performed across all variables using RevMan 5.4.1; p < 0.05 was considered statistically significant. Results: Thirteen studies with 737 eyes were included: 406 eyes were included in the SSF group, and 331 eyes were included in the Yamane group. There was no significant difference in the final BCVA between groups in both the single-surgeon versus multiple-surgeon studies (MD = -0.01, 95% CI: [-0.06, 0.04], p = 0.73). In the single-surgeon studies, the BCVA at POM1 was significantly improved in the Yamane group compared to SSF (MD = -0.10, 95% CI: [-0.16, -0.04], p = 0.002). In the multiple-surgeon studies, there was no significant difference in BCVA at POM1 (MD = -0.06, 95% CI: [-0.16, 0.04], p = 0.23). The Yamane group had a shorter surgical duration than SSF in both single-surgeon and multiple-surgeon studies (MD = -24.68, 95% CI: [-35.90, -13.46], p < 0.0001). The ECC, refractive error, and complication rates did not significantly differ amongst all groups. Conclusions: The Yamane technique demonstrated similar long-term visual outcomes and complication rates to the traditional SSF. Visual recovery was significantly faster in the Yamane group in the single-surgeon studies. The operative times were shorter across all Yamane groups. Based on these findings, it is advisable to consider the Yamane technique as a viable, and perhaps preferable, option for patients requiring secondary IOL placement, alongside traditional SSF methods.

Novel trocar assisted intraocular lens and capsular bag complex fixation

PURPOSE

To describe the innovative technique of trocar-assisted intraocular lens (IOL) and capsular bag complex fixation.

METHODS

In this technique, initial pupil dilatation is achieved either with intracameral adrenaline or with the help of iris hooks. Automated anterior vitrectomy is performed in cases with vitreous prolapse. A 25 G trocar cannula is placed at the limbus through a paracentesis opposite the zonular dialysis area. The cannula lumen act as a guide to pass the double-arm polypropylene suture attached to the needle. This prevents any inadvertent corneal injury and acts as a perpendicular tract to pass the needle through IOL capsular bag complex.

RESULTS

We performed this technique in 9 cases with an excellent outcome with a minimum of 3 months of follow-up. All patients had well-centred IOL. There was no incidence of corneal injury, Descemet membrane detachment, iris trauma, IOL tilt, decentration, dislocation, vitreous prolapse or retinal detachment. All patients achieved excellent visual acuity ranging from 6/12-6/6 postoperatively.

CONCLUSION

The novel trocar-assisted IOL bag complex fixation technique is very effective and allows smooth IOL fixation in technically challenging cases with IOL subluxation. The trocar acts as a guide to prevent injury to the surrounding tissue, and IOL fixation is achieved with minimal manipulations in the anterior chamber. It also prevents the need for IOL explantation in these cases.

Late spontaneous posterior capsule rupture with single-piece hydrophobic acrylic intraocular lens dislocation

In this study, we described and discussed the late onset spontaneous posterior capsule rupture with intraocular lens (IOL) dislocation years after uncomplicated cataract surgery and implantation of hydrophobic acrylic IOLs. Eight patients presented with spontaneous posterior capsule rupture and IOL dislocation 5-20 years after uncomplicated phacoemulsification and IOL (AcrySof, Alcon, US) implantation. None of the patients had undergone posterior capsulotomy in the past. Four of the patients admitted habitual eye rubbing. An intact and well-centered continuous curvilinear capsulotomy edge was observed in all cases. IOLs were dislocated or displaced behind the anterior capsulotomy with a significant decrease in vision. A large rupture with a curled edge of the broken posterior capsule was visible. Dislocated IOLs were removed, and a three-piece IOL was inserted in the sulcus in six cases and suture fixated to the sclera in two cases. Improved vision was achieved in all cases. Although the mechanism underlying this late complication is unclear, habitual eye rubbing or IOL design may play a role. Further investigation is needed to prevent this complication in the future.

A mini-invasive surgical technique for Carlevale IOL implantation: case series study and description of concomitant surgery

PURPOSE

To examine the feasibility and outcomes of a modified technique for the implantation of scleral fixated Carlevale intraocular lens (IOL) (I71 FIL SSF. Soleko IOL Division, Pontecorvo, Italy), and to analyze the occurrence of adverse events.

METHODS

This is a retrospective observational study conducted revising patients charts from 2018 to 2023. Thirty-five eyes of 33 patients were included. Patients requiring IOL explantation had either IOL dislocation or opacification. The implantation of the Carlevale IOL was performed with the subconjunctival positioning of the anchors without any scleral flap. All maneuvers were performed transconjunctivally. The anatomical outcomes considered were IOL positioning, and the absence of postoperative complications. The functional outcomes analyzed were best correctedvisual acuity (BCVA) and refraction.

RESULTS

In all the cases, the IOL was well positioned and centered postoperatively. No cases of conjunctival erosion were recorded. The best corrected visual acuity (BCVA) was 0.9±0.6 logMar (mean±standard deviation) preoperatively and 0.5±0.5 logMar (mean±standard deviation) postoperatively. The mean preoperative spherical equivalent was +6.8±7.7 dioptres, while postoperatively it was -1.1±1.6 dioptres. The most frequent procedure associated to secondary IOL implantation was posterior vitrectomy (25 eyes, 71.4%), which was performed with 25-gauge transconjunctival cannulas in the ciliary sulcus. The follow-up period was 24.5±16.9 months (mean±standard deviation).

CONCLUSION

The described mini-invasive technique for Carlevale IOL implantation is safe and effective. It can be recommended either as a stand-alone operation or associated to concurrent surgical procedures.

Fluid Supplementation Through Weakened Zonules via Side-Port Incision to Maintain Intraocular Pressure in High Myopic Eyes

INTRODUCTION

During phacoemulsification, the infusion pressure can cause the liquefied vitreous fluid to escape through the ciliary fiber interspace in highly myopic eyes, leading to reduced vitreous cavity pressure similar to vitrectomized eyes. This study assessed the probability of low intraocular pressure (IOP) in high myopic eyes with different axial length (AL) group undergoing cataract surgery, as well as the impact of balanced salt solution (BSS) supplementation and the optimal IOP value for such supplementation.

METHODS

The control group consisted of cataract eyes with normal AL (group 1: 22 mm ≤ AL < 24.5 mm), while cataract eyes with high axial myopia were categorized into three groups (group 2: 26 mm ≤ AL < 28 mm, group 3: 28 mm ≤ AL < 30 mm, group 4: AL ≥ 30 mm). IOP was measured using the iCare pro tonometer intraoperatively. BSS supplementation was performed to raise IOP in cases of low IOP, before intraocular lens (IOL) implantation and before the end of surgery. The probability of low IOP was calculated, and the IOP before and after supplementation were compared.

RESULTS

Ninety-five eyes were included. The total probability of low IOP in groups 2, 3, and 4 was 56.52, 62.50, and 70.83%, respectively, significantly higher than that in group 1 (16.67%). Similarly, the probability of low IOP before IOL implantation was significantly higher in groups 2, 3, 4 (43.48, 41.67, and 62.50%) compared to group 1 (4.17%, P < 0.05). The IOP before and after the first BSS supplementation in three high myopia groups were statistically significant (P < 0.05), increasing from 12.10 mmHg (range, 6.0-24.9 mmHg) to 16.60 mmHg (range, 10.2-34.4 mmHg). After the second BSS supplementation before the end of surgery, the IOP of high myopia groups increased from 12.60 mmHg (range, 7.0-25.3 mmHg) to 14.60 mmHg (range, 9.8-25.3 mmHg).

CONCLUSIONS

The condition of highly myopic eyes seems more likely to develop low IOP during cataract surgery. There is an observed correlation: as AL increases, the total probability of low IOP rises. In patients with IOP < 9.5 mmHg intraoperatively, fluid supplementation via a side-port incision can effectively raise IOP to about 16 mmHg before IOL implantation and about 14 mmHg after incision sealing, facilitating smoother IOL implantation and reducing the risk of postoperative low IOP.

TRIAL REGISTRATION

NCT, NCT05201677. Registered 23 November 2021-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05201677 .

Four-Point Flange Intrascleral Fixation With Double Suture Through the Dislocated Plate-Haptic Trifocal Intraocular Lens

PURPOSE

To describe a technique for the replacement of dislocation of plate-haptic trifocal intraocular lens (IOL) through double-suture 4-point flange intrascleral fixation.

DESIGN

Retrospective, interventional, noncomparative, case series.

METHODS

A total of 7 eyes of 7 patients with a dislocated plate-haptic trifocal IOL were enrolled for 4-point flange intrascleral fixation with double 7-0 polypropylene suture. Preoperative and postoperative visual acuity, operating time, refractive results, postoperative IOL tilt and decentration, and intraoperative and postoperative complications were recorded.

RESULTS

The mean postoperative uncorrected distance visual acuity (UDVA) was 0.05 ± 0.06 logarithm of the minimum angle of resolution (logMAR). The mean postoperative uncorrected intermediate visual acuity (UIVA) at 80 cm was 0.09 ± 0.06 logMAR and the mean postoperative uncorrected near visual acuity (UNVA) at 40 cm was 0.06 ± 0.07 logMAR. The mean postoperative residual spherical equivalent values were -0.27 ± 0.39 diopters. The visual function index-14 questionnaire showed that no difficulty was found in >80% of subjects for all tasks. The mean surgical time was 16.23 ± 5.64 min. The mean tilt of IOL was 3.74° ± 1.31° and the mean decentration of the IOL was 0.18 ± 0.09 mm. No important complications appeared.

CONCLUSION

We have described the technique of 4-point flange intrascleral fixation for plate-haptic trifocal IOL.

Clinical Experience of Two Sutureless Intrascleral Fixation Techniques for Secondary Intraocular Lens Implantation

INTRODUCTION

The aim of this study was to evaluate the outcome of the modified Carlevale intraocular lens (IOL) fixation technique, using two different vitrectomy ports (23- vs. 27-gauge) as anchor fixation.

METHODS

Retrospective, consecutive study of 282 eyes (282 patients) who underwent a secondary IOL implantation using the Carlevale IOL (Soleko IOL Division, Italy) with two anchor haptics for intrascleral implantation with either 23- or 27-gauge (G) port.

RESULTS

Transient post-operative ocular hypotonia (intraocular pressure ≤5 mm Hg) was observed less in the 27-G group (13 vs. 4 patients, p = 0.057) three requiring additional tunnel sutures (2 cases for 23-G; 1 case 27-G). Post-operative vitreous haemorrhage was recorded more often in the 23-G group (8 vs. 1 patient, p = 0.034), but all cases in both groups resolved without intervention. Visual acuity did improve post-operatively in the two groups. No post-operative complications such as retinal detachment, endophthalmitis, and IOL-dislocation tilt were observed in the follow-up.

CONCLUSION

The 27-G modified technique for sutureless intrascleral implantation is simple and effective and causes less post-operative hypotony.

Aetiology and Management of IOL Dislocations

Early (< 3 months) intraocular lens (IOL) dislocation occurs due to insufficient fixation in the capsular bag, while late dislocation (≥ 3 months) is due to increasing insufficiency of the zonular apparatus. Iris-fixated IOL (IFIOL) and suture- or sutureless-fixated scleral IOL (SFIOL) are currently the most commonly used methods when IOL exchange is indicated. Different methods of scleral fixation with or without sutures have been described. The most important techniques are summarised in this paper. IFIOL and SFIOL allow comparable visual outcomes but differ in their risk profile. The decision of which method to use should be made case by case and in accordance with the surgeon's preference.

A Novel Multi-Observation System to Study the Effects of Anterior Ocular Inflammation in Zinn’s Zonule Using One Specimen

Zinn’s zonule is a fragile and thin tissue, and little is known about its pathogenesis. The aim of this study was to develop an experimental setup for a comprehensive analysis of Zinn’s zonule. Rats were divided into two groups: a control group (n = 4) and an alkali injury group (n = 4). Seven days after injury, the eyes were enucleated, the anterior eye was dissected and embedded in gelatin, and macroscopic observations were made. The gelatin specimens were then embedded in paraffin and observed in detail by low-vacuum scanning electron microscopy, immunofluorescence, and quantitative reverse transcription polymerase chain reaction (RT-qPCR). The results show qualitative changes in Zinn’s zonules in both macroscopic and microscopic observations. In addition, macrophage infiltration and increased matrix metalloproteinase 2 (MMP2) expression were observed in the injured group, consistent with the RT-qPCR results. The experimental system in this study allowed us to capture the morphological and molecular biological changes of Zinn’s zonule and to gain insight into its pathogenesis. In conclusion, this study presents a new experimental setup for the comprehensive analysis of the rat Zinn’s zonule. The results suggest that this system can be used in the future to study and analyze a variety of paraffin-embedded tissues and specimens.

Zonular and capsular bag disorders: a hypothetical perspective based on recent pathophysiological insights

The purpose of this article was to look at the pathophysiology behind and devise a classification system for the causes of zonular apparatus-capsular bag (ZACB) insufficiency. Also discussed is dystrophic bag syndrome, including clinical cases and addressing where it lies on the ZACB spectrum. There has been interest in the emergence of in-the-bag intraocular lens (IOL) subluxation, the prevalence of which is increasing. There has also been a recent report of dead bag syndrome, which the authors believe is part of the same disease spectrum. The authors put these phenomena into perspective and provide a classification system based on the possible causes of what they have termed ZACB insufficiency. The basic aspects of capsular bag-IOL ocular pathophysiology are summarized with a focus on functional aspects and the consequences for IOL fastening. Within this framework, dystrophic bag syndrome is a form of primary capsular ZACB insufficiency. The contribution of factors such as intraocular drugs may suggest a reconsideration of agents used and their mode of application.

Sudden Gross Visual Deterioration: Importance of Examining the Whole Eye

A 75-year-old caucasian female presented with sudden severe visual deterioration in one eye reduced from 6/9 to counting fingers (CF), with second eye reduction in vision from 6/9 to CF three months later. Past medical history included a background of proliferative diabetic retinopathy, uncontrolled blood pressure, and a 44-year history of poorly controlled type 1 diabetes mellitus (T1DM). Previous ocular history included bilateral pan-retinal photocoagulation for proliferative diabetic retinopathy, followed by bilateral vitrectomies, with subsequent bilateral cataract surgery with intraocular lens implants. A diagnosis of anterior ischemic optic neuropathy (AION) was thought to be the most likely diagnosis due to sudden visual loss, pale discs, and previous long-term history of diabetes and blood pressure with variable control in the absence of a raised erythrocyte sedimentation rate (ESR). However, at the time of the second eye visual loss, the inferior peripheral retina examination revealed bilateral pseudophakic intraocular lens dislocations. With spectacle correction of +11.50/-1.00 x 75 right eye and +11.50/-1.00 x 65 left eye, her visual acuities were 6/12 right eye and 6/9 left eye, and subsequent secondary intraocular lens insertion was planned. This case highlights the importance of a careful review of the whole eye to ensure that remediable causes of visual loss are not missed.

Sutureless scleral fixation Carlevale IOL: a review on the novel designed lens

Background: Complicated cataract surgery is the main cause of secondary lens implantation surgery. Several approaches have been introduced to face those circumstances. As it concerns scleral-fixated IOLs for the posterior chamber, many types of IOL can be implanted. The aim of article is to review the single piece sutureless scleral fixation Carlevale lens; Methods: Narrative review; Results: Several works described as safe the IOL implantation utilizing the handshake approach, without tactile manipulation, which allows for self-centration and lens firm fixation in uncomplicated surgery. This allows to reduce high order aberration such as astigmatism and coma, with a very good postoperative BCVA Conclusions: Carlevale lens is one of the best option to manage insufficient capsular support.

Intraocular lens dislocation: manifestation, ocular and systemic risk factors

PURPOSE

The aim of this study was to evaluate ocular and systemic risk factors for posterior chamber intraocular lens dislocation, as well as forms of manifestation.

METHODS

A retrospective case-control study were all patients presented in the period 2012-2016 having intraocular lens dislocation and being treated with implantation of an iris-fixated intraocular lens was conducted at the University Hospital Mainz. As controls, pseudophakic patients presenting for other reasons were included.

RESULTS

150 eyes of 150 patients (mean age 72.7 ± 12.4 years, range 24-93 years) with IOL dislocation and 150 eyes of 103 controls were included in this study. The average time between primary implantation and IOL luxation was 86 months (iQR: 39.25-127 months) for all dislocations. Previous pars plana vitrectomy (PPV) (crudeOR = 2.14 (95% CI 1.23, 3.72), p = 0.011) and PEX (crudeOR = 11.6 (4.79, 28.12), p < 0.001) was linked with a higher risk of IOL luxation. Luxation occurs also earlier in patients with previous PPV and PEX than in eyes with neither PEX nor previous PPV (82.2 vs. 127 months). Rhegmatogenous retinal detachment was the major pathology that required a previous PPV for eyes with an IOL dislocation (57%). The average time between PPV and IOL dislocation was 74.67 months (range 0-186 months).

CONCLUSION

Patients with a coexistence of both: PEX and a previous PPV had an elevated risk of IOL dislocation, and also had a shorter time interval between primary IOL implantation and IOL dislocation followed by eyes with PEX only and eyes with only a previous PPV.

Review of primary posterior capsulorhexis in cataract surgery

This article reviews the history and technique of primary posterior capsulorhexis with emphasis on anterior hyaloid membrane preservation and combined posterior optic capture of intraocular lenses into Berger's space for the purpose of lens stability and secondary cataract elimination among other potential advantages. Applications, variations, efficacy, and safety of the procedure are reviewed.

Influence of IOL Weight on Long-Term IOL Stability in Highly Myopic Eyes

Purpose

This study aimed to investigate the influence of intraocular lens (IOL) weight on long-term IOL stability in highly myopic eyes.

Materials and Methods

A total of 205 highly myopic cataract eyes of 205 patients implanted with the MC X11 ASP (Group A, 86 eyes) or 920H IOL (Group B, 119 eyes) were included in this retrospective study. Eyes were divided into 3 subgroups according to the IOL power: low (≥-5 to <5 D), medium (≥5 to <14 D), and high (≥14 D) IOL power. At 3 years after surgery, IOL decentration and tilt, high-order aberrations, and anterior capsular opening (ACO) area were measured. The influence of IOL weight on long-term IOL stability was evaluated.

Results

Group B had a significantly greater IOL weight than Group A (Group B vs. Group A: 28.31 ± 2.01 mg vs. 25.71 ± 4.62 mg, P < 0.001). Correspondingly, Group B presented significantly greater overall and inferior decentration than Group A, especially for low and medium IOL power (all P < 0.05). In both groups, overall and vertical decentration was significantly correlated with IOL weight (all P < 0.05). Group B showed a significantly greater ACO area than Group A (P < 0.05). Multivariate analysis showed that decentration in Group A was affected by IOL weight, while decentration in Group B was affected by IOL weight and AL.

Conclusions

Higher IOL weight may lead to greater long-term IOL decentration in highly myopic eyes, while the haptic design may play a role in anterior capsular contraction.

Retropupillary Iris Fixation of an Artisan Myopia Lens for Intraocular Lens Dislocation and Aphakia in Eyes with Extremely High Myopia: A Case Series and a Literature Review

Introduction

To describe the outcomes of retropupillary iris fixation of an iris claw Artisan Myopia intraocular lens (IOL), and to review literature on retropupillary iris fixation of iris claw models for myopia for the correction of aphakia and IOL dislocation in eyes with extremely high myopia.

Methods

Single-center, retrospective case series. Three patients (three eyes) with pathological myopia underwent retropupillary iris fixation of the iris claw Artisan Myopia model 204 for the correction of aphakia and IOL dislocation. After IOL power calculation, we found that the Artisan Aphakia IOL was not available for these patients. One patient had a history of previous extracapsular cataract extraction and two patients exhibited IOL–bag complex dislocation. The target lens power was calculated using ultrasound biometry and the Sanders–Retzlaff–Kraff theoretical and T2 formulae, with an A-constant of 103.8. All surgeries were performed by a single surgeon. Visual outcomes were assessed at 12–48 months after surgery.

Results

The mean axial length was 34.33 ± 0.21 mm. The power of the implanted Artisan IOLs ranged between − 4.00 and − 3.00 diopter. The corrected distance visual acuity, measured in logarithm of the minimum angle of resolution units, improved after surgery in all eyes, from 0.60 ± 0.36 logMAR before surgery to 0.40 ± 0.43 logMAR after surgery at 12 months postoperatively and remained stationary thereafter. There were no postoperative complications.

Conclusions

Retropupillary iris fixation of Artisan Myopia IOLs may be a safe and effective surgical treatment option for the correction of aphakia and IOL dislocation in patients with extremely high myopia.

Visual and refractive outcomes following secondary intraocular lens implantation

PURPOSE

To analyze the visual and refractive results after secondary IOL implantation using different surgical techniques - iris-claw aphakic IOL through a corneal incision or scleral tunnel, and 3-piece IOL into the ciliary sulcus.

PATIENTS AND METHODS

Retrospective study including patients that were submitted to secondary IOL implantation from January 2017 to December 2019 at the Department of Ophthalmology of Hospital de Braga, Portugal. We collected demographic data (age, surgical indication, comorbidities, surgical technique, IOL implanted, and intra and postoperative complications) and visual and refractive data [preoperative and 3-month, 6-month, and 12-month postoperative corrected-distance visual acuity (CDVA), spherical equivalent (SE), manifest cylinder, and intraocular pressure].

RESULTS

128 eyes from 123 patients were included. The most frequent surgical indications were IOL subluxation/luxation (62.5%) and intraoperative posterior capsular rupture (23.4%). CDVA improved from 1.26 ± 0.51 to 0.47 ± 0.49 logMar (p < .001). CDVA was significantly better in the 3-piece into the ciliary sulcus IOL group than both other groups. The final SE was -0.68 ± 0.94 diopters. The mean manifest refractive cylinder remained stable until the 6th month after the surgery (p = .454) and improved in the last 6 months of follow-up (p = .015). In the postoperative period, the cylinder was higher in the corneal incision iris-claw aphakic IOL group and lower in the 3-piece IOL into the ciliary sulcus group (p < 0,05). The corneal incision iris-claw aphakic IOL group presented the most postoperative complications.

CONCLUSION

All techniques showed satisfying results. The 3-piece IOL into the ciliary sulcus group showed the best visual and refractive performance, followed by the scleral tunnel iris-claw IOL group and the corneal incision iris-claw IOL group.

Correlation between neutrophil-to-lymphocyte ratio and clinical manifestations and complications of retinitis pigmentosa

PURPOSE

The role of inflammation in retinitis pigmentosa (RP) has been receiving additional attention. However, the association between inflammation and the clinical manifestations and complications of RP is still unclear. This study aimed to evaluate the neutrophil-to-lymphocyte ratio (NLR) of RP complicated with cataract and explore the correlations between the NLR and specific clinical features of RP.

METHODS

This retrospective study included 79 RP patients complicated with cataract (125 eyes) and 63 age- and sex-matched patients (63 eyes) with age-related cataract (ARC). Patients' ocular examination results were collected and complete blood count results were used to calculate NLRs. The correlations between the NLR of RP patients and the parameters of ocular examinations were analysed.

RESULTS

The NLRs of RP patients with cataracts were significantly higher than those of ARC (1.93 ± 0.83 versus 1.65 ± 0.59, p = 0.029). The NLRs increased with the severity of posterior subcapsular cataract (PSC), zonular deficiency, poor preoperative best-corrected visual acuity (LogMAR>1), and visual field defects. Analysis of receiver operating characteristic curves suggested that NLR > 1.36 could predict higher degrees (PSC area >3%, >P1) of PSC (p = 0.002, 95% CI, 0.672-0.934), and that NLR > 2.12 could predict zonular weakness (p = 0.002, 95% CI, 0.665-0.928) in RP.

CONCLUSION

The NLRs in RP patients with cataract are not only higher but also associated with several clinical manifestations of RP. The NLR can be a predictive biomarker of higher degrees of PSC (>P1) and zonular weakness in RP before cataract surgery. These results suggest that systemic inflammation may play a role in the pathogenesis of RP.

Intrascleral Intraocular Lens Fixation Preserving the Lens Capsule in Cases of Cataract with Insufficient Zonular Support

Purpose

To report our modified simple technique for optic capture and the clinical results of intrascleral IOL fixation preserving the lens capsule, without vitrectomy, in cases of cataract with insufficient zonular support to stabilize the intraocular lens (IOL).

Patients and Methods

In 37 eyes of 25 patients with phacodonesis and two or more risk factors for progressive zonular insufficiency, we inserted a CTR to support the capsule and zonules during cataract surgery and IOL fixation; an optic was inserted into the lens capsule, and a haptic was fixed in the scleral tunnel without vitrectomy. In all cases, anterior or total vitrectomy was not needed.

Results

The postoperative mean (± standard deviation) tilt and decentration of the implanted IOL did not change from 6 to 12 months (6.77 ± 3.15° to 6.33 ± 3.38° and 0.60 ± 0.30 to 0.61 ± 0.35 mm, respectively). We encountered no late IOL dislocation and no retinal complications, including retinal breaks or cystoid macular oedema, postoperatively (follow-up = 21.1 ± 5.2 months).

Conclusion

Our modified techniques preclude the need for vitrectomy. If the lens capsule can be preserved using a CTR, our modified technique can be used to stabilize IOL.

Risk factors for fluctuations in corneal endothelial cell density (Review)

The cornea is a transparent, avascular and abundantly innervated tissue through which light rays are transmitted to the retina. The innermost layer of the cornea, also known as the endothelium, consists of a single layer of polygonal endothelial cells that serve an important role in preserving corneal transparency and hydration. The average corneal endothelial cell density (ECD) is the highest at birth (~3,000 cells/mm²), which then decrease to ~2,500 cells/mm² at adulthood. These endothelial cells have limited regenerative potential and the minimum (critical) ECD required to maintain the pumping function of the endothelium is 400-500 cells/mm². ECD < the critical value can result in decreased corneal transparency, development of corneal edema and reduced visual acuity. The condition of the corneal endothelium can be influenced by a number of factors, including systemic diseases, such as diabetes or atherosclerosis, eye diseases, such as uveitis or dry eye disease (DED) and therapeutic ophthalmological interventions. The aim of the present article is to review the impact of the most common systemic disorders (pseudoexfoliation syndrome, diabetes mellitus, cardiovascular disease), eye diseases (DED, uveitis, glaucoma, intraocular lens dislocation) and widely performed ophthalmic interventions (cataract surgery, intraocular pressure-lowering surgeries) on corneal ECD.

Enhanced surgical technique for sutureless intrascleral fixation of intraocular lenses

A simplified intrascleral fixation technique involving implantation of the Carlevale intraocular lens (IOL) in the posterior chamber is described, which lodges the T-shaped IOL haptics in the scleral wall, not requiring scleral flaps. This surgical modification reduces operative time, limits iatrogenic damage to the sclera, and avoids friction between haptics and the conjunctiva, which may cause conjunctival erosion and infection in the long term. 13 patients with crystalline lens or IOL dislocation/subluxation had surgery to implant the Carlevale IOL in the posterior chamber. Mean corrected distance visual acuity preoperatively was 0.75 ± 0.5 logMAR (range, 0.2 to 1.5 logMAR) and improved to 0.28 ± 0.3 logMAR (range, 0 to 1.0 logMAR) postoperatively. Complications rarely occurred and were not sight-threatening. The sutureless scleral fixation of the Carlevale IOL using the modified surgical technique may represent a safe and effective procedure to restore visual function in patients with damaged zonular-capsular support.

Introduction of longstanding complicated sulcus intraocular lens into the intact capsular bag

AIM

To propose a surgical technique that successfully reopened the empty and intact capsular bag after long periods of closure, with repositioning of the intraocular lens (IOL) from the ciliary sulcus into its preferred habitat inside the capsular bag.

METHODS

This is a case series, prospective, and interventional study. The technique was first performed on an aphakic high myope with a closed posterior capsule for 18y. Afterwards, five patients with recurrently displaced sulcus IOLs for a range of 1mo to 7y were performed for the same technique. During surgery, identifying a "telltale white line" was an important landmark for detecting the site of major adhesions between the edge of the capsulorhexis and the posterior capsule. These adhesions were freed using combined manual and viscoelastic dissection, followed by an easier freeing of adhesions along the whole capsular bag. The IOL was safely implanted, exchanged, or introduced from the sulcus into the fibrotic and closed capsular bag. Patients were followed up for a period ranging from 6 to 17mo postoperatively.

RESULTS

All the patients experienced a remarkable improvement in their subjective refraction. Slit lamp examination showed a postoperative centralized IOL in the bag. The follow up visits confirmed visual and IOL stability.

CONCLUSION

This newly-introduced surgical technique facilitates the reopening of the empty yet intact capsular bag that has been closed by fibrotic proliferations, with secured implantation of the IOL inside the capsular bag. Patients with inadvertent implantation of IOLs into the ciliary sulcus, yet having an intact capsular bag, can benefit from this technique.

Late Nontraumatic Anterior Dislocation of Intraocular Lens with Complete Capsular Phimosis in Retinitis Pigmentosa

Intraocular lens (IOL) dislocation is an unusual but serious complication after cataract surgery. We are here to report a rare case which is nontraumatic IOL dislocated and prolapsed into the anterior chamber in a retinitis pigmentosa (RP) patient. Zonular weakness and capsular contraction are considered to be the main contributing factors of IOL dislocation in RP patients. Patients at risk should be recognized and managed accordingly intraoperatively or postoperatively.

CYSTOID MACULAR EDEMA AFTER FOUR-POINT SCLERAL FIXATION OF INTRAOCULAR LENS

PURPOSE

To assess the incidence of cystoid macular edema (CME) associated with 4-point Gore-Tex suture intraocular lens (IOL) scleral fixation, before and after institution of routine intravitreal triamcinolone acetonide prophylaxis and long-term topical nonsteroidal anti-inflammatory drug usage.

METHODS

Consecutive patients were included after IOL implantation with concurrent pars plana vitrectomy for spontaneous IOL dislocation due to pseudoexfoliation syndrome. We compared short-term prophylactic nonsteroidal anti-inflammatory drugs only (Group A) to prophylactic intravitreal triamcinolone acetonide and long-term nonsteroidal anti-inflammatory drugs (Group B).

RESULTS

Twenty-six eyes of 26 patients with pseudoexfoliation syndrome and spontaneous IOL dislocation were studied. Mean logMAR visual acuity improved from 1.27 ± 0.80 (20/375 Snellen equivalent) preoperatively to 0.46 ± 0.39 (Snellen 20/43) postoperatively (P < 0.001). Visual outcomes were similar for Groups A and B. In Group A, 10/16 eyes had CME, 4/16 had chronic CME longer than 6 months, and 1 longer than 12 months. In Group B, 1/10 had CME (which was both chronic and refractory).

CONCLUSION

In eyes with pseudoexfoliation syndrome and spontaneous IOL dislocation, 4-point Gore-Tex suture IOL ab externo fixation yielded good visual outcomes, although CME was observed more than reported elsewhere. Prophylactic intravitreal triamcinolone acetonide and long-term nonsteroidal anti-inflammatory drugs seem to reduce the risk of postoperative CME.

Outcomes of Re-fixation after the First Intraocular Lens Scleral Fixation

Purpose: To investigate the outcomes of re-fixation after the first intraocular lens (IOL) scleral fixation. Methods: We retrospectively reviewed the charts of patients who underwent second IOL scleral fixation and vitrectomy for dislocation of IOL after the first IOL scleral fixation. We compared the best-corrected visual acuity (BCVA) and spherical equivalent (SE) after 1 month of the first and second surgery, and noted the complications. Results: We included 21 eyes that underwent second IOL scleral fixation: 13 eyes (61.9%) with IOL exchange and eight (38.1%) with one-haptic fixation. Mean BCVAs (LogMAR) were 0.17 ± 0.25 and 0.11 ± 0.23 after the first and second surgery, respectively (<i>p</i> = 0.073); mean SEs were -0.94 ± 1.69 and -0.58 ± 1.46 diopters after the first and second surgery, respectively (<i>p</i> = 0.076). Postoperative complications occurred in eight eyes (38.1%), including temporarily increased intraocular pressure and suture knots exposure. However, none of the complications required re-operation. Conclusions: The outcomes of primary and secondary IOL fixation were similar, and there were no serious complications of the second surgery.

One Year Outcomes and Stability of a Novel Scleral Anchored Intraocular Lens

Purpose

To assess one year results and stability of the implantation of a scleral anchored intraocular lens (IOL).

Design

Interventional prospective case series.

Methods

Sixty eyes of 60 patients affected by either aphakia or IOL dislocation were included in this study. Patients underwent vitrectomy, scleral fixation of the IOL, and, if present, dislocated IOL removal. Patients were evaluated preoperatively and at 1, 3, 6, and 12 months after surgery by best-corrected distance visual acuity (BCVA) assessment, intraocular pressure (IOP) measurement, corneal specular microscopy, and optical coherence tomography (OCT) of both the macula and anterior segment.

Results

At twelve months, mean BCVA significantly improved (p < 0.0001), and none of the patients experienced a decrease of visual acuity. A 10% decrease of endothelial cell count occurred after surgery. Cystoid macular edema occurred in three patients (5%). A transient increase of intraocular pressure was noted in 7 cases (12%). At one month, horizontal and vertical IOL tilt was 1.04 ± 0.87 and 0.74 ± 0.71 degrees, respectively, and did not significantly change in the follow-up (p > 0.05). None of the patients had decentration or dislocation of scleral-fixated IOL during the follow-up.

Conclusion

Implantations of scleral plug fixated IOL provide good visual results, low complication rate, and excellent stability of the lens until one-year follow-up.

Case Report: Diagnosis of Late Spontaneous Intraocular Lens Dislocation on Point-of-care Ultrasound

INTRODUCTION

Spontaneous intraocular lens (IOL) dislocation is a rare, but serious, complication following cataract surgery.

CASE REPORT

We report a case of patient with a remote history of cataract surgery presenting to the emergency department with monocular blurred vision. Ocular point-of-care ultrasound (POCUS) facilitated diagnosis of a late spontaneous IOL dislocation.

DISCUSSION

Prosthetic IOL dislocations are being reported with increasing frequency. Prompt recognition of IOL dislocation is essential to prevent secondary complications, including acute angle-closure glaucoma and retinal detachment, which can result in permanent vision loss.

CONCLUSION

Point-of-care ultrasound is a rapid, noninvasive imaging modality for early detection of IOL dislocation to help guide management, improve patient outcomes, and mitigate long-term sequelae.

Effect of lens capsular tension ring on preventing capsular contraction syndrome in the surgery of retinitis pigmentosa combined with cataract: Retrospective case series

PURPOSE

To observe the effect of phacoemulsification and intraocular lens (IOL) implantation with or without lens capsular tension ring (CTR) on retinitis pigmentosa (RP) combined with cataract patients.

DESIGN

Retrospective cases series study.

METHODS

Sixty-three cases (84 eyes) of RP with cataract were collected, including 30 males and 33 females. Phacoemulsification with 3.0 mm clear corneal incision was performed in all the patients. IOL and CTR implantation were performed in 44 eyes, and IOL implantation alone was performed in 40 eyes. All cases were followed up at 1 day, 1 week and 1, 3, 6,12 months after the surgery to compare the best-corrected visual acuity (BCVA), intraocular pressure (IOP), corneal endothelial cell count (ECC) and complications before and after the surgery.

RESULTS

All surgery were successfully completed by the same physician, and IOL and CTR were all implanted in capsule without complications. The BCVA at 6 months after surgery was 0.91 ± 0.88 LogMAR, showing an improvement compared with the BCVA(1.3 ± 0.7LogMAR) before surgery and there was a statistically significant difference (P = .003). Four cases of capsule contraction syndrome (CCS) occurred in no CTR implantation group and there was no CCS in CTR group. There was a statistically significant difference in the incidence of CCS between two groups (P = .047).

CONCLUSIONS

Phacoemulsification for RP combined with cataract is safe and reliable, and CTR implantation is conducive to reducing the complications caused by capsule contraction.

Capsular tension ring assisted phacoemulsification of morgagnian cataract

Purpose:

To describe a novel technique of phacoemulsification in morgagnian cataract using capsular tension ring (CTR).

Methods:

This was a retrospective, non-comparative, clinical interventional study. Patients with hypermature morgagnian cataract who had undergone CTR-assisted phacoemulsification were included in the study. After capsulorhexis, CTR was inserted in a clockwise manner to stabilize the capsular bag in each case. Phacoemulsification was then performed using either horizontal chopping or vertical chopping. We have used the CTR in these cases without any obvious lens subluxation in order to perform safe emulsification of the nuclear pieces in the capsular bag. We have performed the procedure successfully in eleven eyes with hypermature morgagnian cataract.

Results:

The mean corrected distance visual acuity (CDVA) improved from 2.62 ± 0.25 Log MAR to 0.35 ± 0.28 Log MAR at 3 months postoperatively (P = 0.00008). Total nine out of 11 patients gained CDVA of 20/40 or better at 3 months postoperatively. No intraoperative complications such as posterior capsular rupture, zonular dialysis, iris trauma, vitreous loss were noted. The mean endothelial cell loss was 148.82 ± 41.52 cells/mm² after 3 months of surgery.

Conclusion:

The main culprit for intraoperative complications during phacoemulsification in a morgagnian cataract is the vulnerable capsular bag. Following insertion of a CTR after capsulorhexis, the bag becomes stable and the subsequent steps of the surgery become uneventful, thereby, preventing any further complications.

Outcomes of a new suture technique for the treatment of dislocated intraocular lenses: locked loop on the haptic

PURPOSE

To evaluate surgical and refractive outcomes of a new sutured scleral fixation technique in the management of subluxated intraocular lenses (IOLs).

METHODS

Nineteen eyes treated with the new scleral fixation technique were included. The mean corrected distance visual acuity (CDVA), postoperative refraction error, mean endothelial cell count (ECC), and complications were recorded. All patients were evaluated immediately postoperatively, at 1 and 7 days, and then at 1, 3, and 6 months.

RESULTS

The mean duration of follow-up of the patients was 10 months (range, 6-15 months). The mean CDVA was 0.41 ± 0.1 logMAR (logarithm of minimum angle of resolution) preoperatively and was 0.08 ± 0.07 logMAR postoperatively. The mean astigmatism was - 2.22 ± 1.86 D preoperative and was - 0.86 ± 0.58 D postoperative. The mean preoperative and postoperative ECC was 2455 ± 288 and 2352 ± 288, respectively. One patient (5.26%) experienced vitreous hemorrhage, and two (10.52%) experienced intraocular pressure elevation. IOL tilt and decentralization, conjunctival erosion, and cystoid macular edema were not observed in any eyes during follow-up.

CONCLUSION

This new IOL repositioning technique can be applied in a short surgical time and provides a stable IOL centration on long-term follow-up.