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

Polypseudophakia: from "Piggyback" to supplementary sulcus-fixated IOLs

Polypseudophakia, the concept of using a second intraocular lens (IOL) to supplement an IOL that has already been placed in the capsular bag, was first used as a corrective measure where the power requirement was higher than that of available single IOLs. Subsequently, the technique was modified to compensate for post-operative residual refractive errors. In these early cases, an IOL designed for the capsular bag would be implanted in the sulcus.  Although these approaches were less than ideal, alternative means of correcting residual refractive errors were not without their limitations: IOL exchange can be traumatic to the eye and is not easily carried out once fibrosis has occurred, while corneal refractive surgical techniques are not suitable for all patients. Piggyback implantation was the term first coined to describe the use of two IOLs, placed together in the capsular bag. The term was later extended to include the procedure where an IOL designed for the capsular bag was placed in the sulcus. Unfortunately, the term piggyback has persisted even though these two approaches have been largely discredited. Intraocular lenses are now available which have been specifically designed for placement in the ciliary sulcus. As these newer IOLs avoid the many unacceptable complications brought about by both types of earlier piggyback implantation, it is time to employ a new terminology, such as supplementary IOL or secondary enhancement to distinguish between the placement of an unsuitable capsular bag IOL in the sulcus and the implantation of an IOL specifically designed for ciliary sulcus implantation. In addition to minimising possible complications, supplementary IOLs designed for the sulcus have expanded the options available to the ophthalmic surgeon. With these new IOLs it is possible to correct presbyopia and residual astigmatism, and to provide temporary correction of refractive errors in growing, or unstable, eyes. This article aims to review the literature available on supplementary IOL implantation in the ciliary sulcus and to summarise the evidence for the efficacy and safety of this intervention. KEY MESSAGES: What is known Polypseudophakia has been used for over 30 years to correct hyperopia or residual refractive error, but early techniques were associated with significant complications. What is new The development of specially designed sulcus-fixated supplementary IOLs significantly reduces the risks associated with these procedures, and has also opened up new opportunities in patient care. The reversibility of the procedure allows patients to experience multifocality, and to provide temporary and adjustable correction in unstable or growing eyes. The terms "secondary enhancement" or "DUET" to describe supplementary IOL implantation are preferential to "piggyback".

Capsular Waves: A Warning Indicator for Potentially Malpositioned Intraocular Lenses

Purpose

To share examination findings of the lens capsule which may act as an indicator for malpositioned intraocular lenses (IOL).

Setting

Single large multi-specialty private practice, Houston, Texas, USA.

Design

Focused, observational case series.

Methods

A review of pre-operative images of malpositioned single-piece IOLs with at least one haptic in the ciliary sulcus was conducted. The review included five cases who were referred to a single large multi-specialty private practice from June 2023 to December 2024 for an evaluation of posterior capsular opacification (PCO) and potential Nd:YAG capsulotomy.

Findings

A total of five eyes which previously had undergone cataract surgery and were referred for Nd:YAG capsulotomy for PCO were identified on slit lamp examination to have capsular waves, defined as a centripetal and circumferential striated pattern of PCO that results from a fused anterior and posterior capsule with at least part of the IOL anterior to the capsule. While one eye exhibited transillumination defects and pigment dispersion, the remainder of eyes did not. In some cases, the capsular wave was the only clue to IOL malpositioning due to a small pupil. These eyes had single-piece IOLs with at least one haptic in the sulcus and required subsequent IOL repositioning or exchange.

Conclusion

If capsular waves are seen on slit lamp exam, a thorough inspection of IOL placement should be conducted, especially before treatment with Nd:YAG capsulotomy. Capsular waves result from anterior and posterior capsule contact with an anteriorly situated IOL. This finding is a potential indicator of at least part of an IOL positioned anterior to the anterior capsule.

Efficacy and safety of the implantation of a single-piece angulated foldable IOL in the sulcus

PURPOSE

To study the visual results and tolerance of a Zeiss CT Lucia 601P intraocular lens (IOL) implanted in the sulcus after complicated cataract surgery or during IOL exchange for clouded IOL.

METHODS

In total, 64 patients who underwent sulcus implantation were recalled to the hospital to undergo subjective and objective refraction, best corrected visual acuity measurement, tonometry, optical coherence tomography, laser flare photometry, biometry, and wavefront aberrometry.

RESULTS

In spite of a large variation in preoperative refraction, the target refraction was obtained within 1.5 diopters in approximately 97% of patients and within 0.5 diopter in 53% of patients. Average BCVA was high (Snellen 0.86) and related to concomitant (mostly retinal) pathologies in eyes with poorer visual performance. Wavefront aberrometry showed no evidence of IOL tilting or decentration after long-term implantation in the sulcus. Tonometry was not different from the fellow eye of the patient (p > 0.5). In 53 patients with bilateral pseudophakia, the laser flare photometry was not significantly different from the fellow eye (p < 0.05).

CONCLUSION

This study demonstrates that this single-piece angulated foldable acrylic IOL can be considered for implantation in the sulcus. The visual results are favorable, and the IOL can be well-positioned and tolerated in the sulcus. Moreover, there were no safety issues found since there was no evidence of elevated IOP or chronic uveitis.

Intraocular lens tilt and decentration in secondary ciliary sulcus implantation in paediatric eyes: A 3-year prospective study

PURPOSE

The purpose of this study was to compare the tilt and decentration of one-piece anti-vaulting haptic intraocular lenses (IOL) and three-piece C-loop haptic IOLs in paediatric eyes undergoing secondary IOL implantation into the ciliary sulcus.

METHODS

Paediatric aphakic patients receiving either one-piece anti-vaulting haptic or three-piece C-loop haptic IOL implants into the ciliary sulcus were enrolled in this prospective non-randomized interventional study and followed up for 3 years. IOL decentration and tilt were measured using Scheimpflug images. Preoperative and postoperative information, including demographic data and ocular biometric parameters and complications, were collected and analysed.

RESULTS

Among 123 eyes of 79 paediatric patients, there were 72 eyes (58.54%) in the anti-vaulting haptic IOL group and 51 eyes (41.46%) in the C-loop haptic group. The anti-vaulting haptic IOL group had a lower incidence of clinically significant vertical IOL decentration than the C-loop haptic IOL group (23.88% vs. 43.14%, p = 0.037). No intergroup differences were observed in vertical or horizontal tilt or in horizontal decentration (all p > 0.05). One-piece anti-vaulting haptic IOL implantation was associated with a lower risk of clinically significant vertical decentration than three-piece C-loop haptic IOL implantation (odds ratio: 0.42, p = 0.037). There was a higher incidence of IOL dislocation in the C-loop haptic IOL group (15.22% vs. 4.17%, p = 0.046).

CONCLUSIONS

In paediatric aphakic eyes undergoing secondary IOL implantation into the ciliary sulcus, one-piece anti-vaulting haptic IOLs can reduce the risk of clinically significant vertical IOL decentration compared with three-piece C-loop haptic IOLs and may favour long-term IOL positional stability.

Indications and Outcomes of Intraocular Lens Explantation in a Tertiary Eyecare Center in Hungary between 2006 and 2020

Purpose

Our study aimed to evaluate the indications and outcomes of intraocular lens (IOL) explantation surgeries in a tertiary eyecare center in Hungary.

Materials and Methods

This retrospective study included all IOL explantation surgeries performed between 2006 and 2020 at the Department of Ophthalmology of Semmelweis University, Budapest, Hungary. There were no exclusion criteria for this study. For each patient, the demographics, clinical history, preoperative status, indications for IOL explantation, and operative and postoperative details were reviewed. Primary outcomes included explantation indications and the type of secondary implanted IOL.

Results

A total of 161 eyes from 153 patients were included (96 males; 62.7%); age at the time of the IOL explantation was 65.0 ± 17.4 years. The mean time between primary cataract surgery and IOL explantation was 8.5 ± 7.7 years. In total, 139 (86.3%) PCIOLs and 22 (13.7%) ACIOLs were explanted. The main indications for IOL explantation were dislocation (n = 133; 95.7%) and refractive cause (n = 2; 1.4%) in the PCIOL group. Among ACIOL explantations, the main reasons were pseudophakic bullous keratopathy (n = 14; 63.6%), dislocation (n = 4; 18.2%), and refractive cause (n = 2; 9.1%). In the PCIOL group, 115 (82.7%) primary IOLs were implanted in the capsular bag, 16 (11.5%) were sulcus fixated, and 8 (5.8%) were scleral fixated. The most frequent ocular comorbidities were previous vitrectomy (n = 50, 31.1%), previous ocular trauma (n = 45, 28.0%), glaucoma (n = 16, 9.9%), pseudoexfoliation syndrome (n = 15, 9.3%), and high axial myopia (n = 14, 8.7%). The most commonly used secondary IOL implant was the prepupillary iris-claw IOL (n = 115, 73.7%), followed by the retropupillary iris-claw IOL (n = 32, 20.5%). Uncorrected visual acuity (UCVA) was significantly better following IOL exchange in the entire sample (1.57 ± 0.61 (range: 2.40-0.05) vs. 0.77 ± 0.56 (range: 2.40-0.00); p < 0.001). Best-corrected visual acuity (BCVA) was maintained or improved in 80.7% of cases after IOL explantation.

Conclusions

The most common indication for IOL explantation at a tertiary eyecare center in Hungary is IOL dislocation, followed by pseudophakic bullous keratopathy. Prepupillary and retropupillary iris-claw IOL are the most frequently used secondary implants and their use resulted in a significant UCVA improvement following IOL exchange.

Uveitis-Glaucoma-Hyphema Syndrome Secondary to Implantable Collamer Lens

Purpose: To report the first case of uveitis-glaucoma-hyphema (UGH) syndrome post implantable collamer lens (ICL).Methods: Case reportResults: A 41-year-old female presented to our clinic complaining of bilateral eye pain and redness for two weeks. Her past medical history was significant for ICL, in both eyes and multiple sclerosis controlled with treatment. She had a long-standing history of bilateral recurrent uveitis and glaucoma. Ultrasound biomicroscopy revealed several sulcus cysts displacing the ICLs haptic into the ciliary body, leading to iris abrasion and uveitis-glaucoma-hyphema syndrome.Conclusion: We present the first published case worldwide about UGH syndrome secondary to ICL. This is an unusual complication, and measures can be taken to avoid it. This provides evidence of the importance of postoperative follow-up by the surgeon and appropriate work-up when such cases are suspected.

Surgical outcomes of intraocular lens iris suture fixation in eyes with residual capsule support

PURPOSE

To evaluate the safety and refractive outcomes of eyes after intraocular lens (IOL) iris suture fixation (ISF).

SETTING

Private practice, Los Angeles, California.

DESIGN

Nonrandomized and unmasked retrospective chart review.

METHODS

Eyes that underwent IOL exchange or repositioning with ISF with at least 270 degrees of capsular support were included. Eyes with less than 270 degrees of capsular support and eyes with iris damage were excluded. The primary outcome measures included incidence of cystoid macular edema (CME), IOL dislocation requiring refixation, and chronic inflammation. Secondary outcome measures included worsening intraocular pressure (IOP) control, retinal tear or detachment, worsening of corrected distance visual acuity (CDVA), and corneal decompensation. Refractive outcomes for 26 subgrouped eyes included mean and median spherical equivalent refraction accuracy (SERA), and percentage of eyes within 0.5 diopter (D) and 1 D of the refractive target.

RESULTS

The study included 53 eyes of 50 patients. CME: 2/53 (3.8%), IOL dislocation requiring refixation: 2/53 (3.8%), chronic inflammation: 1/53 (1.9%), worsening IOP control: 5/53 (9.4%), retinal tear or detachment: 2/53 (3.8%). No patient experienced worsening of CDVA from baseline or corneal decompensation. Mean SERA ± SD -0.35 ± 0.29 D, median SERA -0.37 D. Of the 26 eyes subgrouped for refractive analysis, 73% were within 0.5 D and 100% were within 1 D of the desired refractive outcome.

CONCLUSIONS

ISF can offer stability for sulcus-fixated IOLs provided there is some residual capsule support. Although there are measurable complications, there is a relatively low side effect profile. The refractive error tended to be myopic, indicating the need for further refinement of IOL power predictive formulas.

Anterior Segment Optical Coherence Tomography in Uveitis-Glaucoma-Hyphema Syndrome

PURPOSE

Uveitis-Glaucoma-Hyphema (UGH) syndrome results from contact between the intraocular lens (IOL) and the iris or ciliary body, leading to uveal structure erosion and blood-aqueous barrier breakdown. Treatment involves various drugs, with IOL removal often being necessary. Diagnosis relies on clinical signs, but imaging techniques like ultrasound biomicroscopy (UBM) or anterior segment optical coherence tomography (AS-OCT) are crucial. AS-OCT accurately depicts IOL position and potential contact, emerging as a primary alternative to UBM in the diagnosis. Our study aimed to correlate AS-OCT findings with clinically detectable iris atrophy in pseudophakic patients with IOL-iris chafing and UGH syndrome.

METHODS

The study retrospectively analyzed patients diagnosed with UGH syndrome presenting at the Ocular Immunology Unit of Reggio Emilia, Italy, from January 2019 to August 2023. Patients' data were collected. Ophthalmological exams and imaging were performed. The peephole sign in AS-OCT images was evaluated. Statistical analyses were conducted, with a significance level of p ≤ 0.05.

RESULTS

The study reviewed 22 eyes of 22 patients with UGH syndrome. Four eyes were excluded, leaving 18 patients (8 females, 10 males). Common misdiagnoses included idiopathic anterior uveitis (55.5%) and herpetic anterior uveitis (16.7%). All patients had iris transillumination defects, mostly focal (77.8%). AS-OCT revealed IOL chafing in all the eyes, with peephole sign correlation. More peephole signs occurred with IOL in the sulcus (p-value = 0.08).

CONCLUSION

The study recommends AS-OCT for UGH syndrome confirmation and UBM when IOL-iris chafing is not observed on AS-OCT scans.

Pseudophakic Pupillary Block due to the Capsular Bag Intraocular Lens Implant Located in the Sulcus: A Case Report

Introduction

Pupillary block, a concerning complication of cataract surgery, is heightened when a single-piece acrylic (SPA) intraocular lens (IOL) is implanted in the ciliary sulcus. We report an unusual occurrence of relative pupillary block and chronic angle-closure glaucoma (ACG) identified in the late postoperative period due to unintentional SPA IOL implantation in the sulcus.

Case Presentation

An 82-year-old woman presented with a history of chronic ACG 5 years after bilateral cataract extraction. Postoperatively, she experienced anterior chamber shallowing, elevated intraocular pressure (IOP), and two acute angle-closure attacks in the left eye, successfully managed with laser peripheral iridotomies (LPIs). Despite neodymium:YAG capsulotomy, elevated IOP persisted. Maximal medical therapy effectively controlled IOP; however, a shallow anterior chamber remained, prompting referral to our glaucoma service. Slit-lamp examination revealed a shallow peripheral anterior chamber, patent LPIs, and an Alcon SA60WF SPA IOL situated posteriorly with the optic against the pupil margin OS. Gonioscopy indicated a closed angle with peripheral anterior synechiae (PAS). Ultrasound biomicroscopy (UBM) confirmed haptics in the sulcus, with the lens optic and haptics anterior to the bag. These findings suggest relative pupillary block as the cause of her chronic ACG. The SPA IOL's bulky haptics in the sulcus likely induced iris bowing, leading to prolonged appositional angle-closure and chronic PAS formation.

Conclusion

IOLs designed for the capsular bag should not be placed in the sulcus. Therefore, IOLs of varying dimensions should be taken to the operating room in the event of complicated cataract extraction. Finally, UBM proves valuable in identifying causes of pupillary block.

Exogenous Endophthalmitis

PURPOSE

Exogenous endophthalmitis (ExE) results from microbial infection as a complication of ocular surgery, penetrating ocular trauma, and intraocular foreign bodies. We herein review the classification of ExE, etiological agents, differential diagnosis and therapeutic challenges.

METHODS

Narrative Literature Review.

RESULTS

Identification of the causative agent through ocular fluid analysis is central in the diagnostic work-up of ExE. Prompt intravitreal antimicrobial therapy is key to successful management of ExE and vitrectomy is essential in severe cases. In culture-negative cases, and in the presence of specific features, a diagnosis of sterile intraocular inflammation or toxic syndrome should be suspected.

CONCLUSION

Strict adherence to treatment guidelines may improve outcomes of ExE, however the ultimate prognosis, especially in severe cases, may depend more on the virulence of the causative organism and associated ocular complications. Accurate differential diagnosis and effective treatment are crucial elements in the management and prognosis of non-infectious masquerades of ExE.

Technique for Sutured Scleral Fixation of One-Piece Hydrophobic Acrylic Intraocular Lenses Dislocated Into the Vitreous

PURPOSE

To present a suturing technique for safe refixation of posteriorly dislocated one-piece hydrophobic acrylic intraocular lenses (IOLs).

METHOD

Retrospective data analysis of a series of 12 cases operated with vitrectomy, followed by IOL relocation to the retropupillary area, after which polypropylene sutures are passed through the optic-haptic junctions of the dislocated IOL and subsequently secured to the sclera.

RESULTS

In all cases, the IOL remained centered throughout the follow-up period (mean 10.5 months, range 3 weeks-36 months). One case was complicated by vitreous hemorrhage the first postoperative day and later cystoid macular edema. Visual acuity was not compromised at the end of follow-up.

CONCLUSION

The presented technique is safe and provides long-term stable refixation in cases of late posterior dislocation of a one-piece hydrophobic acrylic IOL. The risk that sutures looped around haptics will slip off the haptic is thereby avoided.

Reversible Multifocality Achieved Through Polypseudophakia

Simultaneous implantation of a monofocal or monofocal toric intraocular lens (IOL) into the capsular bag and a multifocal IOL into the ciliary sulcus, referred to as duet procedure, allows us to create multifocality that is more easily reversible than the implantation of a capsular bag-fixated multifocal IOL. The optical quality and results after the duet procedure are equivalent to those of a capsular bag-fixated multifocal IOL. Patients who cannot tolerate the side effects of multifocal optics or who develop an ocular condition leading to loss of function such as age-related macular degeneration (AMD) or glaucoma in the course of their lives may benefit from the reversibility of the procedure.

Comparison of a Presbyopia-Correcting Supplementary Intraocular Lens Combination and a Capsular-Bag Lens: An In Vitro Study

We evaluated the optical quality of two approaches to trifocality: polypseudophakia versus monopseudophakia. The combination (polypseudophakia) of a monofocal Basis Z B1AWY0 and AddOn Trifocal A4DW0M intraocular lens (IOL) was compared to using one Basis Z Trifocal B1EWYN IOL, all from 1stQ GmbH. In both approaches, we measured modulation transfer function (MTF) and Strehl Ratio (SR) values at 3.0 and 4.5 mm pupil sizes. We determined the through-focus (TF) MTF at 25, 50 and 100 lp/mm for the 3 mm aperture. United States Air Force (USAF) target images were recorded. MTF measurement of the trifocal lens and the combined monofocal and trifocal AddOn IOL showed good performance at the far and near focus for the 3 mm aperture. For the 4.5 mm aperture the MTF improved for the far focus but decreased for the intermediate and near focus. TF MTF showed better contrast at the far focus for the polypseudophakic setup but at the expense of the efficiency at the near focus. However, the USAF chart images revealed only minimal differences between both approaches. The optical quality of the polypseudophakic approach was not affected by the presence of two IOLs instead of one and proved to be comparable with the performance of one capsular-bag-fixated trifocal IOL. Differences between the single vs. two-lens approach seen in the TF MTF analysis could be attributed to the optical design that varied between the trifocal models.

Effect of Timing of Pars Plana Vitrectomy on Visual Outcome in Cases of Nucleus Drop during Phacoemulsification

PURPOSE

The purpose of the study was to study the relationship between the timing of pars plana vitrectomy (PPV) with corrected distance visual acuity (CDVA) in cases of nucleus drop during phacoemulsification.

METHODS

This retrospective analysis included 83 patients, who underwent PPV for nucleus or nuclear fragment drop from July 2017 to November 2019. Timing of PPV (≤2 weeks and >2 weeks) after the primary cataract surgery was noted. The primary endpoint was CDVA at 1 month, which was compared with the time of PPV. Visual outcome was assessed as good if CDVA was better than or equal to 20/40 and poor if CDVA was worse than 20/40. Mode of management along with type of secondary intraocular lens (IOL) implanted was also evaluated.

RESULTS

Out of the 83 cases (55 males and 28 females) in which vitrectomy for nucleus drop was performed, 36 cases were operated within 2 weeks and 47 were operated between 2 weeks and 1 month. In cases which were operated within 2 weeks, CDVA of 20/20-20/40 was achieved in 33 cases. For those who were operated on after 2 weeks, CDVA of 20/20-20/40 was achieved in 43 cases. The difference in visual outcome in both the groups was statistically nonsignificant (Fisher's exact t-test, P = 0.97). In 64 (77%) cases, adequate sulcus was present, in which foldable 3-piece IOL was placed in 29 (35%) cases.

CONCLUSION

Timing of intervention has no bearing on the final visual outcome after vitrectomy in cases of nucleus drop during phacoemulsification. The continuity of the capsulorrhexis and the availability of capsular support determines the type of placement of the lens. A foldable lens can be placed in the sulcus if continuous capsulorrhexis is present.

[Enhancement Options after Lens and Corneal Refractive Surgery]

BACKGROUND

 Modern preoperative diagnostics as well as current surgical techniques allow cataract and refractive surgery to deliver precise refractive results.Occasionally, unsatisfactory refractive and visual results occur despite all the care taken. In these cases, subsequent improvement is required to achieve the best final visual outcome. This article shows the therapeutic options for the treatment of residual refractive errors after lens and corneal refractive surgery.

KEY MESSAGES

 The causes of postoperative refractive errors after refractive laser- or lens-based procedures are very diverse and require extensive workup of the cause as well as an individual solution to achieve the desired result. Before any further surgical intervention, specific complications of the primary procedure as well as concomitant ocular diseases must be excluded or treated. The appropriate enhancement after keratorefractive surgery depends primarily on the type of primary surgery, residual stromal thickness, possible complications from the initial surgery, and the patient's personal preference. For enhancements using surface treatments, such as PRK, the use of mitomycin C is recommended for prophylaxis of haze formation. After lens surgery, for low-grade postoperative refractive errors (spherical and astigmatic), keratorefractive enhancements provide the most accurate results. For higher refractive errors, lens-based procedures can be used, with add-on IOLs being safer and more precise compared with one IOL exchange. Low astigmatisms can be successfully treated with LRI or keratorefractive surgery, but higher astigmatisms should be corrected with an IOL exchange in the early postoperative period and with an add-on IOL in the later postoperative period. IOL explantations should be performed very cautiously, especially in cases of pronounced capsular fibrosis, previous posterior capsulotomy, and existing weakness of the zonular apparatus.

Enhancement-Optionen nach Linsen- und refraktiver Hornhautchirurgie

Gelegentlich kommt es trotz aller Sorgfalt und präziser Operationstechnik in der Katarakt- und Refraktivchirurgie zu unbefriedigenden refraktiven und visuellen Ergebnissen. In diesen Fällen ist eine nachträgliche Korrektur erforderlich, um das beste endgültige visuelle Ergebnis zu erzielen. Dieser Beitrag zeigt die Möglichkeiten zur Behandlung residualer Refraktionsfehler nach Linsen- und refraktiver Hornhautchirurgie auf.

Current Concepts of the Uveitis-Glaucoma-Hyphema (UGH) Syndrome

PURPOSE

To discuss the pathophysiology, etiology, and current management strategies of uveitis-glaucoma-hyphema (UGH) syndrome.

METHODS

Literature review.

RESULTS

The classic UGH syndrome associated with anterior chamber intraocular lenses (ACIOL) have decreased in incidence with the modernization of IOL design and surgical techniques. The current UGH syndrome is increasing in prevalence largely related to a parallel increase in late onset dislocations of intraocular lenses (IOLs) and the developing techniques to remedy that condition. The modern features of UGH can present as cystoid macular edema, intraocular pressure elevation typically not attributed to UGH, and recurrent vitreous hemorrhage, unlike the original description as described by Ellingson in 1978. Medical management to control inflammation, reduce intraocular pressure, and reduced the bleeding diathesis are mainstays of therapy. However, surgery with IOL repositioning or exchange should be reserved for cases that are refractory to or progressing despite medical treatment.

CONCLUSIONS

UGH syndrome is an increasingly common, poorly understood, and often subtle, manifestation of an anatomic disturbance post intraocular surgery that persists with continued evolution of intraocular surgical techniques and new imaging modalities to aid in its diagnosis.

Capsulotomy opening diameter outcomes in aphakic eyes after primary congenital cataract removal and its association

Aim

To observe the change of capsulotomy opening diameter (COD) in aphakic eyes after primary congenital cataract removal and investigate its influencing factors.

Methods

Ocular parameters, including corneal diameter (CD), axial length (AL), anterior and posterior COD (ACOD, PCOD), and age at surgery were recorded at primary congenital cataract removal and secondary intraocular lens implantation. The concentrations of 15 kinds of cytokines in aqueous humor samples collected at the primary surgery were detected. The change (Δ) of COD between two surgeries were described, and its association was analyzed.

Results

Fifty eyes from 33 patients with congenital cataract who underwent primary and secondary surgery were enrolled. The changes in ACOD and PCOD were not statistically significant on the whole. ΔACOD was positively correlated with ΔCD and the concentrations of PDGF-AA, VEGF and TGF-β1. The concentration of FGF-2 and the interval between two surgeries showed negative correlations with ΔACOD and ΔPCOD.

Conclusion

COD in aphakic eyes kept changing after primary surgery. The positive correlation between ΔACOD and ΔCD manifested the enlargement of ACOD was influenced by lateral eye growth. Meanwhile, ΔACOD was also associated with cytokines, indicating postoperative inflammation promoted the ACOD constriction.

Accuracy of Intraocular Lens Power Calculation in Pediatric Secondary Implantation: In-the-Bag Versus Sulcus Placement

PURPOSE

To compare the effects of secondary in-the-bag vs ciliary sulcus intraocular lens (IOL) implantation on the accuracy of IOL power calculation in pediatric eyes.

DESIGN

Prospective nonrandomized interventional study.

METHODS

Pediatric aphakic eyes that underwent either in-the-bag or ciliary sulcus secondary IOL implantation were included. The mean prediction error (PE), mean absolute error (MAE), median absolute error, and percentages of eyes with PE within ±0.25 diopter (D), ±0.50 D, ±0.75 D, and ±1.00 D were calculated and compared using SRK/T formula.

RESULTS

One hundred fourteen eyes (38.26%) received in-the-bag IOL implantation and 184 (61.74%) underwent ciliary sulcus IOL implantation. Compared with the sulcus group, the capsular group displayed significantly lower MAE and higher percentage of eyes within ±0.50 D of PE (MAE: 0.90 vs 1.56 D; ±0.50 D: 40.40% vs 14.29%, both P < .001). The eyes receiving in-the-bag IOL implantation (sulcus IOL implantation β: -1.060, 95% CI: -1.415 to -0.705; P < .001), unilateral (β: 0.647, 95% CI: 0.144-1.150; P = .012), or with deeper anterior chamber depth (β: 0.362, 95% CI: 0.068-0.656; P = .016) were prone to maintain hyperopia (PE > 0). To reduce PE, when the predicted capsular IOL power was between 11.50 and 30.00 D, the power of a sulcus-implanted IOL should be reduced by 0.50 to 2.50 D accordingly (the exact amount of reduction is positively related to the predicted power).

CONCLUSIONS

In-the-bag implantation yielded smaller PE in pediatric eyes undergoing secondary IOL implantation. Adjustment of IOL power for ciliary sulcus implantation is required to reduce PE, and the amount of adjustment is positively correlated with the IOL power predicted by SRK/T formula.

Visual and Refractive Outcomes Following Exchange of an Opacified Multifocal Intraocular Lens

Purpose

To assess the visual and refractive outcomes following exchange of an opacified multifocal intraocular lens (IOL).

Patients and Methods

A consecutive series of 37 eyes (31 patients) that underwent IOL exchange between November 2015 and May 2021 were included in this study. The indication for surgery in all cases was opacification of a multifocal IOL. Outcome measures included design and anatomical location of the secondary IOL, intraoperative and postoperative complications, visual acuity and refractive accuracy.

Results

An opacified Lentis Mplus multifocal IOL was explanted from all eyes and replaced with a monofocal IOL in 21 eyes (57%) and multifocal IOL in 16 eyes (43%). Secondary IOLs were implanted in the capsular bag or sulcus or were iris-fixated. IOL exchange was performed at a mean interval of 7 years after the primary surgery. Anterior vitrectomy was required for vitreous prolapse in 9 eyes (24%). Mean corrected distance visual acuity (CDVA) postoperatively was −0.02 ± 0.08 logMAR for eyes with a monofocal secondary IOL and 0.02 ± 0.08 logMAR for eyes with a multifocal secondary IOL. Mean refractive prediction error was −0.57 ± 0.67 D in the multifocal-monofocal group and −0.33 ± 0.59 D in the multifocal–multifocal group.

Conclusion

An opacified multifocal IOL can be exchanged for a monofocal or multifocal IOL, depending on available capsular support and the patient’s desired refractive outcome. Vitreous prolapse requiring anterior vitrectomy is the most common intraoperative complication. An improvement in visual acuity and a low postoperative complication rate were achieved in this cohort of patients.

Outcomes of a Toric Monofocal Piggyback Intraocular Lens for Residual Astigmatic Refractive Error in Pseudophakic Eyes

PURPOSE/AIM

To evaluate the visual outcomes, refractive outcomes and rotational stability of a toric piggyback intraocular lens (1stQ AddOn, GmbH, Mannheim, Germany) for astigmatic refractive error in pseudophakic eyes.

MATERIALS AND METHODS

Visual and refractive outcomes were assessed based on the standard graphs for reporting refractive surgery outcomes. Rotational stability was assessed according to the Intraocular Lens (IOL) standards of the International Organisation for Standards.

RESULTS

Twenty-two eyes of 17 patients (age: 65.1 ± 9.3 years) underwent toric piggyback IOL insertion. After a minimum follow-up of 3 months, 18 eyes (82%) achieved an uncorrected distance visual acuity (UDVA) of 0.00 logMAR (20/20) or better and all eyes achieved 0.1 logMAR (20/25). Mean UDVA improved from 0.27 ± 0.03 to 0.12 ± 0.03 and 0.04 ± 0.04 at one and 3 months (all p < .05). Nineteen eyes (86%) achieved an UDVA at least equal to the pre-operative corrected distance visual acuity (CDVA). No eyes lost more than one line of CDVA. All eyes achieved within 0.5D of target spherical equivalent (SE). In 18 eyes (82%), the residual astigmatism magnitude was 0.5D or less. The mean absolute difference between the target axis and the achieved axis 1 and 3 months postoperatively was 2.5° ± 2.7° and 3.2° ± 3.3°, respectively. The final IOL orientation was within 10 degrees of target axis in 19 of 22 (86.4%) eyes, within 20 degrees in 21 of 22 (95.2%) eyes and within 30 degrees in 22 of 22 (100%) eyes. IOL rotational repositioning was required in two eyes (9.1%).

CONCLUSIONS

In this cohort of patients, the 1stQ AddOn toric monofocal piggyback IOL resulted in very good visual and refractive outcomes and showed reasonable rotational stability. This IOL appears to be an effective treatment option for residual astigmatic refractive error in pseudophakic eyes.

Scleral fixation of subluxated or dislocated multifocal and multifocal toric intraocular lenses

PURPOSE

To evaluate the feasibility of scleral fixation of subluxated or dislocated multifocal/multifocal toric intraocular lenses (IOLs) to rescue the IOL and restore both near and far vision.

METHOD

A total of 18 eyes of 17 patients who underwent transscleral or intrascleral fixation of subluxated or dislocated multifocal or multifocal toric IOLs at 2.5 mm posterior to the limbus were enrolled. Preoperative uncorrected distance visual acuity (UDVA) and postoperative UDVA values were compared in this retrospective cross-sectional study. The postoperative corrected distance visual acuity (CDVA), uncorrected near visual acuity (UNVA) at 40 cm, residual sphere, cylinder, spherical equivalent, and IOL centration were evaluated.

RESULTS

The mean follow-up period was 4.0 ± 5.0 months. The mean preoperative UDVA was 0.73 ± 0.71 logMAR and the postoperative UDVA was 0.05 ± 0.10 logMAR, which was significantly improved relative to the preoperative UDVA. The mean postoperative CDVA was 0.00 ± 0.00 logMAR and the mean postoperative UNVA at 40 cm was 0.05 ± 0.07 logMAR. The mean postoperative residual sphere, cylinder, and spherical equivalent values were - 0.21 ± 0.41 D, - 0.29 ± 0.26 CD, and - 0.33 ± 0.39 D, respectively. Postoperative anterior segment photographs showed good centration of optics in all cases of single-piece foldable multifocal IOLs but a slight inferior decentration in one case of a three-piece multifocal IOL.

CONCLUSION

Scleral fixation of subluxated or dislocated multifocal and multifocal toric IOLs could be one of the treatment options to rescue subluxated or dislocated multifocal IOLs and restore both near and far vision.

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.

Post-operative outcomes in canine eyes receiving a rhexis-fixated prosthetic intra-ocular lens: 30 cases (2014-2020)

OBJECTIVES

To report the outcomes following the insertion of a rhexis-fixated prosthetic intraocular lens (IOL) in dogs undergoing lens removal.

MATERIALS AND METHODS

The results are from 30 eyes of 28 dogs, undergoing lendectomy, in which the lens capsule could not accommodate a conventional prosthetic endo-capsular IOL. The reported cases had sustained either spontaneous or traumatic lens capsule rupture, or accidental intra-operative iatrogenic lens capsule disruption, or had required a planned, large, anterior or posterior continuous curvilinear capsulorhexis, all of which precluded insertion of a prosthetic IOL within the lens capsule. An acrylic IOL (XVET; Medicontur) was modified and positioned across the anterior and/or posterior capsulorhexes.

RESULTS

Other than haptic luxation in three cases, no complications were seen that were directly attributable to the rhexis-fixated lens. Over a follow-up period from three to 76 months (mean 20.7 months) 26/30 eyes remained visual. Blindness developed in three eyes due to retinal detachment and one eye was enucleated due to regrowth of a ciliary body adenoma.

CLINICAL SIGNIFICANCE

Rhexis fixation provided an alternative method to implant a prosthetic IOL when the lens capsule was unable to accommodate a conventional endo-capsular IOL.

Repositioning surgery of different intraocular lens designs in eyes with late in-the-bag intraocular lens dislocation

PURPOSE

To evaluate the long-term efficacy and safety after intraocular lens (IOL) repositioning by scleral suturing of 1-piece IOL compared with other IOL designs in the treatment of late in-the-bag IOL dislocation.

SETTING

Patients referred to Oslo University Hospital Oslo, Norway.

DESIGN

Prospective cohort study.

METHODS

The study comprised 54 patients (54 eyes) with late in-the-bag IOL dislocation treated with IOL repositioning by scleral sutures (10-0 polypropylene). All operations were performed with an anterior approach and by 1 surgeon. The following IOL designs were repositioned: 1-piece foldable (n = 17), 3-piece foldable (n = 28), plate-haptic (n = 8), and 1-piece rigid (n = 1) IOLs. Patients were evaluated comprehensively preoperatively and at 6 months (80%), 1 year (67%), and 2 years (61%) postoperatively. The main outcome measures were efficacy regarding corrected distance visual acuity (CDVA) and spherical equivalent (SE) and safety regarding complications.

RESULTS

Postoperative visual acuity was similar for different IOL designs. The mean SE change to final observation was -0.08 (95% CI, -0.93 to 0.77) in the 1-piece IOL group (n = 11) and -0.98 (-1.73 to -0.23) in the 3-piece IOL group (n = 18) (P = .11). Regarding safety, no patients had uveitis-glaucoma-hyphema syndrome, retinal detachment, or endophthalmitis. The 3-piece IOL group had 1 case of redislocation and 1 case of iritis. No patients had symptoms related to clinical IOL decentration. Long-term intraocular pressure remained within normal limits with overlapping 95% CIs for different IOLs.

CONCLUSIONS

Repositioning surgery of 1-piece IOLs seems as efficient and safe as that for other IOL designs in the treatment of late in-the-bag IOL dislocation.

Late spontaneous posterior capsule rupture after hydrophilic intraocular lens implantation

PURPOSE

To describe and discuss the presentation and management of 4 cases of late (17 to 20 years) postoperative spontaneous posterior capsule rupture (PCR) and intraocular lens (IOL) subluxation in eyes implanted with the same hydrophilic 1-piece IOL.

SETTING

Center for Applied Eye Research, Meir Medical Center and the Ein-Tal Eye Center, Israel.

DESIGN

Case series.

METHODS

Four patients presented with spontaneous rupture and posterior dislocation of the same design IOL (B-Lens) 17 to 20 years after implantation. No trauma or any other direct causative factor was identified in any of the cases.

RESULTS

Of the 4 cases reported, the IOLs were successfully repositioned to the ciliary sulcus and sutured to the scleral wall (1 case) or the iris (2 cases), and the IOL was stable in the sulcus without the need for further sutured fixation in 1 case, with effective vision restored in all cases.

CONCLUSIONS

Spontaneous PCR is a rare postoperative complication and has not been reported, to the authors' knowledge, in cases without predisposing factors. A mechanism of late capsular tear was not confirmed, but the specific design of the IOL might have been a contributing factor.

Femtosecond Laser Assisted Intraocular Lens (IOL) Exchange

ABSTRACT

Intraocular Lens (IOL) exchange in patients with anterior capsule contraction resulting from phimosis can complicate IOL exchange as the fibrotic anterior capsule must be cut to gain access to the IOL. Maintaining a curvilinear capsulotomy is particularly important when the desired outcome is bag to bag IOL exchange. Similarly, when the posterior capsule is open a properly sized curvilinear anterior capsulotomy will allow for optic capture and further stability of the exchanged IOL. Secondary capsulotomy size ranged from 4.9-5.0mm and the energy was set at 4-10mJ (microjoules) depending on diffusiveness of the anterior capsule. We adapted the femtosecond (FS) laser to create a secondary anterior capsulotomy to facilitate IOL exchange.

Fifteen years of IOL exchange: indications, outcomes, and complications

PURPOSE

To report the indications, frequency, and outcomes regarding intraocular lens (IOL) exchange in 2 university hospital tertiary referral settings over a period of 15 years.

SETTING

Ophthalmology departments of the University Hospital Antwerp and the University Hospital Leuven, Belgium.

DESIGN

Retrospective cross-sectional study.

METHODS

In this retrospective study, included were patients who underwent an IOL exchange between 2002 and 2017. Patient demographics, surgical indication, comorbidities, visual outcomes, and complications were reported. Patients who underwent IOL repositioning or add-on IOL implantation or extraction, and patients who were left aphakic, were excluded.

RESULTS

Included in the study were 492 eyes. The mean age was 66.0 ± 13.3 years (range 19-91 years). The mean time between primary surgery and IOL exchange was 54.61 ± 67.07 months (range 0-343 months). Primary indication for explantation was IOL opacification, and the most common ophthalmic comorbidity was a previous history of vitreoretinal surgery. Preoperatively, the mean uncorrected visual acuity (UCVA) and corrected distance visual acuity (CDVA) were 0.47 ± 0.27 (range 0-1) and 0.61 ± 0.32 (range 0-1.2), respectively. Postoperative UCVA and CDVA was 0.7 ± 0.3 (range 0-1.2) and 0.8 ± 0.28 (range 0.05-1.6), respectively. The increase in both CDVA and UCVA was statistically significant (P < .001, paired t test). The most common complication perioperatively was vitreous prolapse, which occurred in 61 eyes (16%).

CONCLUSIONS

IOL exchange is a challenging yet valuable treatment option for a wide spectrum of problematic IOL outcomes. The most common indication remains IOL opacification, although IOL dislocation and patient dissatisfaction are increasing as indications.

Scleral fixation of hydrophobic acrylic intraocular lenses using a suture burial technique

The procedure involved an ab-externo scleral fixation technique using a double-armed 10-0 polypropylene suture with straight needles that require no scleral flaps. The IOLs are sutured to the sclera, the free suture ends are tied to the suture loops, and they are buried together under the sclera. Forty eyes of 37 patients were included. Postoperative complications are IOL capture in five eyes (12.5%), a significant IOL tilt in one eye (2.5%), recurrent UGH (uveitis-glaucoma-hyphema) syndrome in two eyes (5%), glaucoma in three eyes (7.5%), suture exposure in two eyes (5%) and IOL drop due to haptic breakage in one eye (2.5%). The technique can be effectively used for the refixation of dislocated hydrophobic acrylic IOLs by temporary haptic externalization through a corneal incision and for the treatment of aphakia with or without penetrating keratoplasty. Surgeons should be aware of the possibility of UGH syndrome due to IOL capture, especially in young eyes.

Isolated posterior capsule rupture after blunt eye injury

Isolated posterior capsule rupture of the crystalline lens after blunt eye injury is a rare complication and demands a special surgical management strategy in order to achieve a good visual outcome.

Refractive enhancements for residual refractive error after cataract surgery

PURPOSE OF REVIEW

Advances in cataract surgery have allowed surgeons to achieve superior refractive outcomes but have also led to higher patient expectations. Despite ever-evolving technology, residual refractive errors still occur. Postcataract refractive enhancements may be required to deliver satisfactory visual outcomes. This review aims to discuss the potential causes of residual refractive errors and the various enhancement modalities to correct them.

RECENT FINDINGS

A thorough preoperative workup to detect and address underlying pathologic causes of impaired vision should be performed prior to enhancement or corrective procedures. Corneal-based procedures are the safest and most accurate methods of correcting mild cases of residual refractive error. Hyperopic, high myopic, and high astigmatic errors are best managed with lens-based enhancements. Piggyback intraocular lenses (IOLs) are safer and more effective compared with IOL exchange. Toric IOL rotation and IOL exchange are ideally performed in the early postoperative period.

SUMMARY

A multitude of options exist for effective correction of residual refractive errors. The choice on how to best manage these patients depends on many factors such as the cause of refractive error, type of IOL used, ocular comorbidities, and patient preference.

Reversibility of the duet procedure: Bilateral exchange of a supplementary trifocal sulcus-fixated intraocular lens for correction of a postoperative refractive error

Purpose

We present the case of a 49-year old female who underwent bilateral exchange of a supplementary trifocal sulcus-fixated intraocular lens (IOL) to correct a residual refractive error. Six months beforehand, she had been treated for hyperopia, astigmatism and presbyopia with a duet procedure to create reversible trifocality.

Observations

Refractive lens exchange with combined implantation of a monofocal toric IOL into the capsular bag and a trifocal supplementary IOL into the ciliary sulcus (duet procedure) had been performed in both eyes. Decreased uncorrected distance visual acuity due to the refractive outcome of −0.75 diopter sphere (DS)/-0.25 diopter cylinder (DC)x10° for the right eye and −1.0DS for the left eye as well as the perception of photic phenomena were inacceptable for the patient. In the second operations, we exchanged the supplementary IOLs to correct the residual refractive error and achieve the target refraction of emmetropia. UDVA increased from 0.50 logMAR in both eyes prior to the IOL exchange to −0.22 logMAR in the right eye and −0.20 logMAR in the left eye. Binocular uncorrected near and intermediate visual acuity were −0.10 logMAR and 0.00 logMAR respectively after exchanging the sulcus-fixated supplementary IOLs, allowing for complete spectacle independence.

Conclusions

This case demonstrates one of the most important benefits of the duet procedure: the possibility, if necessary, to easily remove or exchange the supplementary IOL from the ciliary sulcus. The duet procedure offers a safe treatment option in the event of postoperative complications like residual refractive error or intolerance to a multifocal optic.

Sekundäre Linsenimplantation: chirurgische Techniken und Ergebnisse

Es stehen verschiedene alternative chirurgische Optionen zur Verfügung, um eine sekundäre Intraokularlinse (IOL) in Augen mit unzureichender Kapselunterstützung zu implantieren. Erfolgreiche Techniken umfassen die Implantation einer irisfixierten IOL (IFIOL), einer kammerwinkelgestützten Vorderkammerlinse (ACIOL) oder verschiedene Variationen zur Sklerafixierung (SFIOL). Jede dieser Methoden hat sich als sicher und effektiv erwiesen, weist jedoch verfahrensspezifische Einschränkungen auf. Jüngste Studien zeigen, dass die Entwicklung neuer chirurgischer Techniken diesen Patienten weiterhin sichere und reproduzierbare Behandlungsmöglichkeiten bietet. Obwohl die Implantation von sekundären IOLs ohne Kapselunterstützung von vielen Faktoren, einschließlich der Präferenz des Chirurgen, abhängt, sind nahtlose sklerafixierende Techniken für die chirurgische Gemeinschaft von wachsendem Interesse. Das Bestreben nach kürzeren und weniger traumatischen Operationen sowie nach reproduzierbaren und funktionell guten Ergebnissen, fördert dabei die Entwicklung von neuen Operationstechniken, Intraokularlinsen und Instrumenten. Diese Übersichtsarbeit gibt einen Einblick in alte und neue Behandlungsmethoden zur Korrektur von Aphakie mit sekundären Intraokularlinsen

Intraocular Lens Complications: Decentration, Uveitis-Glaucoma-Hyphema Syndrome, Opacification, and Refractive Surprises

As cataract surgery has evolved, intraocular lens (IOL) complications are rare. The purpose of this review was to report the incidence, diagnosis, and management of IOL decentrations, uveitis-glaucoma-hyphema (UGH) syndrome, IOL opacifications, and refractive surprises. Literature review was performed by searching PubMed, MEDLINE, EMBASE, and the Cochrane Controlled Trial Database and the reference lists of original studies as well as reviews. Intraocular lens decentrations and dislocations can appear at any time, particularly in patients with predisposing factors such as pseudoexfoliation, prior vitreoretinal surgery, or trauma. Recognizing when they require surgical intervention for UGH or to improve visual function is critical in limiting long-term sequela. Intraocular lens opacifications such as glistenings rarely require intervention, but others, such as subsurface nanoglistenings, calcifications, or discolorations, may require IOL exchange. Finally, despite our best efforts to enhance measurements and IOL calculations, refractive surprises still occur. Intraocular lens complications are uncommon with modern cataract surgery. A number of these complications require proper identification and care to optimize patient outcomes.

Intraocular Lenses: Overview of Designs, Materials, and Pathophysiologic Features

This article provides an overview of intraocular lenses (IOLs) currently used in cataract surgery. Aspects presented include design features related to IOL construction and sites of fixation; optic, filter, and haptic materials; as well as pathophysiologic features of uveal biocompatibility, capsular biocompatibility, and postoperative IOL opacification. This overview also includes supplementary (add-on; piggyback) lenses implanted in eyes that are already pseudophakic and considerations on IOLs used in the pediatric population. Different IOLs are made available to surgeons each year, including lenses with increasingly complex design characteristics owing to advancements in manufacturing and surgical techniques.

Surgical management of uveitis-glaucoma-hyphema syndrome

AIM

To report outcomes of patients after intraocular lens (IOL) repositioning or exchange for the version of the uveitis-glaucoma-hyphema (UGH) syndrome that does not include closed loop anterior chamber IOL (nUGH).

METHODS

Chart review of patients with nUGH who underwent IOL repositioning or exchange by one surgeon were reviewed. The main outcome measures were best corrected visual acuity (BCVA) as a decimal fraction preoperatively and postoperatively after IOL repositioning or exchange. Clinical findings evaluated included the presence of uveitis, hyphema, elevated intraocular pressure (IOP), and other complications such as pigment dispersion or vitreous hemorrhage. The number of anti-inflammatory and glaucoma medications were assessed before and after IOL repositioning or exchange.

RESULTS

The study included 14 pseudophakic eyes. The median time at the onset of contemporary UGH after cataract extraction and IOL implantation (CE/IOL) was 7.5y. IOL repositioning or exchange was performed at a mean duration of 8.1±4.7mo (median: 4mo) after onset of UGH. The mean BCVA was improved from 0.45±0.26 preoperatively after onset of UGH syndrome to 0.76±0.22 (P=0.016) after IOL repositioning or exchange. Among the 14 eyes, uveitis, elevated IOP, and hyphema were present preoperatively in 13, 13, and 6 eyes, respectively. Uveitis and hyphema resolved in all cases after IOL surgery. The mean IOP was reduced from 26.4±4.5 mm Hg preoperatively to 14.7±4.9 postoperatively (P=0.01). The mean number of glaucoma medications used was reduced from 1.7±1.1 medications preoperatively to 0.8±1.08 (P=0.04) postoperatively.

CONCLUSION

IOL repositioning or exchange is an effective treatment in many cases for medically resistant contemporary UGH syndrome.

Diagonal haptic capture of a plate intraocular lens with 4 haptics

A technique of diagonal haptic capture of a plate intraocular lens (IOL) with 4 haptics for cases with insufficient posterior capsular support is presented. The diagonal haptics were captured through the capsulorhexis by sequentially depressing each side of the haptic beneath the rim of the capsulorhexis with a gentle pressure. The IOL is fixated by pure IOL-capsule capture without sulcus fixation of haptics. The technique was used in 12 eyes (12 patients). The IOLs were well centered within the follow-up period. No IOL malposition, pseudophacodonesis, pupil capture, pigmental dispersion, or high intraocular tension was observed postoperatively. Ultrasound biomicroscopy revealed that there was no chafing of the IOL with the posterior iris. The technique provided an instant and definitive fixation with high adaptability to different sizes of capsulorhexis, and thereby could reduce the risk for complications related to haptic-sulcus fixation.

Telemetric Measurement of Intraocular Pressure via an Implantable Pressure Sensor-12-Month Results from the ARGOS-02 Trial

PURPOSE

The aim of this study was to investigate the safety and performance of the second generation of an implantable intraocular pressure (IOP) sensor in patients with primary open angle glaucoma (POAG).

DESIGN

prospective, noncomparative, open-label, multicenter clinical investigation.

METHODS

In this study, patients with POAG, regularly scheduled for cataract surgery, were implanted with a ring-shaped, sulcus-placed, foldable IOP sensor in a single procedure after intraocular lens implantation. Surgical complications as well as adverse events (AEs) during 12 months of follow-up were recorded. At each follow-up visit, a complete ophthalmic examination, including visual acuity, IOP, slit lamp examination, and dilated funduscopy as well as comparative measurements between Goldmann applanation tonometry and the EYEMATE-IO implant were performed.

RESULTS

The EYEMATE-IO implant was successfully implanted in 22 patients with few surgical complications and no unexpected device-related AEs. All ocular AEs resolved quickly under appropriate treatment. Comparative measurements showed good agreement between EYEMATE-IO and Goldmann applanation tonometry (GAT) with an intraclass correlation coefficient (ICC(3,k)) of 0.783 (95% confidence interval [CI]: 0.743, 0.817). EYEMATE-IO measurements were higher than GAT, with a mean difference of 3.2 mm Hg (95% CI: 2.8, 3.5 mm Hg).

CONCLUSIONS

The EYEMATE-IO sensor was safely implanted in 22 patients and performed reliably until the end of follow-up. This device allows for continual and long-term measurements of IOP.

Intraocular Lens Implantation In The Ciliary Sulcus: Challenges And Risks

Purpose

This article reviews the current literature on the risks and challenges associated with intraocular lens (IOL) implantation in the ciliary sulcus.

Recent findings

The development of IOLs designed specifically for placement in the ciliary sulcus continues to be an area of interest for the ophthalmic industry. Currently the one-piece PMMA (polymethylmethacrylate) lens or a three-piece IOL are the best available options for IOL placement in the ciliary sulcus space. Single piece acrylic (SPA) IOLs are not designed for sulcus placement and there is growing evidence of chronic complications related to their use in the ciliary sulcus. Many of these eyes ultimately require surgical intervention, including lens exchange. Endoscopic imaging and ultrasound biomicroscopy (UBM) have enabled a better understanding of ciliary sulcus anatomy and measurements in the living eye.

Summary

When the capsular bag is compromised, IOL placement in the ciliary sulcus is a reasonable option. In these circumstances, appropriate choice of IOL, knowledge of the sulcus anatomy, and correct technique can improve results and reduce postoperative complications.

Intraocular lens explantation in Spain: indications and outcomes at a tertiary referral center from 2010 to 2018

PURPOSE

To evaluate the causes of IOL explantation, techniques for secondary IOL implantation, visual outcomes and complications.

METHODS

Setting: Department of Ophthalmology Complexo Hospitalario Universitario A Coruña, Spain.

DESIGN

Retrospective study. All explanted IOLs from January 2010 to June 2018 were included. Medical records were reviewed to determine the surgical indication for IOL explantation, type of IOL implanted, time between surgeries, visual outcomes and surgical complications.

RESULTS

One hundred forty-one IOLs were explanted (134 patients). Mean time from original surgery to IOL explantation was 7.89 ± 5.81 years. Causes of IOL explantation were IOL dislocation (81.56%)-in-the-bag IOL dislocation (71.63%), out-of-the-bag IOL dislocation (9.9%)-corneal decompensation (12.05%), refractive surprise (3.5%), uveitis-glaucoma-hyphema syndrome (1.4%), IOL opacification (1.4%). Procedures for secondary IOL implantation were retropupillar iris-claw IOL (63.8%), flanged scleral fixated IOL (9.2%), three-piece IOL in ciliary sulcus (8.5%), angle-supported anterior chamber IOL (7.1%), in-the-bag IOL (3.5%), scleral fixated IOL with sutures (0.7%). Ten cases (7.1%) were left aphakic. Mean preoperative and postoperative logMAR CDVA were 1.34 ± 0.87 and 0.63 ± 0.69, respectively (p = 0.000). Mean preoperative IOP and postoperative IOP were 16.78 ± 4.49 and 15.53 ± 3.476 mmHg, respectively (p = 0.005). Complications include cystoid macular edema (7.8%), glaucoma (7.1%), IOL luxation (2.1%), retinal detachment (1.4%), trophic ulcer and leucoma (1.4%), corneal decompensation (1.4%).

CONCLUSIONS

In-the-bag IOL dislocation was the most frequent indication for IOL explantation, followed by pseudophakic bullous keratopathy. Simultaneous IOL exchange for a retropupillar iris-claw IOL was the most frequent procedure for secondary IOL implantation. Mean CDVA improved significantly and IOP decreased significantly after IOL explantation. The most frequent postoperative complication was cystoid macular edema.

Iris suture fixation of out-of-the-bag dislocated three-piece intraocular lenses

PURPOSE

To evaluate the efficacy and safety of iris suture fixation of out-of-the-bag dislocated three-piece intraocular lenses (IOL).

METHODS

In a retrospective interventional consecutive case series, a chart review was performed in two groups of patients: fourteen patients with a dislocated out-of-the-bag three-piece IOL that underwent IOL fixation to the iris using the Siepser sliding knot technique (Iris group) and 18 patients with in-the-bag dislocation that underwent IOL exchange with a new scleral-sutured IOL (Exchange group). The Iris and Exchange groups were compared regarding surgical safety and efficacy. The median follow-up time was 13.5 months [interquartile range (IQR), 10-20] in the Iris group and 12.5 (IQR, 10-14) in the Exchange group.

RESULTS

The best corrected visual acuity (BCVA) improved significantly in both groups (p = 0.005 and 0.00006, respectively). No difference in final BCVA was seen between the groups. Significantly less surgically induced astigmatism (p = 0.03) and a lower number of postoperative visits (p = 0.0006) was noted in the Iris group. Considering the type of surgery, there were few complications in the present material.

CONCLUSION

In the study, suturing dislocated three-piece IOLs to the iris appeared to be an acceptable surgical management with less surgically induced corneal astigmatism and fewer postoperative visits than IOL exchange. A larger study with a longer follow-up time would be desirable to confirm the results.