Transscleral fixation of a foldable posterior chamber intraocular lens

Potential role of the light-adjustable lens in flanged intrascleral haptic fixation

PURPOSE

To compare maximum tensile strength between commonly used 3-piece intraocular lens (IOL) for flanged intrascleral haptic fixation (FISHF).

SETTING

Willis-Knight Eye Institute, Shreveport, Louisiana.

DESIGN

Laboratory investigation.

METHODS

Haptic tensile strength was compared with MA60AC, CT Lucia 602, AR40E, and the light-adjustable lens (LAL). Haptic strength with a 24-diopter (D) IOL was compared across all lenses, as well as across a range of 10 to 30 D with the MA60AC. A custom device was created to hold the IOL in correct haptic orientation. The maximum tension (mean ± SD) was recorded in Newtons (N) when the haptic lost tension or broke.

RESULTS

CT Lucia was the strongest at 1.53 ± 0.11 N vs 1.00 ± 0.15 (MA60AC), 0.87 ± 0.19 (AR40E), and 0.83 ± 0.14 N (LAL) ( P < .001). The LAL and AR40E were similar to a 9-0 polypropylene suture while being significantly stronger than 10-0 polypropylene suture ( P < .001). No difference in haptic tension for the MA60AC from 10 to 30 D ( P > .05). High magnification revealed the highest haptic fractures for MA60AC at 40% compared with LAL, AR40E, and CT Lucia at 0%. CT Lucia and AR40E had 100% of haptics disinserted from the IOL without any damage compared with 60% LAL and 60% MA60AC. CT Lucia, AR40E, and LAL have a flatter haptic angulation at 5 degrees.

CONCLUSIONS

Haptic strength, durability, and angulation of the LAL may support the possibility of FISHF in the hands of experienced surgeons. However, further testing is strongly recommended to verify whether physiologic conditions or light treatments may compromise long-term haptic stability.

LONG-TERM OUTCOME OF TRANSSCLERAL FOUR-POINT FIXATION OF AKREOS INTRAOCULAR LENS WITH CLOSED CONTINUOUS-LOOP SUTURE

PURPOSE

To report the long-term clinical outcomes of transscleral four-point fixation of Akreos intraocular lens using a closed continuous-loop suture technique.

METHODS

This was a retrospective, multicenter, interventional case series. Primary outcome measures were best-corrected visual acuity, intraocular pressure, corneal endothelial cell density, and complications with a minimum of 1-year follow-up.

RESULTS

One hundred and ninety-two eyes of 177 patients from two surgical hospital sites were identified. The mean best-corrected visual acuity improved from 0.88 ± 0.74 logarithm of the minimum angle of resolution (Snellen 20/152) preoperatively to 0.42 ± 0.52 logarithm of the minimum angle of resolution (Snellen 20/53) postoperatively ( P < 0.001). The mean preoperative intraocular pressure was 17.51 ± 8.67 mmHg, and the mean postoperative intraocular pressure at final follow-up was 15.08 ± 4.18 mmHg ( P = 0.001). The mean corneal endothelial cell density significantly reduced from 2,259 ± 729 cells/mm 2 to 2077 ± 659 cells/mm 2 , representing a cell loss of 5.73% ( P < 0.001). The intraocular lens was fixed well during follow-up. There were no intraoperative complications noted. Postoperative complications included transient ocular hypertension in 15 eyes (7.81%), hypotony in two eyes (1.04%), retinal detachment in one eye (0.52%), and macular edema in one eye (0.52%).

CONCLUSION

The transscleral four-point fixation Akreos intraocular lens using the closed continuous-loop suture technique was effective and safe with satisfactory visual acuity with a minimum of 1-year follow-up.

Intraocular Suture Technique for Flapless Two-Point Fixation of Four Fenestrated Haptics Intraocular Lenses

PURPOSE

To describe a flapless technique for two-point fixation of intraocular lens (IOL) with four fenestrated haptics.

METHODS

A transconjunctival puncture of 1-mL syringe needle was used to guide the suture needle out of the eye. The suture was taken out of the eye through the corneal incision, passed through the pair of fenestrated haptics of the IOL and then securely tied with overhand knots. The folded IOL was implanted into the posterior chamber. The anchor knots were created by both ends of the thread approximately 4 mm to 5 mm apart from the transconjunctival puncture and was intrasclerally buried.

RESULTS

The technique was used in 18 eyes (18 patients). The mean postoperative follow-up period was 17.22 ± 8.82 months. The IOLs of all the eyes remained well positioned and stable at the final follow-up. The visual acuities of all the eyes were improved postoperatively. No suture loosening, suture erosion, hypotony, scleral atrophy, chronic inflammation, retinal tears, and/or detachments were observed in any of the patients.

CONCLUSION

The present technique provides minimal trauma and reliable stability for the two-point transscleral fixation of four fenestrated haptics IOL.

Comparison of sutureless intrascleral fixation and sutured scleral fixation for the treatment of dislocated intraocular lenses

BACKGROUND

To compare the outcomes of sutured transscleral fixation and sutureless intrascleral fixation for the treatment of a dislocated intraocular lens (IOL).

METHODS

Thirty-five eyes of 35 patients who required IOL repositioning surgery due to IOL dislocation were included in this retrospective study. Sixteen eyes underwent two-point sutured transscleral fixation, eight eyes underwent one-point sutured transscleral fixation, and 11 eyes underwent sutureless intrascleral IOL fixation. The patients were followed for ≥ 12 months after repositioning surgery, and their postoperative outcomes were recorded and analyzed.

RESULTS

The major cause of IOL dislocation was ocular blunt trauma (19/35, 54.3%). The mean corrected distance visual acuity (CDVA) improved significantly after IOL repositioning (P = 0.022). The mean postoperative change in endothelial cell density (ECD) was - 4.5%. There were no significant differences in the changes in CDVA or ECD among the three groups with different repositioning techniques (both P > 0.1). The mean vertical tilt of the IOLs in all enrolled patients was significantly greater than the horizontal value (P = 0.001). The vertical tilt was greater in the two-point scleral fixation group than that in the sutureless intrascleral fixation group (P = 0.048). The mean decentration values in the one-point scleral fixation group in the horizontal and vertical directions were greater than those in the other two groups (all P < 0.01).

CONCLUSION

All three IOL repositioning techniques resulted in favorable ocular prognosis.

Intraocular Lens Formula Comparison of Flanged Intrascleral Intraocular Lens Fixation with Double Needle Technique

Purpose

To analyze visual outcomes and accuracy of intraocular lens (IOL) calculation formulas in predicting postoperative outcomes in patients undergoing flanged intrascleral IOL fixation.

Design

Case Series.

Subjects

Twenty-three patients who had undergone secondary IOL placement using flanged intrascleral fixation technique.

Methods

Retrospective chart review.

Main Outcome Measures

Corrected distance visual acuity (CDVA) and postoperative spherical equivalent based on manifest refraction.

Results

Visual acuity improved from 20/577 to 20/58. Overall, the actual refraction was 0.06 D more myopic than predicted. Holladay 2, Sanders Retzlaff Kraff/Theoretical (SRK/T) and Barrett Universal II resulted in mild myopic surprise (-0.55, -0.18 and -0.20 D). Haigis and Hill-RBF (Radial Basis Function) resulted in mild hyperopic surprise (+0.28 and +0.28 D). Hoffer Q and Holladay 1 were the most accurate (-0.02D and -0.08 D).

Conclusion

Flanged intrascleral IOL fixation improved vision even in patients with other posterior segment pathologies. The effective lens positioning is likely similar to in-the-bag positioning. Hoffer Q and Holladay 1 formulas with in-the-bag calculations were the most accurate.

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.

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.

Massive Delayed Hemorrhagic Choroidal Detachment and Giant Retinal Tear Detachment Following Scleral-Fixated Akreos IOL

A 78-year-old woman underwent 25-gauge pars plana vitrectomy and scleral fixation for a dislocated intraocular lens in the left eye under general anesthesia. She developed massive hemorrhagic choroidal detachment 1 day later. A giant retinal tear detachment and proliferative vitreoretinopathy was noted at postoperative Week 7 and repaired with choroidal drainage, 240° peripheral retinectomy, perfluorocarbon liquid, endolaser, and silicone oil. Hypotony associated with the 25-gauge sclerotomies used for suture fixation was the suspected etiology for this complication. Use of 27-gauge instrumentation or application of fibrin glue to superior sclerotomies may help reduce the incidence of postoperative hypotony. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:288-292.].

Scleral fixation of a single-piece foldable acrylic IOL through a 1.80 mm corneal incision

A new scleral fixation technique of a single-piece acrylic foldable intraocular lens (IOL) (enVista MX60, Bausch & Lomb, Inc.) through a 1.80 mm corneal incision, using the IOL eyelets as anchoring point, is described. It was a retrospective review of 26 cases. The preoperative mean corrected distance visual acuity was 0.51 ± 0.21 logarithm of the minimum angle of resolution (logMAR). It improved significantly to 0.25 ± 0.27 logMAR (P < .01), 0.18 ± 0.16 logMAR (P < .01), and 0.17 ± 0.16 logMAR (P < .01) (at 1 month, 3 months, and 6 months postoperatively, respectively, repeated measures analysis of variance, P < .0001). No astigmatism increase of more than 0.75 diopters was recorded at any time point. In all 26 patients, the IOL was well centered and stable for the entire monitoring period. No complications were observed during follow-up. Scleral fixation of the foldable IOL through a 1.80 mm corneal incision provided excellent IOL stability during the 6-month follow-up of this study and might be an effective and safe surgical technique.

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.).

Clinical observation of a novel technique: transscleral suture fixation of a foldable 3-looped haptics one-piece posterior chamber intraocular lens implantation through scleral pockets with intact conjunctiva

Background

To present the follow-up outcomes of a modified technique of transscleral suture fixation of posterior chamber intraocular lens (PCIOL) in eyes with inadequate capsule support.

Methods

A retrospective chart review of 21 patients underwent transscleral suture fixation of a foldable 3-looped haptics one-piece PCIOL implantation through scleral pockets was conducted. Preoperative data and follow-up data for at least 3 months were collected for all patients.

Results

The mean operative duration was 36.62 ± 10.70 min. The mean pre- and post-operative LogMAR uncorrected distance visual acuity was (1.25 ± 0.50 vs. 0.41 ± 0.22, P < 0.01). The mean pre- and post-operative LogMAR best corrected visual acuity was (0.48 ± 0.25 vs. 0.33 ± 0.24, P < 0.01). The mean proportion of postoperative endothelial cell loss was 11.46 ± 4.78%. The mean postoperative anterior chamber depth was 3.05 ± 0.44 mm. The mean postoperative IOL tilt degree was 2.81 ± 1.41^°, and the mean postoperative IOL decentration degree was 0.31 ± 0.13 mm. Four patients with transient corneal edema (19.0%) and three patients with transiently elevated IOP (14.3%) were observed after operation, and such complications were resolved within 1 week. No severe complications were observed.

Conclusions

The modified technique was a feasible method of PCIOL implantation.

Electronic supplementary material

The online version of this article (10.1186/s12886-019-1113-2) contains supplementary material, which is available to authorized users.

[Complications in sutured scleral fixation of artificial lens implantation]

BACKGROUND

Sutured scleral fixation of an artificial posterior chamber lens is a frequently used method for the treatment of eyes with poor or absent capsular support; however, the complication profile is often considered unfavorable.

OBJECTIVE

To analyze the postoperative complication profile.

METHODS

In this monocentric and retrospective analysis of a consecutive case series of patients with standardized sutured scleral fixation of a posterior chamber lens between 2007 and 2017, the documented complications were categorized as a permanent threat to visual acuity, such as endophthalmitis, choroidal hemorrhage, retinal detachment and clinically relevant but without a permanent threat to visual acuity, such as hemorrhage and hypotension. Additionally, the time point when complications first occurred was categorized into the 3 periods 0-3, 4-30 and ≥31 days.

RESULTS

This is the largest patient collective of a study with scleral fixation of a posterior chamber lens published so far. A total of 338 eyes from 338 patients were included in the study (women 47%) and the median postoperative follow-up period was 60 days (range 1-5833 days). In 68% of the patients at least 1 complication was documented. Complications with a permanent threat to visual acuity occurred in 3% (n = 10) of the patients. The most frequent clinically relevant complications were intraocular hypotension ≤10 mm Hg (35%; n = 119), pupil decentration (28%; n = 93), hyphema, iris or vitreous hemorrhage (10%; n = 34), secondary glaucoma (9%; n = 32) and iris capture (5%; n = 17). Of the complications 41% occurred within the first 3 days and 70% within the first 30 days. Revision surgery was carried out in 4.5% (n = 15) of the patients.

CONCLUSION

Although complications occurred in two thirds of the interventions, the number of permanent complications with a permanent threat to visual acuity was low. Scleral fixation of an artificial posterior chamber lens is still a justifiable intervention.

Simple Technique for Transscleral Fixation of a Foldable Posterior Chamber Intraocular Lens Using a Single Suture

Objective: To explore the simplified technique for transscleral fixation of a foldable posterior chamber intraocular lens (IOLs) in patients with aphakia or inadequate posterior capsule support. Methods: A review was conducted of 18 eyes of eighteen patients with the absence of-or inadequate-capsule support, after the simplified technique of using a foldable posterior chamber intraocular lens (PC IOLs) with stable four-point transscleral fixation, as performed by a skilled surgeon. This technique uses only a single suture and a knot to fix a PC IOL firmly without creating a scleral flap. The mean follow-up time was 18 ± 5.8 months (ranging from 12 to 24 months). Results: All patients exhibited improved visual acuity. No IOL tilt or dislocation or iris capture was observed, and all patients exhibited stable and centered IOL after surgery. No complex complications, such as suture shedding and exposure, corneal endothelial decompensation, persistent uveitis, or retinal detachment and endophthalmitis were observed. Conclusion: The simplified technique proposed here is a reliable, economical, and reproducible method of treating patients with aphakia or inadequate posterior capsule support. It provides excellent IOL stability, reduces surgical duration and complexity, and prevents certain complications.

Combined 23-gauge transconjunctival vitrectomy and scleral fixation of intraocular lens without conjunctival dissection in managing lens complications

Background

To evaluate the safety and efficacy of combined 23-gauge transconjunctival pars plana vitrectomy and scleral fixation of intraocular lens (IOL) without conjunctival dissection.

Methods

A retrospective study in Chang Gung Memorial Hospital, Keelung and Taoyuan, Taiwan. Patients receiving combined 23-gauge transconjunctival pars plana vitrectomy and scleral fixation of IOL without conjunctival dissection were enrolled. The ocular findings, causes of lens complication, surgical procedures, type of IOL used, and complications were documented.

Results

We included 40 eyes from 39 patients (27 male, 12 female) with a mean age of 59.5 [standard deviation (±) 14.8] years old. The mean follow-up duration was 6.8 ± 5.4 months. The cause of lens complications was ocular trauma in 24 (60%) eyes, cataract surgery complications in 11 (28%) eyes, and spontaneous subluxation of crystalline lens in 5 (13%) eyes. The overall best corrected visual acuity (BCVA) (logMAR) improved from 1.359 ± 0.735 to 0.514 ± 0.582 (p < 0.001). The BCVA also improved significantly in each group with different causes of lens complications. Preoperative BCVA was the only factor associated with the postoperative visual outcome (p = 0.008). Most surgery-related complications were self-limited, including mild vitreous hemorrhage (5%), microhyphema (5%), transient elevated intraocular pressure (3%), and transient hypotony (3%). Cystoid macular edema and IOL decentration was found in 3 (8%) eyes and 1 (3%) eye respectively.

Conclusions

Combined 23-gauge transconjunctival vitrectomy and scleral fixation of IOL without conjunctival dissection is effective and safe in managing a wide variety of lens complications, with good postoperative comfort and visual recovery.

Trial registration

Retrospective study, not applicable.

Electronic supplementary material

The online version of this article (10.1186/s12886-018-0776-4) contains supplementary material, which is available to authorized users.

Three cases of a torn haptic after scleral fixation using a hydrophobic acrylic intraocular lens: Case reports

RATIONALE

We report 3 cases of a torn haptic after successful scleral fixation with a hydrophobic acrylic intraocular lens.

PATIENT CONCERNS

Patients complained of decreased visual acuity about 1 week to 1 month after scleral fixation.

DIAGNOSES

In all 3 cases, the direction of the damaged haptic correlated with the direction of the pulling force made by the hung suture material. Observation of a cheese-wiring effect on scanning electron microscopy suggested that the haptic was cut by the suture.

INTERVENTIONS

Patients underwent re-scleral fixation with caution.

OUCTOMES

There was no complication of broken haptic after re-scleral fixation.

LESSONS

To avoid unexpected haptic tears, great caution is needed; surgeons should avoid applying excessive pulling force to the intraocular lens when performing scleral fixation using a hydrophobic acrylic intraocular lens.