Outcomes of scleral-sutured conventional and aniridia intraocular lens implantation performed in a university hospital setting

Research on the Z.S. technique for 8 - 0 polypropylene suture in scleral fixation of one-piece intraocular lens

BACKGROUND

To introduce a new flange technique (called the Z.S. fixation technique) for 8 - 0 polypropylene suture in scleral fixation of a one-piece intraocular lens (IOL) and evaluate its effectiveness and safety.

METHODS

All surgeries were performed using two strategies. First, the Z.S. fixation technique was used to fix 8 - 0 polypropylene sutures to the sclera and the two haptics of a one-piece IOL, respectively. The one-piece IOL previously implanted in the anterior chamber was then relocated to the posterior chamber. Finally, the suture ends outside the sclera were cauterized into flanges and buried in the sclera. All effectiveness and safety data related to the Z.S. technique were recorded and compared.

RESULTS

The Z.S. fixation technique was employed in 16 eyes of 13 patients, with a follow-up duration of at least 6 months. Postoperative uncorrected distance visual acuity (UDVA) was greatly improved in most of the operated eyes (11/16). The mean log MAR UDVA after surgery was significantly improved compared with that before surgery (0.93 ± 0.72 vs. 1.53 ± 0.73, P = 0.002). IOLs in the vast majority of operated eyes (15/16) remained stable during half-year follow-up. No severe intra-/post-operative complications were observed in any of the operated eyes.

CONCLUSION

The Z.S. fixation technique for 8 - 0 polypropylene suture in scleral fixation of one-piece IOL reduced surgical injuries and had ideal surgical effectiveness and safety.

Adjustable flanged technique for secondary implantation of four-point scleral‑fixated posterior chamber intraocular lenses using two parallel 6-0 polyglactin sutures

OBJECTIVE

To assess the efficacy and safety of using the adjustable flanged technique for secondary implantation of four-point scleral‑fixated posterior chamber intraocular lenses with two parallel 6-0 polyglactin sutures.

METHODS

Two parallel 6-0 polyglactin sutures were passed separately through the two haptics on the horizontal line of the 4-haptic IOL. The four externalized sutures were then trimmed and cauterized to form flanges. The best corrected visual acuity, intraocular pressure, and complications in all patients were observed and recorded.

RESULTS

The flanged technique using two parallel 6-0 polyglactin sutures was applied to 14 aphakic eyes. The average preoperative best corrected visual acuity was 1.00 ± 0.88 LogMAR (Snellen 20/200), which improved to 0.42 ± 0.38 LogMAR (Snellen 20/48) at the final follow-up (P = 0.004). None of the patients experienced vitreous hemorrhage, low intraocular pressure, or issues with exposed or broken sutures.

CONCLUSION

The simplicity of the technique, along with its ability to accommodate adjustments post-implantation, allows for optimal positioning and reduces risks like IOL tilt or dislocation. Overall, this is a promising approach to secondary IOL implantation, with potential benefits for both patient outcomes and surgical efficiency.

Management of complications of sutureless intrascleral intraocular lens fixation

PURPOSE

The purpose of the study was to report the complications of sutureless intrascleral (SIS) intraocular lens (IOL) fixation and its management.

MATERIALS AND METHODS

A multicenter, retrospective, consecutive interventional case series of patients with intra or postoperative complications after SIS IOL fixation during the technical learning curve of vitreoretinal surgeons from three Taiwanese referral hospitals. The used surgical techniques were the Scharioth technique for intrascleral tunnel fixation, Yamane technique (double-needle scleral fixation), and modified Yamane technique (double-needle flanged haptic scleral fixation). The IOL models and surgical instruments used as well as each patient's ocular characteristics and complication management were recorded.

RESULTS

Of the eight included patients, the complications of 3 (37.5%) and 5 (62.5%) were noted intraoperatively and postoperatively, respectively. Haptic-related complications, including haptic breakage, slippage, and haptic disinsertion, occurred in six eyes. Other complications included uveitis-glaucoma-hyphema syndrome, retinal detachment, and IOL tilt. For the two patients with haptic slippage, repositioning was achieved using a modified cow-hitch technique that resulted in favorable IOL centration and restored visual acuity.

CONCLUSION

Most complications surgeons encountered during their early exposure to SIS IOL fixation were haptic related. Surgeons should be aware of such complications to prevent and manage them during surgery. Our modified cow-hitch technique could be used to reposition IOLs with unilateral haptic slippage.

Assessment of refractive outcomes in eyes that underwent intraocular lens implantation in the posterior chamber but not "in-the-capsular bag:" A comparative retrospective study

PURPOSE

The purpose of this study was to report visual and refractive outcomes in eyes that underwent intraocular lens (IOL) fixation in the absence of capsular support.

METHODS

This was a retrospective chart review of cases undergoing posterior chamber iris-fixated IOL (IFIOL) and scleral-fixated IOL (SFIOL) implants from June 2014 to March 2020 with more than 3 months of follow-up and having a preoperative best-corrected visual acuity of 20/80 and more.

RESULTS

Records of 120 eyes of 112 patients were reviewed. The mean age of the patients was 46.9 ± 22.3 (14.4-98.0) years, and 62% (n = 70) of participants were male. Most of the eyes (102: 85%) were aphakic at the time of surgery. The mean follow-up was 22.95 ± 17.1 months. The efficacy index of sutured IFIOL and glued SFIOL outperformed sutured SFIOL at 3 months and final visits postoperatively (P < 0.001). All techniques studied here resulted in a similar safety index at 3 months (P = 0.4). The mean predictive error (postoperative spherical equivalent refraction minus intended target refraction) was +0.07 ± 1.5 D and -0.12 ± 1.4 D at 3 months and the final postoperative visit, respectively.

CONCLUSION

The studied techniques have relatively good visual and refractive outcomes in this series. In addition, techniques involving a small corneal incision with foldable IOL fixation to the iris or scleral tissue have superior efficacy and safety indices compared to creating large corneoscleral wounds for rigid IOL fixation techniques.

Four-Point Scleral Fixation of An Akreos Adapt AO Intraocular Lens Using Double-Strand 9-0 Polypropylene Suture

PURPOSE

To report the results of a novel surgical four-point transscleral suture fixation of intraocular lens (IOL) with four hollow haptics using the double-suture technique.

METHODS

We retrospectively reviewed the medical records of 15 eyes of 15 patients who underwent 4-point transscleral suture fixation of a foldable IOL using the double-suture technique. Preoperative data and follow-up data for at least 4 months were collected for all patients.

RESULTS

The IOLs were fixed and centered well. The mean preoperative corrected distance visual acuity was 0.70 ± 0.54 logarithm of the minimum angle of resolution (Snellen 20/102), and it improved to 0.29 ± 0.26 logarithm of the minimum angle of resolution (Snellen 20/39) at the final follow-up ( P = 0.001). No vitreous hemorrhage, hypotony, suture breakage, retinal detachment, IOL dislocation, and iris capture was detected during the follow-up period in any of the patients.

CONCLUSION

We have developed a novel technique for 4-point transscleral suture fixation of IOL using the double-suture technique with 9-0 polypropylene suture. This technique seemed to be safe and it may not require the surgeon to learn any new technique.

Scleral Fixation of a Hydrophobic Acrylic Intraocular Lens with Eyelets Using 8-0 Polypropylene Suture

Purpose

To report clinical outcomes of a scleral fixation technique of a hydrophobic acrylic intraocular lens with eyelets using 8-0 polypropylene suture.

Methods

Nine eyes of nine patients who underwent combined pars plana vitrectomy and sclera fixation of an intraocular lens using this technique were analyzed.

Results

The mean follow-up period was 7.11 months (range, 6–12 months), and there was a significant visual improvement at 6 months after surgery. The mean logarithm of the minimum angle of the resolution changed from 0.54 at baseline to 0.29 at postoperative 6 months (p = 0.016). The mean postoperative spherical equivalent at 6 months was −0.90 ± 0.90 diopters, and the mean predictive error was −0.49 ± 0.62 diopters.

Conclusions

Postoperative visual and refractive outcomes were favorable, and the positions of intraocular lenses were well centered in all cases. This technique could be a useful alternative for surgeons without easy access to Gore-Tex suture.

Biomechanical Testing of Flanged Polypropylene Sutures in Scleral Fixation

OBJECTIVE

To optimize the flanged belt-loop technique of scleral fixation through biomechanical testing and report clinical outcomes of resultant modifications.

DESIGN

Experimental study.

METHODS

The force to disinsert flanged polypropylene suture from human cadaveric sclera was assessed using a tensile testing machine and compared to the breaking strengths of 9-0 and 10-0 polypropylene. The effects of modifying suture gauge (5-0, 6-0, 7-0, or 8-0), amount of suture cauterized (0.5 or 1.0 mm), and sclerotomy size (27, 30, 32, 33 gauge) were investigated. Belt-loop intrascleral fixation using 6-0 and 7-0 polypropylene with 30 and 32 gauge needles, respectively, was performed in 4 patients. Main outcome measures were flanged suture disinsertion forces in cadaveric sclera.

RESULTS

The average force to disinsert a flange created by melting 1.0 mm of 5-0, 6-0, 7-0, and 8-0 polypropylene suture from human cadaveric sclera via 27, 30, 32, and 33 gauge needle sclerotomies was 3.0 ± 0.5 N, 2.1 ± 0.3 N, 0.9 ± 0.2 N, and 0.4 ± 0.1 N, respectively. The disinsertion forces for flanges formed by melting 0.5 mm of the same gauges were 72%-79% lower (P < .001). In comparison, the breaking strengths of 9-0 and 10-0 polypropylene were 0.91 ± 0.4 N and 0.52 ± 0.03 N. Belt-loop fixation using 6-0 and 7-0 polypropylene with 30 and 32 gauge sclerotomies demonstrated good outcomes at 6 months.

CONCLUSIONS

The flanged belt-loop technique is a biomechanically sound method of scleral fixation using 1.0 mm flanges of 5-0 to 7-0 polypropylene paired with 27, 30, and 32 gauge sclerotomies. In contrast, 8-0 polypropylene and 0.5 mm flanges of any suture gauge will likely be unstable with this technique.

Over 10-year follow-up outcomes and failure analysis of black diaphragm intraocular lens implantation in traumatic Aniridia

PURPOSE

To determine the over 10-year follow-up outcomes and analyse the reason for failure in patients who underwent black diaphragm intraocular lens (IOL) implantation for the management of traumatic aniridia.

METHODS

Fifty-three patients underwent black diaphragm IOL implantation for the treatment of traumatic aniridia from September 1998 to August 2007. 33 eyes of 33 patients were enrolled in our study, and the mean follow-up period was 185.6 ± 36.2 months (range: 126-247 months). The primary methods employed for assessment of the safety of the IOL and the causes of failure were the ultrasound biomicroscopy (UBM) and observation during reoperation.

RESULTS

In the current study, 13 patients (39.4%) who underwent IOL implantation by means of trans-scleral fixation were observed to maintain a transparent cornea and normal intraocular pressure. 20 patients (60.6%) developed corneal endothelial decompensation, and 14 patients (42.4%) developed secondary glaucoma. 27 patients were examined by means of UBM or reoperation and the position of black diaphragm IOL in 18 patients was observed to be abnormal; the IOL had shifted forward and directly contacted with the anterior chamber and even the corneal endothelium.

CONCLUSION

The forward displacement of black diaphragm IOL is a direct cause of treatment failure. Although the implantation of black diaphragm IOL is an effective method of management of traumatic aniridia, the treatment should be guarded and performed in an appropriate manner. Patients should be informed regarding the need for life-long follow-up, so that the complications can be identified in a timely manner.

Outcomes and Complications of Sutured Scleral-Fixated Foldable Intraocular Lens Implantation: A Retrospective Study of 5-Year Follow-Up

Purpose

To evaluate long-term outcomes and complications of sutured scleral-fixated foldable intraocular lens (IOL) implantation.

Design

Retrospective study.

Methods

Patients who underwent sutured scleral-fixated foldable IOL implantation using 10-0 polypropylene suture were followed up for at least 5 years at one Chinese tertiary hospital and two primary hospitals.

Results

52 eyes among 48 patients (35 male and 13 female) were evaluated. The mean age (years) was 50.27 ± 20.08 (range: 6 to 81). The mean postoperative follow-up time (months) was 79.70 ± 18.84 (range: 60 to 121). The mean best-corrected visual acuity (BCVA) improved from 0.83 ± 0.69 logarithm of the minimum angle of resolution (logMAR) at baseline to 0.50 ± 0.45 logMAR at the last follow-up visit. There was improved or unchanged BCVA in 44 eyes (84.62%) and reduced BCVA in 8 eyes (15.38%). Mild intraoperative intravitreal hemorrhage was observed in 3 eyes (5.77%). Early postoperative complications included transient elevated intraocular pressure (IOP) in 5 eyes (9.62%) and hypotony in 1 eye (1.92%). Secondary epimacular membrane occurred in 5 eyes (9.62%) and retinal detachment (RD; 3 years postsurgery), subconjunctival suture knot exposure (5 years postsurgery), and persistent elevated IOP (in a GRAVES patient) occurred in 1 eye (1.92%) each. No suture erosion or breakage nor IOL dislocation was observed. No visually threatening IOL tilt or decentration was reported in any patient.

Conclusion

Sutured scleral-fixated foldable IOL implantation demonstrated satisfactory long-term outcomes and rare suture-related complications. This technology was safe and did not require complicated equipment and is of considerable interest in the setting of aphakia without adequate capsule support.

POSITION OF IN-THE-BAG POSTERIOR CHAMBER INTRAOCULAR LENSES RELATIVE TO THE LIMBUS: Applications to Scleral-Sutured Lenses

PURPOSE

To characterize the true position of in-the-bag intraocular lenses (IOLs) relative to the limbus using ultrasound biomicroscopy and estimate scleral-sutured IOL positioning.

METHODS

This prospective single-center study included 70 eyes of 41 patients with in-the-bag posterior chamber IOLs. Four vertical ultrasound biomicroscopy captures were performed in each eye in the superior, inferior, nasal, and temporal quadrants. Postoperative biometric data were collected. The primary outcome was the vertical distance of the in-the-bag IOL from the sclerocorneal limbus. Secondary outcomes included anterior shift and refractive change of a theoretical scleral-sutured IOL using sclerotomies at 2.5 mm and 3 mm posterior to the limbus.

RESULTS

A total of 265 ultrasound biomicroscopy images were analyzed, including 64 superior, 69 inferior, 66 nasal, and 66 temporal. The true in-the-bag IOL position measured as distance posterior to the sclerocorneal limbus was 4.23 ± 0.56 mm superiorly, 4.22 ± 0.46 mm inferiorly, 3.95 ± 0.48 mm nasally, and 3.86 ± 0.52 mm temporally. The anterior shift of a theoretical scleral-sutured IOL was 0.60 mm for a 3-mm sclerotomy and 0.93 mm for a 2.5-mm sclerotomy, resulting in a theoretical myopic shift of 0.45 diopter (D) and 0.79 D, respectively, assuming a 15-D IOL. Larger biometric measurements correlated with a more posterior in-the-bag position.

CONCLUSION

True in-the-bag IOL position was found to be more posterior than estimates of scleral-sutured IOLs. Additional corrections in scleral-sutured IOL calculations may improve refractive outcomes.

Transfixion of Foldable Intraocular Lens With Polytetrafluoroethylene Suture for Scleral Fixation

PURPOSE

To describe a new scleral fixation technique potentially usable for every acrylic foldable intraocular lens (IOL) available in the market, regardless of whether it is a three-piece, single-piece, or haptic shape.

METHODS

Before surgery, the authors performed the transfixion of the IOL optic in four points with the polytetrafluoroethylene suture under a surgical microscope. Four sclerotomy sites were marked 2 mm from the limbus, and two scleral grooves were created in between. The IOL was introduced into the posterior chamber. The four ends of the needleless polytetrafluoroethylene sutures were externalized through the sclerotomies, tightened for optimum IOL centration, and tied. The exposed sutures were placed within the scleral grooves, and the knots were buried within the sclerotomies. This technique was performed uneventfully in 7 cases.

RESULTS

The foldable IOL was stable in all eyes 6 months after surgery, with no signs of IOL subluxation, dislocation, tilt, or suture-related complications, such as erosion or infection.

CONCLUSIONS

The transfixion of the foldable posterior chamber IOL for stable four-point scleral fixation using a polytetrafluoroethylene suture provides excellent stability and prevents IOL tilt and decentration. This technique can immensely benefit patients requiring secondary foldable posterior chamber IOL implantation in the absence of capsular support. [J Refract Surg. 2021;37(3):180-185.).

Long-Term Stability of Intraocular Lens with Trimmed or Untrimmed Haptics in Yamane Sutureless Intrascleral Fixation Technique

Background

In intraocular lens (IOL) sutureless intrascleral fixation using the Yamane technique, untrimmed haptics may be overlong in some cases due to varied haptic lengths and individual differences. However, whether trimming the haptic affects IOL stability remains unknown.

Material/Methods

Thirty-nine eyes of 39 patients who underwent Yamane sutureless intrascleral fixation surgery between October 2017 and February 2018 were analyzed retrospectively. Nineteen patients underwent surgery with untrimmed haptics and 20 patients with trimmed haptics. The slit-lamp examination, best-corrected visual acuity (BCVA), corneal endothelial cell density (ECD), IOL position, and complications were assessed.

Results

The mean follow-up periods in the untrimmed and trimmed groups were 27.84±2.89 months and 27.85±2.41 months, respectively. The BCVA improved and ECD decreased in both groups postoperatively (all P<0.01). No significant differences were seen between the 2 groups in postoperative BCVA, postoperative ECD, IOL tilt at 3 months and 24 months, and IOL decentration at 3 months (all P>0.05). There were significant differences between the 2 groups in IOL decentration at 24 months (P<0.05). Compared with postoperative 3 months, both the postoperative IOL tilt and decentration at 24 months increased in the 2 groups (all P<0.01). Postoperative complications included IOL elevation (11% in the untrimmed group and 10% in the trimmed group), as well as haptic extrusion (16% in the untrimmed group).

Conclusions

The position of the IOL may change with time, but trimming the haptic to an optimum length tends to provide greater IOL stability.

Novel use of an adjustable single 8-0 polypropylene suture of scleral fixation without conjunctival dissection

Background

This report serves to describe the use of a novel adjustable single 8–0 polypropylene suture for scleral fixation without conjunctival dissection, and to describe related clinical outcomes associated with this approach.

Methods

In this study, we retrospectively reviewed 28 eyes from 27 patients that underwent scleral fixation of the intraocular lens (IOL) without conjunctival dissection using an adjustable single 8–0 polypropylene suture at the Beijing Tongren Eye Center between April 2018 and April 2019. For this surgical approach, a 23-gauge infusion cannula was set, after which two Hoffmann scleral pockets were created. Next, 8–0 polypropylene sutures were inserted into the eye guided by 10–0 polypropylene sutures of a long straight needle. The 8–0 suture was then used to fix the haptic IOs. Finally, these 8–0 polypropylene sutures were removed from the scleral pockets, and knots were tightened with the adjustable single suture. Primary outcomes included visual acuity and postoperative complication incidence.

Results

For this study, outcomes for 28 eyes from 27 patients (9 female, 18 male) were assessed. Patients had a mean age of 54 ± 15.11 years-old and were followed for an average of 10.18 ± 2.76 months postoperatively. Uncorrected visual acuity in these patients improved significantly from a preoperative value of 1.269 ± 0.464 logMAR to a 3-month postoperative value of 0.409 ± 0.413 logMAR (p = 0.000). The majority of postoperative complications in these patients were temporary and self-limiting, including corneal edema (35.71%), hypotony (14.29%), elevated intraocular pressure (28.58%), and mild hyphema (7.14%). No evidence of exposure or erosion of the trimmed suture end was detected in any patients. An ultrasound biomicroscope was able to readily detect the IOL and all sutures, and IOLs were found to be well-centered without any dislocation, tilting, or subluxation upon follow-up.

Conclusions

An adjustable single 8–0 polypropylene suture can reliably and effectively be used for scleral fixation without conjunctival dissection for the treatment of patients with aphakia or inadequate posterior capsule support. The novel procedure described herein may therefore be an effective means of minimizing the risk of suture-related complications in patients undergoing scleral-fixated IOL implantation.

Trial registration

Retrospective case series study, not applicable. NCT04476264.

IOL repositioning using iris sutures: a safe and effective technique

This retrospective non-comparative consecutive case series study was conducted at Azienda Ospedaliera Universitaria Careggi, Florence, Italy and describes a useful intraocular lens (IOL) repositioning technique using iris sutures. In our study, 41 consecutive cases of posteriorly dislocated IOLs were surgically treated between January 2015 and May 2017. Six of the cases were post-traumatic luxations, and 20 patients had pseudoexfoliation syndrome. All the patients underwent pars plana vitrectomy and same IOL repositioning using iris sutures. The mean follow-up was 12.2mo. The mean preoperative best corrected visual acuity (BCVA) was 0.10±0.15 logMAR, whereas the mean postoperative BCVA was 0.08±0.14 logMAR. The mean postoperative BCVA did not change significantly from the preoperative BCVA. The final mean spherical equivalent was -0.44±0.49 SD. Three lenses (7.31%) were found tilted during post-operative follow-up. Two eyes (4.87%) had postoperative cystoid macular edema. No eyes had endophthalmitis, hypotony, retinal or choroidal detachment. The iris fixation technique seems to be a safe and valid option for the management of dislocated IOLs.

Long-term outcome of scleral-fixated intraocular lens implantation without conjunctival peritomies and sclerotomy in ocular trauma patients

Background

To investigate the long-term outcomes and complications of scleral-fixated intraocular lens (SFIOL) implantation without conjunctival peritomies and sclerotomy in patients with a history of ocular trauma with inadequate capsular support during primary pars plana vitrectomy or silicone oil removal.

Methods

Records of ocular trauma patients who underwent implantation of SFIOL without conjunctival peritomies and sclerotomy during primary pars plana vitrectomy or silicone oil removal.

Results

Sixty-nine eyes of 69 patients were included in this study. The median follow-up period was 34 months (range, 6–99 months). The average patient age at the time of surgery was 44 years old (range, 4–80 years). At the end of follow-up, the preoperative mean of best corrected visual acuity (BCVA) was 0.79 ± 0.86 log of the minimum angle of resolution (logMAR), which improved 0.20 ± 0.26 logMAR postoperatively (P = 0.01). BCVA improved or remained unchanged in 64 eyes (92.8%), VA decreased two lines in five eyes (7.2%). Early postoperative complications included transient corneal edema in seven eyes (10.1%), minor vitreous hemorrhage in four eyes (5.8%), transient elevated intraocular pressure (IOP) in one eye (1.4%), and hypotony in three eyes (4.3%). Late postoperative complications included persistent elevated IOP in five eyes (7.2%), epiretinal membrane formation in three eyes (4.3%), and cystoid macular edema noted in one eye (1.4%).

Conclusions

Use of a scleral-fixated intraocular lens implantation without conjunctival peritomies and sclerotomy in ocular trauma patients during either primary pars plana vitrectomy or second silicone oil removal is a valuable approach for the management of traumatic aphakia in the absence of capsular support.

Electronic supplementary material

The online version of this article (10.1186/s12886-019-1172-4) contains supplementary material, which is available to authorized users.

Scleral Fixation of Intraocular Lenses with Gore-Tex Suture: Refractive Outcomes and Comparison of Lens Power Formulas

PURPOSE

To report refractive outcomes of scleral-fixated intraocular lens (IOL) implantation with Gore-Tex (W.L. Gore & Associates, Newark, DE) suture and combined pars plana vitrectomy and compare predicted refractive outcomes among 5 IOL power calculation formulas.

DESIGN

Retrospective case series.

PARTICIPANTS

Patients undergoing scleral-fixated IOL implantation with Gore-Tex suture at our institution between January 2015 and June 2018.

METHODS

Comparison of preoperative biometrics with postoperative refraction and calculation of predicted refractive outcome with 5 different IOL formulas.

MAIN OUTCOME MEASURES

Prediction error and absolute error to compare postoperative refraction with refraction predicted by lens power calculation formulas.

RESULTS

Thirty-one eyes of 31 patients were included. All power calculations assumed in-the-bag position of the IOL. The Akreos A060 (Bausch & Lomb, Rochester, NY) was implanted in 23 eyes and the CZ70BD (Alcon, Fort Worth, TX) in 8 eyes, and all lenses were sutured 3 mm behind the limbus. Average postoperative spherical equivalent (SE) was -0.79±0.95 diopters (D). Average prediction error (postoperative SE refraction minus target refraction) was -0.19±0.72 D. Postoperative SE was within 1.0 D of target in 25 of 31 patients (81%) and 2.0 D of target in 31 of 31 patients (100%). The repeated-measures analysis of variance of absolute error by lens power formula was significant (P = 0.012), with Haigis demonstrating greater error. There was no significant difference among Barrett II, Sanders-Retzlaff-Kraff theoretical (SRK/T), Holladay 2, or Hoffer Q.

CONCLUSIONS

For eyes undergoing pars plana vitrectomy with scleral-sutured IOL implantation, assumption of in-the-bag IOL position when calculating lens power leads to acceptable refractive outcomes. Barrett II, SRK/T, Holladay 2, and Hoffer Q formulas were noninferior to each other.

Black Diaphragm Intraocular Lens Implantation in Patients with Aniridia

Purpose

To review the management outcomes of black diaphragm intraocular (BDI) lens implantation in Arab patients with aniridia.

Methods

Patients with aniridia undergone BDI lens implantation at our institution between 2013 and 2014 were included. Uncorrected visual acuity (UCVA), manifest refraction, and best-corrected visual acuity (BCVA) were evaluated before and 6 months and yearly after BDI lens implant surgery until the last visit. Intra- and postoperative complications were noted.

Results

Our series comprised 14 patients (8 males) with aniridia. The median duration of follow-up was 30 months (25% quartile). Ocular parameters, refractive status, and vison were all significantly improved at the last follow-up compared to the preoperative values (P < 0.05 for all comparisons). All patients reported a significant decrease in photophobia and glare. Postoperatively, 11 eyes (78%) gained 2 or more lines of UCVA. At the last follow-up, BCVA increased by 2 or more lines in all cases. Early postoperative complications included main wound leakage (one eye) and anterior chamber hyphema (one eye). Late (≥6 months) complications included corneal decompensation (one eye), failed penetrating keratoplasty graft (2 eyes), and subluxation of a scleral fixated BDI lens (one eye). Surgical interventions performed to manage complications included penetrating keratoplasty in 2 eyes with corneal decompensation and failed graft (one each), and re-suturing of a subluxated intraocular lens (one eye).

Conclusion

BDI lenses seem to be a safe and effective iris prosthetic with intraocular lens combination surgery for patients with congenital or traumatic aniridia. Periodic evaluation and prompt management of complications are recommended.

New use of 8-0 polypropylene suture for four-point scleral fixation of secondary intraocular lenses

We describe 4-point scleral fixation of a posterior chamber intraocular lens (PC IOL) using 8-0 polypropylene (Prolene) sutures, without the handshake technique. First, 4 sclerotomy sites are marked 2.5 mm from the limbus, and 2 scleral grooves are created in between. Two sets of 8-0 polypropylene sutures are then passed through the IOL haptics. The PC IOL is inserted behind the iris, and the sutures are pulled ab interno and tightened for optimum IOL centration. The sutures and exposed knots are imbedded within the scleral groove and sealed with fibrin glue. This 4-point scleral fixation technique was performed uneventfully in 9 cases (4 men, 5 women; mean age 71.4 years ± 12.2 [SD]) and the PC IOL was stable for 10 months (range 8 months to 1 year) with no signs of IOL subluxation, dislocation, tilt, or suture-related complications such as erosion or infection.

Surgical Synechiolysis of Iridocapsular Adhesion and Sulcus Placement of a Rigid Intraocular Lens on an Oversized Residual Capsular Rim

Purpose

To report the surgical outcomes of surgical synechiolysis of iridocapsular adhesion and sulcus placement of a polymethyl methacrylate scleral-sutured intraocular lens (IOL) in aphakic eyes with an oversized residual capsular rim.

Methods

Eight aphakic eyes from eight consecutive patients were studied retrospectively. Synechiolysis was performed to maximally expose the residual capsulorhexis. Then, the rigid IOL was placed on the preserved capsulorhexis into the ciliary sulcus.

Results

Synechiolysis of iridocapsular adhesion was achieved in all eight eyes intraoperatively. Six eyes had extensive dissection to facilitate IOL sulcus placement. Consequently, seven of the eight eyes had the IOL secured by the residual capsulorhexis, and the other eye had the IOL haptics supported by the narrow residual capsular rim. A visual acuity of 0.25 or above was achieved in four of eight patients, and a well-centered IOL was observed in seven of the eight eyes 26 to 53 months after surgery. A mild IOL decentration was detected in the eye whose capsular rim was not securing the IOL optic.

Conclusions

A large-optic and rigid IOL in the sulcus is a feasible alternative when a sulcus-based IOL is considered for aphakic eyes with an oversized residual capsulorhexis. A preserved capsulorhexis after sufficient synechiolysis, which can secure the IOL optic intraoperatively, may yield better stability of the IOL position.

[Outcomes of intraocular lens implantation in the absence of capsular support: a review of current literature]

Тhe prevalence of complications associated with the deficiency or absence of capsular support in cataract patients is 5-15%. Moreover, approximately 20% of patients have an inconspicuous zonular weakness, which is often left undetected preoperatively.

AIM

to classify and comparatively analyze the latest published data on the outcomes of various kinds of complicated cataract surgery.

MATERIAL AND METHODS

Analysis of available literature on the subject of research published in 2003-2016.

RESULTS

The method of sutured scleral fixation of the intraocular lens (IOL) is the most fully covered in the current literature. It has been used long enough and is, therefore, well tested. Its typical complications include sutures degradation, hemorrhage, and inflammation. Sutureless fixation of the IOL, which has become more common in recent years, is free of complications associated with degradation of the sutures. However, studies on the long-term results of this technique are few and most of them were conducted in a small clinical material.

CONCLUSION

Basing on the present analysis, one may conclude that at the current level of surgery, sutureless scleral and iridal fixation of the IOL is more preferable in terms of possible postoperative complications.

Complications of Scleral-Fixated Intraocular Lenses

INTRODUCTION

Understanding the evolution of complications after scleral-fixated lens placement demonstrates advantageous surgical techniques and suitable candidates.

MATERIALS/METHODS

A literature search in PubMed for several terms, including "scleral intraocular lens complication," yielded 17 relevant articles.

RESULTS

Reviewing complication trends over time, lens tilt and suture erosion have decreased, cystoid macular edema has increased, and retinal detachment has remained the same after scleral-fixated lens placement. The successful reduction in complications are attributed to several alterations in technique, including positioning sclerotomy sites 180 degrees apart and using scleral flaps or pockets to bury sutures. Possible reduction in retinal risks have been proposed by performing an anterior vitrectomy prior to lens placement in certain settings.

DISCUSSION

Complications after scleral-fixated lens placement should assist patient selection. Elderly patients with a history of hypertension should be counseled regarding risk of suprachoroidal hemorrhage, while young patients and postocular trauma patients should be considered for concurrent anterior vitrectomy.

Scleral-Fixated Intraocular Lenses: Past and Present

Intraocular lenses (IOLs) can have inadequate support for placement in the capsular bag as a result of ocular trauma, metabolic or inherited conditions such as Marfan's syndrome or pseudoexfoliation, or complicated cataract surgery. Surgical options for patients with inadequate capsular support include alternative placement in the anterior chamber (ACIOLs), fixation to the iris, or fixation to the sclera. The surgical techniques for each of these approaches have improved considerably over the last several decades resulting in improved visual and ocular outcomes. If no capsular or iris support exists, the surgeon can fixate an IOL to the sclera or the patient can remain aphakic. IOLs can be fixated to the sclera using sutures or by tunneling the IOL haptics into the sclera without sutures. This review summarizes the pre-operative considerations, surgical techniques, outcomes, and unique complications associated with implantation of scleral-fixated IOLs.

Small-incision 4-point scleral suture fixation of a foldable hydrophilic acrylic intraocular lens in the absence of capsule support

PURPOSE

To determine the visual outcomes and complications of a new small-incision technique for 4-point fixation of a hydrophilic acrylic posterior chamber intraocular lens (IOL) in the absence of capsule support.

SETTING

Three North American tertiary referral centers and a private practice.

DESIGN

Retrospective case series.

METHODS

Secondary IOL placement was performed from 2011 to 2014. Indications for surgery, clinical results, and complications were analyzed. Primary outcomes included postoperative corrected distance visual acuity (CDVA) and surgical complications.

RESULTS

Charts of 35 patients (37 eyes) were reviewed. The mean age at surgery was 56 years, and the mean follow-up was 6 months (range 3 to 24 months). Clinical indications included a dislocated IOL (30%), ocular trauma (19%), crystalline lens subluxation (19%), uveitis-glaucoma-hyphema syndrome (5%), post-complicated cataract (8%), congenital cataract (8%), and decompensated cornea (3%). The mean CDVA improved from 20/80 preoperatively to 20/40 postoperatively (P < .01). Thirty-six eyes (97%) had an improved or unchanged CDVA, and 1 eye (3%) had a reduced CDVA because of worsening glaucoma. Postoperative complications included ocular hypertension (24%), iritis (5%), wound leakage (3%), transient corneal edema (3%), glaucoma requiring a tube shunt (3%), and IOL dislocation (3%).

CONCLUSION

Small-incision 4-point scleral fixation of the Akreos AO60 hydrophilic acrylic IOL in the absence of capsule support appears to be a safe and effective technique for secondary IOL placement.

FINANCIAL DISCLOSURES

Drs. Berdahl and Ayres are consultants to Bausch & Lomb, Inc. Drs. Ayres and Fram have received speaker fees from Bausch & Lomb. Dr. Terveen does not have a financial or proprietary interest in any material or methods mentioned.

Transscleral fixation of single-piece foldable acrylic lens with eyelets at the optic-haptic junction

OBJECTIVE

To report the clinical outcomes of transscleral fixation using a single-piece foldable acrylic intraocular lens (IOL) with eyelets at the optic-haptic junction (enVista; Bausch & Lomb).

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Sixty eyes of 60 patients who underwent transscleral fixation with an enVista IOL were reviewed.

METHODS

Preoperative patient status, postoperative visual and refractive outcomes, and postoperative complications were analyzed.

RESULTS

The study included 60 eyes of 60 patients (52 males, 8 females) with a mean age of 56.65 ± 15.57 years. At final follow-up visit, the mean follow-up was 11.40 ± 4.24 months. The mean uncorrected visual acuity (logMAR) improved from 1.95 ± 0.90 to 0.85 ± 0.77 (p < 0.001), and best corrected visual acuity (logMAR) improved from 1.11 ± 1.13 to 0.64 ± 0.70 (p = 0.006). The mean spherical equivalent improved significantly from 6.90 ± 6.10 to 0.21 ± 2.10 D postoperatively (p < 0.001). Complications included transient ocular hypertension (15%), transient hypotony (7%), and hyphema (5%), but no serious complications were observed. In all cases, the IOL remained stable and well centred.

CONCLUSIONS

Transscleral fixation using a foldable acrylic IOL with eyelets at the optic-haptic junction can be a safe and effective alternative technique to manage cases with broken capsular bag or weak zonular support.

Visual management of aphakia with concomitant severe corneal irregularity by mini-scleral design contact lenses

Purpose

To evaluate visual results, comfort of use, safety, and efficacy of mini scleral contact lenses in optical management in patients with traumatic aphakia and severe concomitant irido-corneal injury.

Methods

In a case series, eight eyes with post traumatic aphakia and severe concomitant irido-corneal injury that were evaluated at the Contact Lens Clinic of Farabi Eye Hospital, Tehran, Iran for contact lens fitting and could not be corrected with conventional corneal RGP contact lenses were fitted with miniscleral contact lenses. Uncorrected visual acuity (UCVA), best spectacle corrected visual acuity (BSCVA), and BCVA (Best corrected visual acuity) with miniscleral lens were recorded. Slit lamp examination, comfortable daily wearing time, and any contact lens-related complication were documented in each follow-up visit.

Results

The mean UCVA and BSCVA of the cases was >2.7 and 0.41 LogMAR, respectively (BSCVA could not be assessed in one case due to severe corneal irregularity). The mean final BCVA with the miniscleral lens was 0.05 LogMAR (range from 0.4 to −0.04 LogMAR). The mean follow-up period was 14.6 months. The mean comfortable daily wearing time (CDWT) was 11.6 h, ranging from 8 to 16 h. The only contact lens-related complication was mild redness and irritation that was observed in 2 patients during the follow-up visits. All patients were comfortable with handling these lenses.

Conclusion

Miniscleral contact lenses can be considered a safe and effective option in aphakia patients with concurrent corneal scarring secondary to ocular injury for whom surgical intervention would be complicated.

Long-Term Outcomes of Iris-sutured Posterior Chamber Intraocular Lenses in Children

PURPOSE

To report the long-term outcomes and complications of iris-sutured posterior chamber intraocular lenses (PCIOLs) in the pediatric population.

DESIGN

Retrospective interventional case study.

METHODS

This study involved 12 consecutive pediatric patients (17 eyes) who underwent placement of foldable iris-sutured PCIOLs between September 2004 and September 2007. Outcome measures included change in visual acuity and complications.

RESULTS

Of the 17 eyes were reviewed, 6 (35%) had hereditary or idiopathic ectopia lentis, 5 (29%) had Marfan syndrome, 2 (12%) were aphakic after pars plana vitrectomy and 4 (24%) were aphakic after surgical intervention for trauma. Average follow-up was 4.69 ± 3.21 years and mean age of surgery was 7.21 ± 3.78 years. Seven eyes suffered dislocation of the PCIOL an average of 12.11 ± 11.97 months after surgery, with 2 patients undergoing dislocation a second time. There was a higher rate of dislocation in patients with a history of ectopia lentis due to Marfan syndrome, idiopathic causes, or hereditary causes than in patients being treated for aphakia resulting from other causes (71% vs 29%). Mean visual acuity improved in 12 of 17 patients (71%), from 0.80 ± 0.6 logMAR preoperatively to 0.35 ± 0.5 logMAR at most recent visit, P = .009. One eye of a Marfan patient sustained a retinal detachment 8 months after dislocation of the PCIOL, and 1 patient experienced iris capture of the PCIOL after surgery.

CONCLUSIONS

Iris-sutured intraocular lenses have been used as an alternative to transsclerally sutured intraocular lenses to correct aphakia in pediatric patients. Dislocation of the intraocular lenses can occur frequently, however. The procedure should be considered with caution in pediatric patients.