Modified technique for intrascleral fixation of posterior chamber intraocular lens without scleral flaps

Scleral Suture Intraocular Lens Fixation Under Microscope-Intraoperative Optical Coherence Tomography

PURPOSE

The aim of this study was to evaluate the accessibility and potential value of intraoperative optical coherence tomography (iOCT) during scleral suture intraocular lens (IOL) fixation.

METHODS

This was a prospective cohort study in the Department of Ophthalmology, Eye and ENT Hospital, Fudan University, China. Seven eyes with insufficient capsular support and undergoing two-point scleral suture IOL fixation were included. The potential value of iOCT was evaluated, as well as the safety and efficacy of the surgery.

RESULTS

Seven eyes were included. With a tailor-made iOCT, the structure of the anterior segment could be clearly visualized during the surgery. Intraoperatively, iOCT helped locate the proper place for fixation and access the position of the IOL. After an average 4.43-month follow-up, the spherical equivalent changed significantly ( P < 0.001), but the intraocular pressure, best-corrected visual acuity, and endothelial cell density remained unchanged ( P > 0.05). The IOL was well-centered with a horizontal and a vertical tilt of 0.74 ± 0.60° and 1.13 ± 0.65°, and decentration of 0.28 ± 0.12 mm and 0.30 ± 0.13 mm. The estimated IOL-induced astigmatism was -0.11 diopters (D) ± 0.46 D.

CONCLUSION

Real-time high-resolution images of the anterior segment acquired by the iOCT helped the surgeon to achieve satisfactory results in scleral suture IOL fixation.

Comparison of three different intraocular lens implantation techniques in the absence of capsular support: sutured scleral, haptic flanged intrascleral, and four flanged intrascleral fixations

INTRODUCTION

After lens extraction, if the capsular bag insufficiency occurs, there are different IOL implantation techniques. IOL implantation in the posterior chamber is safer in eyes with low endothelial cell count, peripheral anterior synechiae, shallow anterior chamber, and glaucoma. Alternative approaches for scleral fixation techniques, both with and without sutures, continue to undergo development. In this study, we aimed to compare the postoperative outcomes of the sutured scleral fixation (SSF), haptic flanged intrascleral fixation (HFISF) and four flanged intrascleral fixation (FFISF) IOL implantation techniques in eyes with the absence of capsular support.

MATERIALS AND METHODS

A hundred and thirty-seven aphakic eyes with the absence of capsular support were included in the study. The patients were divided into three groups: group 1-SSF, group 2-HFISF (Yamane technique), and group 3-FFISF. Surgical time in minutes, preoperative and postoperative parameters such as best corrected visual acuity (BCVA), corneal astigmatism, lenticular astigmatism, intraocular pressure (IOP), specular microscopy, central macular thickness (CMT) were recorded. Pseudophacodonesis was assessed at 6 months postoperatively using a slit lamp, and early and late complications were recorded.

RESULTS

Of the 137 eyes, 69 eyes were included in the SSF group, 41 eyes in the HFISF group, and 27 eyes in the FFISF group. No statistically significant differences were observed among the three groups in terms of age, gender, preoperative mean BCVA, corneal astigmatism, IOP, endothelial cell density, and CMT. It was observed that the mean BCVA significantly improved compared to the preoperative visual acuity in all three groups. Postoperative lenticular astigmatism, pseudophacodonesis score, percentage of the endothelial cell loss were found to be higher in FFISF groups. The surgical time was found to be shorter in the HFISF group. IOL decentration was observed in 1.44% of the SSF group and 7.40% of the FFISF group. Cystoid macular edema was observed in 5.79% of the SSF group, 4.87% of the HFISF group, and 7.40% of the FFISF group. Retinal detachment was observed in 1.44% of the SSF group and 7.31% of the HFISF group.

CONCLUSIONS

The optimal technique for treating aphakia without capsular support remains uncertain. Surgeons are tasked with a complex decision, aiming for both excellent vision and minimal risk. This decision is based on their expertise, the distinctive ocular condition of the patient, and the availability of essential operating room equipment. In this study, the following findings were observed: in the HFISF technique, the average surgical time was found to be shorter, the SSF technique demonstrated greater stability in terms of astigmatism and pseudophacodonesis and the FFISF technique was recognized for its relatively straightforward application method. It is important to note that the three IOL implantation techniques yielded comparable outcomes in terms of postoperative BCVA, as well as early and late complications.

Two-way adjustable double-knots intrascleral fixation and single sclerotomy looping technique: a novel minimal invasive adjustable intraocular lens fixation technique

BACKGROUND

IOL fixation without capsular support presents challenges for surgeons. Although innovative techniques were developed to address subluxated IOLs, adjustable IOL fixation methods are seldom reported. We introduce a novel two-way adjustable double-knots intrascleral fixation combined with single sclerotomy looping technique for fixing intraocular lenses (IOL) or IOL-capsular bags.

METHODS

A bent 30-gauge needle threaded with 8 - 0 polypropylene was introduced into the eye. A gripping forceps assisted the haptic looping. Two overhand knots were made with 8 - 0 polypropylene thread. The knots were incarcerated into a scleral tunnel made by a 30-gauge needle, with two ends of the thread left at each side of the tunnel. The IOL was adjusted to the premium position with adequate tension by pulling either end of the threads. The study included 19 eyes with aphakia, subluxated IOL-capsular bags, or subluxated crystalline lenses. The mean followed up period was 18.9 ± 7.1 months with evaluations of uncorrected visual acuity (UCVA), intraocular pressure, slit-lamp examination, and swept-source optical coherence tomography of the anterior segment.

RESULTS

UCVA increased from 1.28 ± 0.74 at baseline to 0.44 ± 0.51 (logMAR) at final visit (P < 0.001). All IOLs were fixed well-centered. The mean IOL tilt was 3.5°±1.1°. Postoperative complications included transient IOP elevation (15.8%), hypotony (10.5%), and cystoid edema (5.3%) which resolved within 4 weeks.

CONCLUSIONS

We presented a novel adjustable technique for IOL fixation, which stabilize IOLs by using an intrascleral double-knots structure. This technique minimized surgical manipulations by using a single sclerotomy looping technique without large conjunctival dissection and scleral flap creation. The technique offers a reliable and optimal IOL positioning and improved visual outcomes in patients undergoing scleral fixed IOL implantation.

Trans-Scleral Plugs Fixated FIL SSF IOL: A Review of the Literature and Comparison with Other Secondary IOL Implants

Purpose. To revise the current literature on FIL SSF (Carlevale) intraocular lens, previously known as Carlevale lens, and to compare their outcomes with those from other secondary IOL implants. Methods. We performed a peer review of the literature regarding FIL SSF IOLs until April 2021 and analyzed the results only of articles with a minimum of 25 cases and a follow-up of at least 6 months. The searches yielded 36 citations, 11 of which were abstracts of meeting presentations that were not included in the analysis because of their limited data. The authors reviewed 25 abstracts and selected six articles of possible clinical relevance to review in full text. Of these, four were considered to be sufficiently clinically relevant. Particularly, we extrapolated data regarding the pre- and postoperative best corrected visual acuities (BCVA) and the complications related to the procedure. The complication rates were then compared with those from a recently published Ophthalmic Technology Assessment by the American Academy of Ophthalmology (AAO) on secondary IOL implants. Results. Four studies with a total of 333 cases were included for results analysis. The BCVA improved in all cases after surgery, as expected. Cystoid macular edema (CME) and increased intraocular pressure were the most common complications, with an incidence of up to 7.4% and 16.5%, respectively. Other IOL types from the AAO report included anterior chamber IOLs, iris fixation IOLs, sutured iris fixation IOLs, sutured scleral fixation IOLs, and sutureless scleral fixation IOLs. There was no statistically significant difference in the rates of postoperative CME (p = 0.20), and vitreous hemorrhage (p = 0.89) between other secondary implants and the FIL SSF IOL, whereas the rate of retinal detachment was significantly less with FIL SSF IOLs (p = 0.04). Conclusion. The results of our study suggest the implantation of FIL SSF IOLs is an effective and safe surgical strategy in cases where there is a lack of capsular support. In fact, their outcomes seem to be comparable to those obtained with the other available secondary IOL implants. According to published literature, the FIL SSF (Carlevale) IOL provides favorable functional results with a low rate of postoperative complications.

Real world outcomes of sutureless and glueless sclerally fixated intraocular lens implantation

PURPOSE

To report the outcomes of sutureless intrascleral fixation of a 3-piece intraocular lens in the ciliary sulcus, in a large cohort of patients with aphakia of various aetiology METHODS: Retrospective, non-comparative, single centre interventional study of 250 aphakic eyes of various causes, which underwent sutureless and glueless intrascleral fixation of 3-piece intraocular lens (IOL). All patients were required to have at least 3 months of follow up post procedure to be included in the study. Anatomical and functional outcomes obtained were statistically analysed for significance.

RESULTS

A total of 250 eyes of 246 patients were included in the study population. The average age was 56.5 years ± 16.4 (range 6-86 years). The mean best-corrected visual acuity (BCVA) significantly improved from 0.74 ± 0.6 logMAR (approx. Snellen equivalent 20/110) to 0.48 ± 0.36 logMAR (approx. Snellen equivalent 20/60), (p < 0.001) following surgery. Early postoperative complication (<2 weeks) included hypotony (n = 10, 4%), ocular hypertension (n = 38,15.2%) and vitreous haemorrhage (n = 50, 20%). Late complications included retinal detachment (n = 14, 5.6%%), cystoid macular oedema (n = 24, 9.6%), scleral erosion (n = 1, 0.4%), haptic extrusion to subconjunctival space (n = 3, 1.2%) and IOL subluxation or dislocation (n = 5, 2%) CONCLUSION: This cost-effective and easier technique of sutureless scleral fixated 3-piece IOL implantation provided good visual acuity outcomes in a large cohort of patients and was well tolerated.

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

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

Trocar-assisted flanged transconjunctival intrascleral sutureless intraocular lens fixation

PURPOSE

To study the safety and efficacy of 25-gauge trocar-assisted flanged intrascleral sutureless IOL fixation in patients with insufficient posterior capsular support.

METHODS

Five aphakic eyes with capsular insufficiency were included in this prospective interventional case series study, at Dar El Oyoun Hospital, Cairo, Egypt. Twenty five-gauge trocar-assisted flanged intrascleral sutureless technique was used for IOL fixation, in which retinal microforceps were used to capture and externalize both haptics through a scleral tunnel. CDVA, IOP measurements and IOL centralization were reported pre- and one day, one & 3 months postoperatively. Any intra- or postoperative complications were recorded.

RESULTS

The mean LogMAR CDVA had significantly improved one day, 1 & 3 months postoperatively (0.74 ± 0.1, 0.42 ± 0.07 and 0.26 ± 0.08 respectively, p < 0.001) compared to the preoperative value (1.7 ± 0.17). The mean IOP showed no significant changes along the follow-up period (16.9 ± 0.1; 16.2 ± 1.1; 16.3 ± 0.9 mmHg, p = 0.68, 0.58, 0.89) respectively at 1^st day, 1 & 3 months postoperatively) compared to the preoperative measurement (16.4 ± 1.8 mmHg). The IOL was found to be centralized in all cases. No intra- or postoperative complications were encountered.

CONCLUSION

25-gauge trocar-assisted flanged intrascleral sutureless IOL fixation is found to be a reliable and effective technique that overcomes Yamane technique's challenges for IOL fixation in cases with posterior capsular insufficiency.

Scleral Fixation of Intraocular Lens in Aphakic Eyes without Capsular Support: Description of a New Technique

Purpose

To study the efficacy and safety of a modified trans-scleral intraocular lens (IOL) fixation technique in aphakic eyes when performed by ophthalmologists in training.

Methods

The study was conducted in an institutional setting that included 43 surgeries performed by surgeons training in small incision cataract surgeries. The data were analyzed for stability and position of IOL, refractive changes, best-corrected vision, and associated complications.

Results

Mean age of the subjects was 53.8 ± 18.5yrs (range 6–81yrs). Surgical aphakia (58.14%) was the most common cause. The corrected distance visual acuity improved significantly at six weeks (p = 0.0003). The mean residual spectacle correction was +0.74 ± 1.2D spherical equivalent (cylinder −1.6±1.5D at 84 ± 50°) at the 6th-month follow-up (24.35 ± 6.71wks). Lens tilt on ultrasound biomicroscopy (kappa 0.762; p < 0.001) and the IOL centration (kappa 0.411; p = 0.001), assessed by two independent masked observers, were satisfactory at the 6th-month visit. Transient postoperative vitreous hemorrhage was the most common complication (46.5%). Cellular deposits on the IOL surface (18.6%), cystoid macular edema (11.6%), subconjunctival haptic exposure (4.66%), and haptic slippage (2.33%) were the other complications.

Conclusion

This method of trans-scleral IOL fixation is an effective rescue procedure for eyes with deficient capsular support when ophthalmologists perform in training.

Sutureless intrascleral fixation using a uniquely designed intraocular lens

We report our experience in the surgical technique of sutureless intrascleral posterior chamber intraocular lens (PC IOL) fixation in patients with insufficient capsular support using a uniquely designed, foldable, acrylic Carlevale IOL. It is specifically designed for sutureless scleral fixation and is equipped with a small plug attached to each of two haptics to anchor the lens to the sclera with a self-retaining mechanism. This surgery does not require creation of a scleral tunnel or transscleral exposure or excessive manipulation of the haptics. The harpoon-like plugs provide great stability to this implant, which can be injected through a 2.2mm incision. The characteristics of this IOL and the relative simplicity of this implantation technique makes it widely applicable in aphakic patients after previous complicated cataract surgery.

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.

Sutureless Intrascleral Posterior Chamber Intraocular Lens Fixation: Analysis of Clinical Outcomes and Postoperative Complications

PURPOSE

To report a technique for performing sutureless intrascleral fixation of a posterior chamber intraocular lens (PC-IOL) and analyzing the clinical outcomes and postoperative complications. Study Design. 68 eyes of 66 patients who received the technique were studied retrospectively.

METHODS

The best-corrected visual acuity (BCVA), intraocular pressure (IOP), anterior chamber depth (ACD), IOL tilt and decentration, corneal topography (K1 and K2), and postoperative complications were determined at 3 months.

RESULTS

The mean preoperative BCVA was 1.63 ± 1.24 logMAR units, and the mean postoperative BCVA was 0.74 ± 0.59 logMAR units at 3 months (P < 0.05). The mean preoperative IOP was 21.9 ± 12.6 mmHg, and the mean postoperative IOP was 16.9 ± 4.5 mmHg at 3 months (P = 0.001). The mean preoperative corneal topography (K1 and K2) was K1 = 42.14 ± 1.91 and K2 = 43.54 ± 1.51; the mean postoperative corneal topography (K1 and K2) was K1 = 43.03 ± 2.18 and K2 = 43.40 ± 1.71 at 3 months (P = 0.678 and 0.468, respectively). The mean preoperative spherical equivalent was +11.00 ± 13.19 diopters (D), and the mean postoperative spherical equivalent was +0.06 ± 0.86 D (P < 0.005). The mean IOL tilt was 2.4 ± 1.7°, and the mean decentration was 0.35 ± 0.21 mm. The mean ACD was 4.31 ± 0.29 mm.

CONCLUSIONS

The 27-gauge sutureless intrascleral PC-IOL implantation technique minimizes intraoperative injury, simplifies procedure, and provides good PC-IOL fixation with few postoperative complications.

Sutureless Scleral Fixated IOL: The "Catcher Pole" Technique

Purpose

To describe a new surgical technique for sutureless intrascleral intraocular lens (IOL) fixation with an adapted retinal scraper used as an instrument “the Catcher Pole” to retrieve the IOL haptic through a scleral tunnel.

Setting

Public Eye Hospital, Roma, Italy.

Design

Retrospective case series.

Methods

Twenty-one eyes from 19 patients who underwent sutureless intrascleral IOL fixation were studied. A standard three-piece posterior chamber IOL (PCIOL) was implanted in aphakia or rescued and fixated in cases of dislocated PCIOL. A 23 to 25 G retinal loop scraper (the “Catcher Pole“) was inserted through a 1.5 mm long tunneled sclerotomy performed on the horizontal meridian, to capture, hold and externalize the tip of the haptic of the IOL. A flange created with an handheld cautery on the externalized haptic tip prevents IOL slippage. The best-corrected visual acuity (BCVA), central corneal pachymetry (CCP), IOL tilt and complications were assessed.

Results

In twenty-one eyes of 19 patients, the mean preoperative BCVA was 0.61 logMAR units ±0.05 SD, and the mean postoperative BCVA improved significantly to 0.18 logMAR units at three months ±0.05 SD (P=0.002). The mean preoperative CCP was 610 µ ±17 SD and the mean postoperative CCP 623 µ ±16 SD, (P=0.73). In the subgroup that underwent IOL tilt evaluation, mean IOL tilt was 3.19±2.01. The postoperative complications included iris capture of the IOL in one eye (4,7%) and transient ocular hypertension in two eyes (9,4%).

Conclusions

The “Catcher Pole” sutureless intrascleral IOL fixation technique is easy to perform with reduced anterior chamber manipulations and achieves both anatomical and optical stability.

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The forceps-needle: Combining needle and grasping functions in a single instrument

A new forceps-needle to facilitate intrascleral haptic fixation surgery is described. In an initial series of 10 cases, the forceps-needle was used to grasp and externalize the haptic of a 3-piece intraocular lens (IOL) for transscleral fixation. The site of perforation was marked at 180 degrees 2.0 mm away from the limbus. Then, the IOL with polypropylene haptics was folded and implanted partially into the anterior chamber. A transconjunctival, scleral tunnel of about 2.0 mm length parallel to the limbus was prepared with the forceps-needle on 1 side, with the second hand holding the leading haptic through a side-port incision. The end of the first haptic was grasped and externalized after which the end of the haptic was flanged. Subsequently, a second scleral tunnel was prepared with the forceps-needle, and the second haptic was externalized and flanged. All procedures could be performed without any intraoperative complication.

Scleral Fixation of Single-Piece Foldable IOL Using Double-Flanged Technique

Purpose

To describe the efficiency and visual results of a new method of transconjunctival intrascleral fixation of single-piece foldable IOL using double-flanged 6/0 prolene suture.

Materials and Methods

Seventeen aphakic eyes of 17 patients without adequate capsular support were involved in this study. Lens was prepared by passing the 6/0 prolene suture in a track in the haptic of single-piece foldable IOL created by 31 g needle. The 6/0 prolene suture was retrieved through a 30 g needle transconjunctivally to outside the globe; then, IOL was implanted and a terminal bulb was created at the outer end of the prolene suture.

Results

All cases were aphakic after complicated phacoemulsification. In 10 cases hydrophilic IOLs were used and in 7 cases hydrophobic IOLs were used. There is clear statistically significant difference between pre-UCVA and post- UCVA. Complications included suture slippage in 2 cases and prolene bulb exposure in one case. There was no significant difference in endothelial cell count and IOP before and after 3 months.

Conclusion

Transconjunctival intrascleral fixation of foldable single-piece IOLs is a safe efficient method for correcting aphakia.

A Simple Modified Way of Glueless, Sutureless Scleral Fixation of an IOL: A Retrospective Case Series

PURPOSE

To evaluate the outcome and viability of a modified self-sealing scleral pocket technique for scleral fixation of an intraocular lens (IOL).

DESIGN

Retrospective interventional case series.

METHODS

A retrospective, interventional case series in which 81 eyes underwent this modified technique, performed in the previous 4 years. Cases included a dislocated IOL and an absent posterior capsule or subluxated cataract. Two diagonally opposed paralimbal, curved self-sealing scleral pockets were made 3 mm away from the limbus along with a vitrectomy. A multipiece IOL was used, and the haptics were fixed under the scleral pockets inside a linear scleral tunnel underneath the superficial scleral flap. The conjunctiva was opposed by using cautery. Postoperatively, anterior segment optical coherence tomography (AS-OCT) was performed in order to detect intrascleral hyper-reflective cross-section of the haptics and optic tilt. The optic position was re-evaluated using ultrasound biomicroscopy (UBM). Main outcomes were mean pre- and postoperative best corrected visual acuity (BCVA), postoperative astigmatism. Postoperative AS-OCT was performed to detect the position of the haptics and optics. UBM was done to recheck any optic tilt.

RESULTS

Mean pre- and postoperative BCVA were LogMAR 1.2 ± 0.59 and LogMAR 0.47 ± 0.3 (P < 0.001). Mean postoperative astigmatism was 1.27 ± 1.02 Dcyl. In AS-OCT, an intrascleral hyper-reflective shadow signified stable haptics without any optic tilt. UBM also showed a stable position of the IOL optic without any tilt.

CONCLUSIONS

This modified, simple way of scleral fixation of an IOL decreases the duration of surgery with minimal complication.

Intraocular Lens Implantation in the Absence of Zonular Support: An Outcomes and Safety Update: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature on the visual acuity results and complications of different surgical techniques for intraocular lens (IOL) implantation in the absence of zonular support.

METHODS

Peer-reviewed literature searches were conducted last in PubMed and the Cochrane Library in July 2019. The searches yielded 734 citations of articles published in English. The panel reviewed the abstracts of these mostly retrospective case series studies, and 45 were determined to be relevant to the assessment objectives. Three articles were rated as level II evidence, and 42 articles were rated as level III evidence.

RESULTS

Eight different types of IOL fixation techniques with at least 6-month follow-up were evaluated: anterior chamber IOL (ACIOL), iris-claw IOL, retropupillary iris-claw IOL, 10-0 polypropylene iris-sutured posterior chamber IOL (PCIOL), 10-0 polypropylene scleral-sutured PCIOL, 8-0 polypropylene scleral-sutured PCIOL, CV-8 polytetrafluoroethylene, and intrascleral haptic fixation (ISHF). Eight articles reported data comparing 2 techniques. The 45 studies had insufficient statistical power to compare the techniques conclusively. A qualitative analysis of similar types showed that trends in visual acuity outcomes were not inferior to those of ACIOL implantation, but the severity of preoperative pathologic features was not controlled for. Compared with ACIOL, complications of cystoid macular edema were higher in 10-0 polypropylene iris-sutured PCIOL and 8-0 polypropylene scleral-sutured PCIOL. Non-anterior chamber IOL techniques were less likely to report chronic uveitis. Chronic glaucoma was highest in the 8-0 polypropylene scleral-sutured PCIOL group. Although retinal detachment was infrequent overall, it was twice as common in both iris- and scleral-sutured PCIOLs (except CV-8 polytetrafluoroethylene suture) compared with nonsutured methods: ACIOL, iris-clipped IOL, and ISHF PCIOL.

CONCLUSIONS

The evidence reviewed shows no superiority of any single IOL implantation technique in the absence of zonular support. The various techniques seem to have equivalent visual acuity outcomes and safety profiles. Each technique has its own profile of inherent risk of postoperative complications. Surgeons must educate patients on the importance of close, long-term follow-up as a result of the uncertain nature of these techniques. Large prospective studies are needed to confirm the long-term complication profiles of these various IOL implantation techniques.

Sutured Intrascleral Posterior Chamber Intraocular Lens Fixation with Ciliary Sulcus Location Guided by Ultrasonic Biological Microscopy: A Retrospective Analysis of Anatomical and Refractive Outcome

PURPOSE

To report the outcome of sutured intrascleral posterior chamber intraocular lens (PC IOL) fixation with ciliary sulcus location guided by ultrasonic biological microscopy (UBM).

METHODS

Patients who underwent a sutured intrascleral PC IOL fixation were reviewed and divided into four groups. In group 1, the traditional sulcus fixation (2 mm from limbus) of IOL was performed. In groups 2, 3, and 4, UBM was performed before surgery to locate the position of the ciliary sulcus as the haptics insertion position. IOL power was selected by decreasing the calculated value of the IOL power by 1.0 D, 1.0 D, 0.5 D, and 0.0 D, respectively.

RESULTS

Sixty-one patients (63 eyes) were included in the four groups. After 4.1 ± 3.0 months' follow-up, the postsurgery spherical equivalent (SE) was 0.73 ± 1.86, 0.71 ± 0.84, 1.14 ± 0.45, and 0.07 ± 0.89 diopters (D), respectively. Statistical significance was reached for the postsurgery SE with target refraction between group 1 (p = 0.027, <0.05), group 2 (p = 0.003, <0.01), and group 3 (p = 0.017, <0.05). No significant difference existed for the postsurgery SE with target refraction in group 4 (p = 0.779, >0.05), and the postsurgery SE in group 4 was the nearest to target refraction.

CONCLUSION

Intrascleral PC IOL fixation guided by UBM is helpful for locating the ciliary sulcus and satisfactory visual outcomes with a predictable IOL power calculation.

Sutureless intrascleral fixation using different three-piece posterior chamber intraocular lenses: a literature review of surgical techniques in cases of insufficient capsular support and a retrospective multicentre study

We present a literature review of surgical techniques of intraocular lens placement in eyes with insufficient capsular support, focusing on the most recent publications, together with a retrospective multicentre consecutive case series analysis of 103 eyes undergoing pars plana vitrectomy and sutureless intrascleral (SIS) fixation of a standard three-piece PCIOL. Many different approaches appear in the literature without any specific procedure achieving superior outcomes. Advantages and disadvantages vary between techniques. Common complications related to IOL fixation techniques were as follow: anterior chamber IOL: transient/permanent corneal oedema (9-66.6%), uveitis (1.1-39.3%); iris-fixated IOL: pupil ovalization (16-47.7%); and sutured scleral-fixated IOL: suture breakage/exposure (6.1-11%), vitreous haemorrhage: (5.5-16.6%). In our retrospective case series, indications for surgery were postoperative aphakia in 50 eyes (49%), IOL dislocation in 38 eyes (37%) and natural lens dislocation in 15 eyes (14%). Scleral tunnels for haptic fixation were created with (28 eyes, 27.2%) or without (75 eyes, 72.8%) 25 gauge trocar cannulas. Complications included transient hypotony (n = 20; 19.4%), corneal decompensation (n = 7; 6.7%), IOL dislocation (n = 6; 5.8%), cystoid macular oedema (n = 5; 4.8%), vitreous haemorrhage (n = 4; 3.8%) and retinal detachment (n = 4; 3.8%). Mean best corrected visual acuity improved from logMAR 0.65 to 0.36 at the final visit (p = 0.001). In conclusion, SIS fixation provides good anatomical and functional outcomes; however, complications can occur. The number of surgical approaches for IOL dislocation described in the literature indicates that optimal treatment remains to be found.

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.

A modified intrascleral intraocular lens fixation technique with fewer anterior segment manipulations: 27-gauge needle-guided procedure with built-in 8-0 absorbable sutures

Background

To report a modified surgical technique for intrascleral intraocular lens (IOL) fixation with fewer anterior segment manipulations in eyes lacking sufficient capsular support.

Methods

Eyes from 14 patients who underwent 27-gauge needle-guided intrascleral IOL fixation with built-in 8–0 absorbable sutures were studied. The 8–0 absorbable sutures were inserted into 27-gauge round needles and used to create sclerotomies at the 4 o’clock and 10 o’clock positions under the scleral flap. The sutures were used to tie knots at the end of each haptic and guide haptic externalization through the sclerotomy. After externalization, a sufficient flange was created at the end of each haptic and fixed under the scleral flaps. The best corrected visual acuity (BCVA), corneal endothelial cell density (ECD), IOL tilt and decentration, previous surgery history, and complications were determined.

Results

Fourteen cases were analyzed. The majority of eyes exhibited an improvement in the BCVA after surgery. When comparing the last follow-up to preoperative visual acuity, the mean change in BCVA was + 26.32 letters (p = 0.011). Postoperative complications included postoperative hypotony in 3 eyes, ocular hypertension in 2 eyes. No cases of postoperative cystoid macular edema (CME), vitreous hemorrhage (VH), IOL dislocation, or endophthalmitis were observed.

Conclusions

The 27-gauge needle-guided intrascleral IOL fixation technique with built-in 8–0 absorbable sutures is easy to perform with fewer anterior chamber manipulations and achieves both anatomical and optical stability.

Novel technique of sutureless glueless scleral fixated intraocular lens (SFIOL)

Purpose:

To report results of a novel technique for sutureless, glueless intrascleral fixation of three-piece posterior chamber intraocular lens (IOL) using 26-G needle for management of aphakia.

Methods:

In this prospective series, 30 eyes of 20 patients with aphakia, subluxated IOL, or crystalline lens were included. 26-G-needle-guided intrascleral fixation of three-piece posterior chamber IOL was performed according to the described technique. The patients were evaluated on day 2, 1 week, 6 weeks, and 3 months postoperatively for change in best-corrected visual acuity (BCVA), intraocular pressure (IOP), IOL centration, and any other complications. The postoperative tilt of the IOL was indirectly measured by determining the lenticular astigmatism which in turn was calculated by the difference between net corneal astigmatism and refractive astigmatism. Paired t-test was used to determine the significance of any association between the preoperative and postoperative BCVA and IOP. P < 0.05 was considered significant.

Results:

Of 30 eyes (n = 30 patients), 18 were surgical aphakia, 6 traumatic aphakia, 5 subluxated IOL, and 1 ectopia lentis (Marfan syndrome). The mean preoperative BCVA was 1.37 ± 0.37 (logMAR) and postoperative BCVA at 3 months was 0.37 ± 0.29 (logMAR). A significant improvement in the mean BCVA (P < 0.05) was observed after the procedure. The mean IOP preoperatively was 13.33 ± 4.18 and postoperatively at 3 months was 12.82 ± 3.97 (P > 0.05), which was not significant. None of the eyes developed any intraoperative and postoperative complications. The IOLs had appropriate centration and stability.

Conclusion:

We have developed this new technique for intrascleral IOL fixation which is quite simple, cost-effective, minimally invasive, neither requires glue nor suture and gives consistent outcome.

Intrascleral IOL Fixation

Intrascleral sutureless intraocular lens (IOL) fixation utilizes direct haptic fixation within the sclera in eyes with deficient capsular support. This has advantages of long-term stability, good control of tilt and decentration, and lesser pseudophakodonesis. This review summarizes various techniques for intrascleral haptic fixation, results, complications, adaptations in special situations, modifications of the technique, combination surgeries, and intrascleral capsular bag fixation techniques (glued capsular hook).