Management of dislocated intraocular lenses

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

BACKGROUND

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

METHODS

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

SURGICAL TECHNIQUE

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

RESULTS

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

CONCLUSIONS

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

Inflammatory reaction in eyes with late in-the-bag intraocular lens dislocation

PURPOSE

To investigate the inflammatory reaction in eyes with late in-the-bag intraocular lens (IOL) dislocation.

METHODS

This prospective clinical study with fellow-eye comparison consists of 76 of the patients (76 eyes) with late in-the-bag IOL dislocation enrolled in the LION trial. The main outcome measure was anterior chamber flare before surgery measured with a laser flare meter in photon counts per millisecond (pc/ms). The dislocation was graded as 1 (small: optic still covering the visual axis), 2 (optic equator close to the visual axis) or 3 (optic decentred beyond the visual axis, but the IOL-capsule complex partly visible in the pupillary area). The secondary aim was to compare intraocular pressure (IOP) before surgery.

RESULTS

Flare levels before surgery were significantly higher in the dislocation eyes than in the fellow eyes with a median flare of 21.5 (range 5.4-135.7) pc/ms versus 14.1 (2.0-42.9) pc/ms, respectively (p ˂ 0.001). A regression analysis of log-transformed flare values showed that the dislocation eyes had a non-significant tendency towards higher flare in dislocation grade 1 with a median flare of 24.6 (5.4-135.7) pc/ms compared to grade 2; 19.6 (6.5-41.5) pc/ms (p = 0.06), and no significant difference compared to grade 3; 19.4 (10.2-53.5) pc/ms (p = 0.47). The IOP was significantly higher in the dislocation eyes than in the fellow eyes (p ˂ 0.001).

CONCLUSIONS

Eyes with late in-the-bag IOL dislocation had increased flare levels compared to their fellow eyes. This suggests that inflammation is part of the clinical picture of late in-the-bag IOL dislocation.

BCLA CLEAR Presbyopia: Evaluation and diagnosis

It is important to be able to measure the range of clear focus in clinical practice to advise on presbyopia correction techniques and to optimise the correction power. Both subjective and objective techniques are necessary: subjective techniques (such as patient reported outcome questionnaires and defocus curves) assess the impact of presbyopia on a patient and how the combination of residual objective accommodation and their natural DoF work for them; objective techniques (such as autorefraction, corneal topography and lens imaging) allow the clinician to understand how well a technique is working optically and whether it is the right choice or how adjustments can be made to optimise performance. Techniques to assess visual performance and adverse effects must be carefully conducted to gain a reliable end-point, considering the target size, contrast and illumination. Objective techniques are generally more reliable, can help to explain unexpected subjective results and imaging can be a powerful communication tool with patients. A clear diagnosis, excluding factors such as binocular vision issues or digital eye strain that can also cause similar symptoms, is critical for the patient to understand and adapt to presbyopia. Some corrective options are more permanent, such as implanted inlays / intraocular lenses or laser refractive surgery, so the optics can be trialled with contact lenses in advance (including differences between the eyes) to better communicate with the patient how the optics will work for them so they can make an informed choice.

Visual Improvement and Lowered Intraocular Pressure After Surgical Management of In-The-Bag Intraocular Lens Dislocation and Aphakia Correction; Retrospective Analysis of Scleral Suturing versus Retropupillary Fixated Iris-Claw Intraocular Lens During a 5-Year Period

Purpose

We compare and evaluate the visual outcome and complication rate of two different techniques of surgical management of in-the-bag intraocular lens (IOL) dislocation or aphakia correction. In addition, we evaluate possible risk factors for IOL dislocation or aphakia.

Patients and Methods

This retrospective case series reviewed medical records for all patients who had undergone surgery for IOL dislocation or aphakia during a 5-year period at a single ophthalmic center in Sweden. The two most common procedures, scleral suturing of dislocated in-the-bag IOL and retropupillary fixation of iris-claw IOL, were further analyzed. Main outcome measures were best-corrected visual acuity (BCVA), reoperations, and complications.

Results

The study comprised 110 eyes, including scleral suturing procedures (n=35) and retropupillary iris-claw IOL (n=75). There was a significantly higher rate of dense cataract (p=0.030) and posterior capsular rupture (PCR), (p=0.016) among iris-claw cases at the primary cataract extraction with pseudoexfoliations in about two-thirds of patients in both groups. All eyes in the scleral suturing group had an IOL dislocation. In the iris-claw group, 23 eyes (30.7%) were aphakic following complicated cataract surgery with PCR. No intraoperative complications occurred in any eyes during the secondary IOL procedure. Both groups showed significant improvement in BCVA, yet there was no significant difference between groups in postoperative BCVA (p=0.263). However, the scleral suturing group experienced a significantly larger improvement in BCVA due to worse BCVA preoperatively (p=0.005). Intraocular pressure decreased significantly after both repositioning and exchange surgery (p=0.002 and 0.010 respectively), but improvement between groups was not significantly different (p=0.264).

Conclusion

Both surgical methods resulted in significantly improved BCVA and lowering of IOP and can be considered safe with limited complications. The outcome was similar between groups. Pseudoexfoliation prevalence was high in both groups indicating that it may be a risk factor for either aphakia or late IOL dislocation.

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

PURPOSE

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

DESIGN

Retrospective, interventional, noncomparative, case series.

METHODS

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

RESULTS

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

CONCLUSION

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

Rescuing an Akreos 4-Point Haptic Intraocular Lens: A Novel Surgical Technique

PURPOSE

To present a surgical technique that allows rescue (repositioning) of a dislocated Akreos AO model intraocular lens using scleral sutures.

METHODS

The surgical technique is described with supplemental video.

RESULTS

The technique was used in 4 eyes of 3 patients with 2 to 18 months of follow-up information. The intraocular lens was well positioned, and the visual acuity (as limited by other disease) was good, without adverse events.

CONCLUSION

Scleral suture techniques for repositioning of the Akreos AO intraocular lens offer a suitable alternative to intraocular lens exchange.

Scleral Suture Fixation of Dislocated Posterior Chamber Intraocular Lens: Modification for Tapered Haptics

PURPOSE

To present a surgical modification to a previously published technique that allows repositioning and scleral fixation of one-piece acrylic intraocular lenses with tapered haptics.

METHODS

A retrospective review of three consecutive cases.

RESULTS

Our technique modification enables repositioning using scleral suture fixation of one-piece intraocular lenses with tapered haptics by looping the haptic at its proximal, notched junction to the optic with the polypropylene suture. The suture knot is internalized which effectively suspends the intraocular lens and allows for better adjustment of the intraocular lens centration. Two cases were endocapsular dislocations; the third case was dislocated extracapsularly due through a posterior capsule rupture. All showed adequate lens centration at 3 months of follow-up. One case had suffered a vitreous hemorrhage a month postoperatively that is clearing.

CONCLUSION

Repositioning using scleral fixation of one-piece intraocular lenses with tapered haptics is possible with a minor technique modification. This offers an alternative to intraocular lens exchange.

Indications, Complications, and Early Postoperative Course of Recovery of Intraocular Lens Exchange Surgery: a Single-Center Retrospective Study

PURPOSE

To analyze the indications, complications, and early course of recovery of intraocular lens (IOL) exchange surgery.

MATERIAL AND METHODS

Records of patients who underwent IOL exchange during a 6-year period at a tertiary referral center were reviewed and the indications and complications after surgical intervention were analyzed. Their effects on postoperative corrected distance visual acuity (CDVA), intraocular pressure (IOP), use of IOP-lowering medications, and refractive cylindrical power were assessed.

RESULTS

One hundred and seventy-one eyes (165 patients) were investigated. The most frequent indication for IOL exchange was lens dislocation in 163 eyes (95.32%). The main causes of IOL dislocation were pseudoexfoliation syndrome (PEX) in 98 eyes (57.31%) and complications during cataract surgery in 40 eyes (23.39%). During IOL exchange, an anterior iris-claw fixation was performed in 159 eyes (92.98%). After significant initial deterioration to 1.59 ± 1.08 logMAR on postoperative day 1 (p ≤ 0.001), the CDVA recovered to preoperative levels within 28 days. A significant decrease in IOP was observed on postoperative day 1 (p = 0.04). The most common postoperative complications were corneal edema in 114 eyes (66.67%) and vitreous hemorrhage in 67 eyes (39.18%).

CONCLUSION

The high early postoperative prevalence of corneal edema and intraocular hemorrhage was found to affect visual recovery after IOL exchange, causing a significant initial deterioration of CDVA and a delay of full visual recovery. These findings suggest that surgical approaches minimizing the risk of this type of complications should be favored.

Repositioning of in-the-bag Dislocated Intraocular Lenses: A Randomized Clinical Trial Comparing Two Surgical Methods

INTRODUCTION

The aim of this study was to evaluate intraocular lens (IOL) tilt, IOL-induced astigmatism (IIA), refractive change, and impact of capsular fibrosis on IOL position after scleral fixation of dislocated IOL using two methods: ab externo scleral suture loop fixation (group A) and a modification, embracing the continuous curvilinear capsulorhexis (group B).

METHODS

In this prospective randomized clinical trial conducted at St. Erik Eye Hospital, 117 patients with dislocated IOL were randomized to group A (n = 61) or B (n = 56). Patients with ordinary pseudophakia (n = 60) served as controls. IOL tilt was measured three-dimensionally with anterior segment optical coherence tomography (AS-OCT).

RESULTS

The median IOL tilt was similar with both methods (A: 7.8°; B: 8.3°; p = 0.51) but higher than in ordinary pseudophakia (5.4°; p < 0.001). Both groups showed a myopic shift, p < 0.001. In cases without capsular fibrosis, the median IOL tilt was 15.5° in group A (n = 7) and 7.0° in group B (n = 5), p = 0.19. For each degree of IOL tilt, IIA increased by 0.075 D (p < 0.001). IOL position could be measured with AS-OCT in all patients given that the IOL was visible in the pupil.

CONCLUSION

After IOL fixation surgery, IOL tilt is higher than in normal pseudophakia. A study involving more patients without capsular fibrosis could clarify whether IOL position is better with method B in this subgroup. IAA is low, but myopic shift is common. AS-OCT is useful for IOL tilt assessment after IOL fixation surgery.

Intraocular Inflammation in Eyes Operated for Late In-the-bag intraOcular lens dislocatioN (LION): A Randomized Clinical Trial

PURPOSE

To compare the intraocular inflammation after 2 surgical approaches for late in-the-bag intraocular lens (IOL) dislocation.

DESIGN

Prospective, randomized, parallel-group clinical trial.

METHODS

We randomly assigned 100 patients (100 eyes) referred to Oslo University Hospital (tertiary referral center) with late in-the-bag IOL dislocation into IOL repositioning by scleral suturing (n=49) or IOL exchange with retropupillary fixation of an iris-claw lens (n=51). Patients were examined before surgery and 2 weeks, 6 weeks, and 6 months after surgery. The main outcome measure was anterior chamber laser flare, measured with a laser flare meter as photon counts per millisecond (pc/ms).

RESULTS

Two weeks following surgery, median flare values were 28.9 pc/ms (range, 7.9-140) in the repositioning group and 31.6 pc/ms (range, 9.8-92.3) in the exchange group (P = .83). Flare levels were still elevated after 6 weeks with no difference between the groups (P = .93), whereas it decreased to baseline levels after 6 months. Six weeks following surgery, the central retinal thickness was similar (P = .97); cystoid macular edema (CME) was found in 4 and 5 patients, respectively (P = .85); and the mean best corrected visual acuity was 0.17 (95% CI 0.09, 0.25) and 0.21 (95% CI 0.09, 0.32) logarithm of the minimum angle of resolution, respectively (P = .61).

CONCLUSIONS

This study revealed similar levels of intraocular inflammation following IOL repositioning and IOL exchange. There was no significant difference regarding risk of CME and visual outcome. The prolonged elevation in postoperative flare indicates a possible requirement for an extended anti-inflammatory treatment period after these operations.

Clinical Characteristics of recurrent intraocular lens dislocation after scleral-fixated sutured intraocular lens and long-term outcomes of intraocular lens re-fixation

PURPOSE

This study aimed to investigate the clinical characteristics of patients with recurrent intraocular lens (IOL) dislocation after scleral-fixated sutured IOL implantation and evaluate the long-term outcomes of scleral re-fixation of IOL.

METHODS

The medical records of patients who underwent surgery for IOL dislocation between January 2011 and January 2021 were reviewed. The study included 164 patients (male: 131, female: 33) (176 eyes). Patient demographics, preoperative, intraoperative and postoperative data, and the ocular and systemic conditions associated with IOL re-dislocation were analyzed.

RESULTS

The study included 176 consecutive cases of scleral-fixated sutured IOL. Twenty-six eyes (14.8%) showed re-dislocation of IOL after the initial IOL scleral fixation and underwent reoperation (mean 75.5 ± 62.5 months after the first surgery); three (11.5%) of them required a third surgery. Younger adults (aged less than 40 years), and patients who underwent IOL scleral fixation in complicated cataract surgery or aphakic state had a higher risk of re-dislocation. Diabetes mellitus (DM) was the only statistically significantly higher risk factor in the re-dislocated group (p = 0.041). The complication rate with scleral re-fixation was higher than that in the non-re-dislocated group. No statistically significant differences were observed, except for vitreous hemorrhage (p = 0.024).

CONCLUSIONS

Caution should be exercised when performing sutured scleral fixation of IOL in younger patients, cases of complicated cataract surgery and aphakia, and patients with DM to prevent IOL re-dislocation. Scleral-fixated sutured IOL in eyes with recurrent IOL dislocation seems to be a safe and effective procedure with a relatively low complication rate.

Two Surgical Approaches for Intraocular Lens Dislocation: Pars Plana Vitrectomy Versus Core Vitrectomy with Lens Exchange

PURPOSE

To compare the efficacy and safety of core vitrectomy and pars plana vitrectomy for lens exchange in patients with intraocular lens dislocation.

METHODS

This is a retrospective study conducted at one eye center in Zurich, Switzerland. We reviewed 124 eyes with dislocated intraocular lens undergoing lens exchange carried out by two surgeons between 03/2016 and 12/2019 (45 months). Intraocular pressure (IOP) and best-corrected visual acuity (BCVA) were analyzed preoperatively and at 5 time points up to 12 months after lens exchange. Data on postoperative complications were collected.

RESULTS

There were 124 eyes with intraocular lens dislocation that were referred for lens exchange. Of these eyes, 59 (48%) received core vitrectomy and 65 (52%) received pars plana vitrectomy with lens exchange. Glaucoma was more frequent in the core vitrectomy group (78%) than in the pars plana vitrectomy group (32%; p < 0.001). In the core vitrectomy group, 19 (32%) eyes presented with visual impairment, 17 (29%) eyes presented with high IOP alone, and 23 (39%) eyes presented with both at the same time prior to surgery. Mean preoperative IOP in the core vitrectomy group decreased from 22.4 ± 9.2 mmHg to 14.7 ± 3.1 mmHg 12 months after surgery (p < 0.001). Mean BCVA changed from 0.40 ± 0.41 logMAR preoperatively to 0.32 ± 0.37 logMAR at 12 months postoperatively (p = 0.598) in the core vitrectomy group. In the pars plana vitrectomy group, 44 (68%) eyes presented with a change in vision, 7 (11%) eyes presented with high IOP alone, and 14 (22%) eyes presented with pressure elevation and visual impairment at the visit prior to surgery. Mean preoperative IOP in the pars plana vitrectomy group decreased from 20.9 ± 8.3 mmHg to 15.1 ± 3.5 mmHg at 12 months after lens exchange (p < 0.001). Mean BCVA in the pars plana vitrectomy group was 0.57 ± 0.62 logMAR preoperatively and 0.22 ± 0.35 logMAR 12 months postoperatively (p < 0.001). Postoperative pressure decompensation occurred more frequently in the core vitrectomy group (20%) than in the pars plana vitrectomy group (6%; p = 0.018). There was no statistically significant difference for postoperative cystoid macular edema (p = 0.055), anisometropia (p = 0.986), and high astigmatism (p = 0.362).

CONCLUSION

Core vitrectomy and pars plana vitrectomy with lens exchange are equally efficient and safe in the management of intraocular lens dislocation.

Intraocular Pressure in Eyes with Intraocular Lens Dislocation and Pseudoexfoliation Syndrome

PURPOSE

To investigate intraocular pressure in eyes with intraocular lens subluxation and pseudoexfoliation syndrome.

METHODS

In this retrospective study conducted at one eye centre (tazz) in Zurich, Switzerland, we reviewed 85 eyes with intraocular lens subluxation and pseudoexfoliation syndrome. Intraocular lens exchange was carried out by two surgeons between 03/2016 and 12/2019 (45 months). Information on baseline characteristics and diagnosis of glaucoma was recorded. Intraocular pressure and best-corrected visual acuity were analysed preoperatively and at five time points up to 12 months after lens exchange. Data on antiglaucomatous medication was collected before surgery and at two different time points after surgery. Postoperative pressure lowering procedures and complications were further analysed.

RESULTS

This study includes 85 pseudoexfoliation eyes with intraocular lens subluxation. The mean interval between cataract surgery and lens exchange was 8.9 ± 5.2 years. Intraocular pressure elevation in the event of intraocular lens subluxation was found in 54% (46/85) of eyes. Mean intraocular pressure decreased from 22.9 ± 9.4 mmHg preoperatively to 15.2 ± 3.4 mmHg at follow-up 12 months after lens exchange (p < 0.001). Postoperative topical antiglaucomatous drug requirements were comparable to preoperative levels (p = 0.520). Less systemic acetazolamide was required 12 months postoperatively (p = 0.018). A pressure lowering procedure was required in seven (8%) eyes in the postoperative period due to persistence of high intraocular pressure. Intermittent increase or persistence of high intraocular pressure occurred in 13 (15%) eyes.

CONCLUSION

This study emphasises the connection between acute pressure elevation and intraocular lens subluxation in patients with pseudoexfoliation syndrome. Intraocular pressure decreases after lens exchange and decrease sustains for a postoperative period of 12 months. Postoperative pressure lowering procedures were not required in the majority of eyes. We therefore conclude that intraocular lens exchange is efficient in the management of lens subluxation and pressure elevation in patients with pseudoexfoliation syndrome.

Outcomes of Flanged Intrascleral Haptic Fixation with CT Lucia Three-Piece Intraocular Lens

BACKGROUND AND OBJECTIVE

To report the clinical outcomes of the flanged intrascleral haptic fixation technique (FIHFT) with the Zeiss CT Lucia 602 three-piece intraocular lens (IOL).

PATIENTS AND METHODS

This was a retrospective case series of patients who received FIHFT secondary implantation of the Zeiss CT Lucia 602 IOL from January 2018 to August 2020. Clinical and refractive outcomes were assessed including best-corrected visual acuity (BCVA), refractive prediction error, and complications.

RESULTS

Of the 22 patients in the series, 19 were included in the study. Mean vision improved from logarithm of the minimum angle of resolution (log-MAR) 1.14 to 0.54 (P = .03). BCVA of those without preoperative trauma improved from logMAR 0.68 to logMAR 0.25 (P = .02). Refractive spherical equivalent improved from 2.46 diopters (D) to 0.50 D (P = .07), but astigmatism increased from 1.09 D to 1.31 D (P = .67).

CONCLUSIONS

FIHFT with the Zeiss CT Lucia 602 three-piece lens is a safe and effective option for secondary IOL placement. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:658-662.].

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

The influence of intraocular lens dislocation surgical correction method on corneal endothelium

BACKGROUND:Intraocular lens (IOL) dislocation is a rare but serious complication of surgical treatment of patients with cataract. Among the factors contributing to its development, the main ones are pseudoexfoliation syndrome (PEX), high axial myopia, chronic uveitis, history of eye injury and age. There is no universal IOL dislocation correction technique. PURPOSE:To evaluate the impact on corneal endothelium of two different methods of IOL dislocation correction: IOL repositioning with transscleral suture fixation or IOL exchange to iris-claw one. MATERIALS AND METHODS:Within the study, 78 patients were examined and operated. All patients were divided into two groups: in the first group, IOL was repositioned with transscleral suture fixation, and in the second group IOL was exchanged to iris-claw IOL. Groups were equal by gender and age. Key estimated indicators were endothelial cell density and coefficient of variation reflecting the degree of polymegatism. RESULTS:Endothelial cell density was significantly lower both before surgery and at any term after it, in the group with IOL exchange, and coefficient of variation was significantly higher in the group with IOL exchange throughout this study. CONCLUSION:The choice of technique for IOL dislocation correction is the basis of success in surgical treatment. Certain preoperative examination data should be definitely considered, including the degree of dislocation, IOL type, IOP level, endothelial cell density and presence of concomitant ocular conditions.

Intrascleral 4-flanged technique for in-the-bag intraocular lens subluxation

PURPOSE

To present a series of cases in which the 4-flanged technique was used in the management of in-the-bag intraocular lens (IOL) subluxation.

SETTING

Shamir Medical Center, Israel.

DESIGN

Retrospective cohort analysis.

METHODS

Included were consecutive cases with secondary IOL subluxation that underwent scleral fixation with the 4-flanged technique using 6-0 polypropylene and low temperature cautery. Surgeries were performed during September 2019 to April 2020. Postoperative IOL angle tilt was evaluated using high-resolution ocular coherence tomography.

RESULTS

Eleven eyes of 11 patients were included. The mean age was 82.7 ± 5.5 years, and 60% were men. Pseudoexfoliation was noted in 82% of patients, and only 1 case was related to trauma. The mean corrected distance visual acuity (CDVA) postoperatively was within 1 line of the original presubluxation CDVA (0.55 ± 0.41 vs 0.54 ± 0.6 logMAR, P = .965). The mean postoperative IOL tilt was 5.78 ± 3.85 degrees. Surgery duration decreased from 70 ± 14 minutes to 39 ± 15 minutes (first to last operations). No intraoperative complications were reported. Postoperatively, transient intraocular pressure elevation, which resolved at 1 week, was recorded in 45% of cases. Cystoid macular edema, which resolved within a few months under topical treatment, was seen in 2 patients.

CONCLUSIONS

Among a cohort of patients with secondary in-the-bag IOL subluxation, the 4-flanged technique was safe and resulted in satisfactory visual outcomes and a stable IOL position, with a short learning curve.

Late in-the-bag intraocular lens dislocation

This review aimed to evaluate the cumulative incidence, patient characteristics, predisposing conditions, and treatment outcomes for late in-the-bag intraocular lens (IOL) dislocation. Literature searches in PubMed (MEDLINE), Embase, and Cochrane Library Central database identified 1 randomized clinical trial, 1 prospective case series, 2 prospective cohort studies, and 36 retrospective studies of this condition, which showed that the cumulative incidence was 0.5% to 3%, it occurred on average 6 to 12 years after cataract surgery, and mean patient age was 65 to 85 years. Pseudoexfoliation syndrome, myopia, and previous vitreoretinal surgery were the most common predisposing conditions. Studies indicated that IOL repositioning and IOL exchange provided similar visual outcomes and were equally safe. The long-term visual outcome seemed satisfactory. However, the quality of evidence regarding treatment was in general quite low. More studies of late in-the-bag IOL dislocation are needed, and in particular, different surgical techniques should be included in high-quality clinical trials.

Scleral fixation of Carlevale intraocular lens: A new tool in correcting aphakia with no capsular support

PURPOSE

To report the clinical outcomes of the use of a novel specially designed scleral fixated intraocular lens, the Carlevale intraocular lens (carlevale IOL, Soleko, Italy) for the correction of aphakia in the absence of capsular support of variable etiology.

METHODS

This retrospective, non-comparative study included 169 eyes of 169 consecutive patients who underwent 3-port pars plana vitrectomy and scleral fixation on Carlevale IOL. Inclusion criteria were at least 6 months' follow-up period, patients > 18 years old who underwent vitrectomy and Carlevale IOL placement for aphakia and inadequate capsular support.

RESULTS

The median follow up period of 9 months (range 6-18 months). Mean post-operative BCVA at the last follow-up visit was 20/25 (0.09 ± 0.1 LogMAR), improving from a mean baseline BCVA of 20/80 (0.58 ± 0.49 LogMAR), a statistically significant change (p = 0.0001). Regarding the post-operative complications, a transient rise in the IOP was observed in 28 patients (16.5%) and mild vitreous hemorrhage was observed in the immediate post-operative period in eight eyes (4.7%) and it spontaneously resolved within 3 weeks. All patients demonstrated good IOL position at the end of the follow-up without IOL capture. None of the patients required re-operation.

CONLCUSION

The present study represents the largest to date in evaluating the use of carlevale IOL in patients with aphakia and inadequate capsular support. The technique is safe and provides excellent post-operative IOL fixation without IOL capture in any of the patients studied.

A NOVEL TECHNIQUE FOR EXTRACTION OF DROPPED BROKEN HAPTICS OF HARD POSTERIOR CHAMBER INTRAOCULAR LENS

BACKGROUND/PURPOSE

To report a novel technique for extraction of dropped haptics of hard posterior chamber intraocular lens.

METHODS

A 58-year-old woman had undergone cataract extraction, and while implanting the posterior chamber intraocular lens it was dislocated in the anterior vitreous, and the cataract surgeon, tried to remove it by the anterior approach, but he succeeded to remove the optic part only, leaving the haptics dropped, then he referred the case after giving topical and systemic medications to control intraocular inflammation and, the case was prepared for pars plana vitrectomy, then injection of perfluorodecaline to keep the haptics away from the posterior pole then by 23 G vitrectomy probe and, the use of vacuum only, the haptics were removed and the perfluorodecaline was removed.

RESULTS

After extraction of both haptics by 23 G vitrectomy probe, the case was implanted by a hard polymethylmethacrylate posterior chamber intraocular lens on the sulcus, and postoperatively, the inflammatory signs were subsided and her visual acuity was improved, without any posterior segment complications.

CONCLUSION

Dropped haptic of hard posterior chamber intraocular lens can be removed successfully with 23 G vitrectomy probe.

Long-term myofibroblast persistence in the capsular bag contributes to the late spontaneous in-the-bag intraocular lens dislocation

Late spontaneous in-the-bag intraocular lens (IOL) dislocation is a complication presenting 6 months or later after cataract surgery. We aimed to characterize the cells in the lens capsules (LCs) of 18 patients with spontaneous late in-the-bag IOL dislocation. Patients' average age was 82.6 ± 1.5 years (range 72-98), and most of them had pseudoexfoliation syndrome (PEX). Cells from the LCs were positive for myofibroblast (αSMA), proliferation (Ki-67, PCNA), early lens development/lens progenitor (SOX2, PAX6), chemokine receptor (CXCR4), and transmembrane (N-cadherin) markers, while negative for epithelial (E-cadherin) marker. Moreover, the cells produced abundant fibronectin, type I and type V collagen in the nearby extracellular matrix (ECM). During ex vivo cultivation of dislocated IOL-LCs in toto, the cells proliferated and likely migrated onto the IOL's anterior side. EdU proliferation assay confirmed the proliferation potential of the myofibroblasts (MFBs) in dislocated IOL-LCs. Primary cultured lens epithelial cells/MFBs isolated from the LC of dislocated IOLs could induce collagen matrix contraction and continuously proliferated, migrated, and induced ECM remodeling. Taken together, this indicates that long-lived MFBs of dislocated IOLs might contribute to the pathogenic mechanisms in late in-the-bag IOL dislocation.

[Evolution of IOL exchange. Part 1. Development of methods for IOL exchange]

The review presents the history of development and improvement of methods for intraocular lens (IOL) exchange. Existing techniques of IOL exchange are comparatively analyzed.

Impact of intraocular lens characteristics on intraocular lens dislocation after cataract surgery

Background

To assess the influence of intraocular lens (IOL) characteristics on IOL dislocations after cataract surgery.

Methods

Patients who underwent cataract surgery at the Department of Ophthalmology Graz, Austria, between 1996 and 2017 were included and medical records were reviewed. Cox proportional-hazard regression models were used to assess the influence of IOL characteristics on IOL dislocation.

Results

From 68 199 eyes out of 46 632 patients (60.2% women, mean age: 73.71 SD±10.82 years), 111 (0.16%) had an in-the-bag (ITB) disloaction and 35 (0.05%) had an out-of-the-bag (OTB) dislocation. The HRs adjusted for predisposing factors significantly associated with a higher risk for an ITB dislocation were 2.35 (95% CI, 1.45 to 3.8) for hydrophilic IOLs, 2.01 for quadripode IOLs (95% CI, 1.04 to 3.86) and 1.61 (95% CI, 1.04 to 2.48) for haptic angulation. A lower risk was observed for three-piece IOLs (HR=0.58, 95% CI, 0.34 to 0.98) and larger overall IOL diameter (HR=0.79, 95% CI, 0.66 to 0.95). For an OTB dislocation, the HR associated with a higher risk was 18.81 (95% CI, 5.84 to 60.58) for silicone IOLs and 2.12 (95% CI, 0.62 to 7.29) for hydrophilic IOLs. Larger overall IOL diameter (HR 0.40, 95% CI; 0.25 to 0.63) showed a lower risk.

Conclusion

Hydrophilic IOLs, quadripode IOLs and haptic angulation were associated with a higher risk for an ITB dislocation, whereas three-piece IOLs and a larger overall diameter were associated with a lower risk. Risk factors for OTB dislocation were silicone IOLs, hydrophilic IOLs and a smaller overall IOL diameter.

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.

Outcomes and Determinants of Posterior Dislocated Intraocular Lens Management at a Tertiary Eye Hospital in Central Saudi Arabia

PURPOSE:

The aim of this study is to evaluate the determinants of visual outcomes, complications after managing the posterior dislocated intraocular lens (IOL).

METHODS:

Patients with posterior dislocated IOL managed between 2002 and 2016 in our institute were reviewed. Ocular status and causes for dislocation were noted. Success was defined as uncorrected visual acuity (UCVA) of 20/20–20/200 at the last follow-up. The risk factors were associated with the success.

RESULTS:

Of the 79 eyes with posterior dislocated IOL, 40 (50.6%) eyes had vision <20/400 at presentation. Glaucoma and retinal detachment were present in 12 (15.2%) and 5 (6.3%) eyes. IOL was removed from 33 (41.8%) eyes. Secondary IOL was implanted in 25 (31.6%) eyes, and IOL was repositioned in 19 (24.1%) eyes. The median duration of follow-up was 2.1 years. The final UCVA was “20/20–20/60” and “>20/200” in 45 (57%) and 14 (17.7%) eyes. The main causes of Severe visual impairment (SVI) included glaucoma (5), corneal decompensation (5), retinal detachment (4), and macular edema (3). Young age (P = 0.02), late IOL dislocation (P = 0.005), primary IOL implant (P < 0.01), SVI (P = 0.09), IOL removal (P = 0.06), and no glaucoma at presentation were significantly associated to the success. Late IOL dislocation (P = 0.05) and no glaucoma (P = 0.05) were independently associated to the success.

CONCLUSION:

The management of the dislocation of IOL had promising visual outcomes. Glaucoma and early dislocation predict poor vision after dislocated IOL management. Close monitoring is needed to manage complications.

Scleral fixated intraocular lens by a modified technique: Methods and results

PURPOSE

A certain number of conditions can result in compromised anterior and/or posterior capsular integrity. Several surgical options have been employed for repositioning dislocated intraocular lenses in the absence of adequate capsular support. The purpose of this study is to assess the functional outcomes and complication profile of a modified surgical technique for replacing dislocated intraocular lenses.

MATERIAL AND METHODS

All patients who had undergone the modified surgical procedure for dislocated intraocular lenses between 2012 and 2017 were retrospectively reviewed for visual outcomes and complications. Patient demographic characteristics, pre- and postoperative visual acuity, surgical indications, refractive outcomes, intraocular pressure and postoperative complications were recorded and analysed at baseline and at six months, which was the conclusion of the study. We also present our modified surgical technique.

RESULTS

Sixty-eight eyes of sixty-eight patients (74% male) were included. Mean age at surgery was 58 years (range 4-89 years). Mean best-corrected visual acuity increased significantly from 0.80 (SD±0.2) LogMar to 0.40 (SD±0.1) LogMar (P<0.005). Median astigmatic error at the conclusion of follow-up remained stable. There were no intraoperative complications and a low postoperative complication rate (10.2%), mainly related to the surgical context.

CONCLUSION

Sutureless intrascleral fixation of dislocated intraocular lenses is an option in case of deficient capsular support. Visual outcomes and complication rates are comparable to other case series.

Long-Term Outcomes after Surgery for Late In-The-Bag Intraocular Lens Dislocation: A Randomized Clinical Trial

PURPOSE

To compare the long-term efficacy and safety of 2 operation methods for late in-the-bag intraocular lens (IOL) dislocation.

DESIGN

Prospective, randomized, parallel group surgical clinical trial.

METHODS

During a 3-year period, 104 patients (104 eyes) were assigned one group for IOL repositioning by scleral suturing (n = 54) or one group for IOL exchange by retropupillary fixation of an iris claw IOL (n = 50). A single surgeon performed all operations using an anterior approach. Patients were examined before surgery and at 6 months and 1 and 2 years after surgery. The present study included the 66 patients (63%) who completed the 2-year follow-up, and the main outcaome measurement was corrected distance visual acuity (CDVA) 2 years after surgery.

RESULTS

After 2 years, the mean CDVA was 0.20 ± 0.29 logarithm of the minimum angle of resolution (logMAR) units (range, -0.18 to 1.10) in the repositioning group and 0.22 ± 0.30 logMAR (range, -0.10 to 1.22) in the exchange group (P = .69). A CDVA of 20/40 or better was achieved by 76% of all patients. Four eyes (12%) had cystoid macular edema in the repositioning group compared with 5 eyes (15%) in the exchange group. Two eyes underwent redislocation (1 in each group). There were no cases of endophthalmitis or retinal detachment.

CONCLUSIONS

There were no significant differences between the visual acuity using IOL repositioning and that using IOL exchange 2 years after surgery. The two methods were equally efficient and safe from a long-term perspective and are both considered acceptable treatments.

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

PURPOSE

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

METHODS

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Late in-the-bag spontaneous IOL dislocation: risk factors and surgical outcomes

AIM

To evaluate the possible predisposing risk factors for late in-the-bag spontaneous IOL dislocations and to study the early surgical and visual outcomes of repositioning and exchange surgeries.

METHODS

Medical and surgical records of 39 eyes of 39 patients who underwent IOL repositioning or exchange surgery for dislocation between 2010 and 2018 were reviewed. Possible predisposing risk factors and some characteristics of late in-the-bag spontaneous IOL dislocations; outcomes of IOL repositioning and exchange surgeries, including visual acuity, refractive status before and after surgery and postoperative complications were evaluated.

RESULTS

The predisposing factors for late in-the-bag spontaneous IOL dislocations were pseudoexfoliation [PEX; 12/39 (30.8%)], previous vitreoretinal surgery [7/39 (17.9%)], axial myopia [3/39 (7.7%)], both PEX and axial myopia [1/39 (2.6%)], both previous vitreoretinal surgery and axial myopia [2/39 (5.1%)] and uveitis [1/39 (2.6%)]. The mean interval between cataract and dislocation surgery was 7.23y, greater in PEX positive group (8.63y). The mean best corrected visual acuity (BCVA) improved significantly after dislocation surgery (P<0.001) and also improved significantly after exchange surgery (P=0.001). The mean value of spherical equivalant decreased significantly after dislocation surgery (P=0.011), whereas corneal astigmatism increased but this difference was not significant after dislocation surgery and exchange surgery (P=0.191, P=0.074, respectively).

CONCLUSION

The most prevelant risk factors for late in-the-bag spontaneous IOL dislocations are PEX, previous vitreoretinal surgery and axial myopia. In the management of IOL dislocations, exchange surgery with small corneal incision seemed effective with improved BCVA and safety with low postoperative complications.

Trans-iris fixation of dislocated in-the-bag intraocular lenses

Purpose:

The aim of this article is to describe the safety and efficacy of trans-iris suture fixation for the management of late dislocation of in-the-capsular-bag intraocular lenses following uncomplicated cataract surgery.

Patients and methods:

Eleven eyes of 11 patients with late in-the-capsular-bag intraocular lens dislocation following uneventful phacoemulsification cataract surgery were recruited in the study. The dislocated intraocular lens–capsular bag complex was sutured to the iris at two points 180° apart using 9-0 polypropylene sutures on long needles.

Results:

Mean patient age was 67 ± 6 years. Seven eyes had pseudoexfoliation syndrome, one eye had Marfan syndrome, and another eye had a traumatic cataract; no risk factor was identified for intraocular lens dislocation in two eyes. A capsular tension ring had been implanted during cataract surgery in four eyes. In six eyes, the posterior chamber intraocular lenses were one-piece foldable while the remaining were three-piece intraocular lenses. Compared to the preoperative value, corrected distance visual acuity was significantly improved postoperatively ( p < 0.005). Intraoperative hyphema occurred in two eyes. Pupil ovalization was observed in all eyes. Mean endothelial cell count decreased by 4 ± 1.7% after intraocular lens fixation. The capsular bag–intraocular lens complex was stable and well-centered in the pupillary area in all eyes at the final follow-up examination which was performed 16 ± 4 months postoperatively.

Conclusion:

Trans-iris fixation is a simple and effective procedure for management of late intraocular lenses–capsular bag complex dislocation, without major complications.

Surgical management of intraocular lens dislocation: A meta-analysis

Purpose

To compare the efficacy and safety of intraocular lens (IOL) repositioning and IOL exchange for the treatment of patients with IOL dislocation.

Methods

We systematically searched for relevant publications in English or Chinese in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, WHO International Clinical Trial Registration Platform, Clinical Trial.gov, China Biology Medicine Database, China National Knowledge Infrastructure Database and grey literature sources. Study quality was assessed using the STROBE template for observational studies and the Cochrane template for randomized controlled trials (RCTs). Data were meta-analyzed using RevMan 5.3.

Results

The review included 14 English-language studies reporting 1 RCT and 13 retrospective case series involving 1,082 eyes. Average follow-up time was 13.7 months. Pooled analysis of 10 studies showed that the two procedures had a similarly effect on best corrected visual acuity (MD -0.00, 95%CI: -0.08 to 0.08, P = 0.99). Pooled analysis of nine studies showed no significant difference in incidence of IOL redislocation (RR 2.12, 95%CI 0.85 to 5.30, P = 0.11); pooled analysis of seven studies showed greater extent of incidence of cystoid macular edema in IOL exchange (RR 0.47, 95%CI 0.21 to 1.30, P = 0.06). Pooled analysis of three studies showed greater extent of incidence of anterior vitrectomy in IOL exchange (RR 0.11, 95%CI 0.04 to 0.33, P<0.0001). Pooled analysis of two studies showed greater postoperative spherical equivalents in IOL repositioning (MD 1.02, 95%CI 0.51 to 1.52, P<0.0001). pooled analysis suggested no significant differences between the two procedures in terms of intraocular pressure, endothelial cell density, surgically induced astigmatism, or incidence of retinal detachment, intraocular hemorrhage or pupillary block.

Conclusion

IOL repositioning and exchange are safe and effective procedures for treating IOL dislocation. Neither procedure significantly affects best corrected visual acuity and IOL redislocation. IOL exchange was superior to repositioning in terms of postoperative SE, but IOL repositioning was associated with lower incidence of anterior vitrectomy, potentially lower incidence of cystoid macular edema.

Intraocular pressure changes before and after surgery for spontaneous in-the-bag intraocular lens dislocation

PURPOSE

To evaluate changes in intraocular pressure (IOP) after surgical correction of spontaneous late in-the-bag intraocular lens (IOL) dislocation.

SETTING

Two tertiary referral hospitals in Spain.

DESIGN

Retrospective case series.

METHODS

Cases of in-the-bag IOL dislocation from 2004 to 2014 were included. The IOP and grade of IOL dislocation were correlated before surgery. The IOP and number of drugs to treat glaucoma were compared before and after surgery in cases with more than 6 months of follow-up in the whole group and in separate groups according to the technique used to correct IOL position.

RESULTS

This study evaluated 134 eyes. The mean IOP at diagnosis decreased significantly as the grade of dislocation increased (P = .012). After surgery, the mean corrected distance visual acuity improved significantly and the mean IOP decreased significantly after surgery in all groups (both P = .000); the IOP decrease was significantly more pronounced in the glaucoma group than in the entire sample (P = .011). No statistically significant differences were detected in preoperative or postoperative IOP between the surgical technique groups. There was no significant increase in the number of drugs to treat glaucoma (P = .064).

CONCLUSIONS

There was a significant trend toward a decrease in IOP as the grade of IOL dislocation increased. The IOP decreased significantly after surgical management of in-the-bag dislocated IOLs without a significant increase in number of drugs to treat glaucoma. The decrease was independent of the technique used to correct IOL dislocation.

Current status of late and recurrent intraocular lens dislocation: analysis of real-world data in Japan

PURPOSE

To describe relevant patient demographic characteristics and investigate the influence of known risk factors for late intraocular lens (IOL) dislocation. To explore the associations between these risk factors and the incidence of recurrent IOL dislocation.

STUDY DESIGN

Retrospective cohort study.

METHODS

This study was performed using Nationwide Diagnostic Procedure Combination data in Japan from April 1, 2008 through July 31, 2016. Descriptive statistics for late and recurrent IOL dislocation, incidence rates, and risk factors for recurrent IOL dislocation were analyzed using a Cox proportional hazard model.

RESULTS

We identified 678 patients with late IOL dislocation. Most were men (72%, 488/678), and the men were younger than their women counterparts (mean age 65.2 years vs. 74.5 years). The incidence rate of recurrent IOL dislocation was 5.1 per 100 person-years. All 20 cases of recurrent IOL dislocation were observed within the year following surgery. There were no significant associations between potential risk factors and recurrent IOL dislocation (adjusted hazard ratio [HR] 1.53, 95% confidence interval [CI] 0.55-4.26 for diabetes mellitus; adjusted HR 0.77, 95%CI 0.09-6.40 for atopic dermatitis); no recurrences occurred in patients with pseudoexfoliation syndrome, retinitis pigmentosa, or connective tissue disease.

CONCLUSIONS

Late IOL dislocation occurs more frequently in men. We found that recurrent IOL dislocation was rare during long-term follow-up and there were no significant associations between the potential risk factors and recurrent IOL dislocation. Further studies are needed to clarify the sex-related differences involved in IOL dislocation.

Management of subluxated capsular bag-fixated intraocular lenses using a capsular anchor

We describe the use of the capsular anchor (AssiAnchor) to manage a subluxated intraocular lens (IOL) in the capsular bag. The anchor comprises 2 prongs that hold the anterior lens capsule and a central rod that is sutured to the scleral wall, enabling centration of the IOL-capsular bag complex. Six pseudophakic patients presenting with subluxated posterior chamber IOLs in the capsular bag were operated on using the device. The anchor was used successfully in all cases, although in 2 cases only 1 prong was placed under the capsulorhexis edge. In 1 eye, 2 anchors were used 1 month apart following repeated traumatic zonular injury. The capsular bag holding the IOL remained centered and stable throughout the follow-up period. The anchoring device, which was originally designed to preserve the lens capsule and stabilize subluxated crystalline lenses, can also be used to treat subluxation of a capsular bag-fixated IOL.

FINANCIAL DISCLOSURE

Dr. Assia is the inventor of the AssiAnchor, has a licensed patent of the anchor, and is consultant to Hanita Lenses. Dr. Lapid-Gortzak is a consultant to and speaker for Alcon Surgical, Inc., Hanita Lenses, Orca Surgical, and Sanoculis Ltd.; a speaker for Santen; and a consultant to Icon. Drs. Ton and Naftali have no financial or proprietary interest in any material or method mentioned.

Intraocular lens exchange surgery at a tertiary referral center: Indications, complications, and visual outcomes

PURPOSE

To identify indications for and visual outcomes of intraocular lens (IOL) exchange to understand recent changes in this surgery.

SETTING

Academic tertiary referral center.

DESIGN

Retrospective case series.

METHODS

Cases were identified by searching the institution's electronic medical records from January 2010 to September 2015 for patients treated by 1 staff physician with the American Medical Association's Current Procedural Terminology code for IOL exchange. These cases were reviewed to determine the surgical indication, type of IOL removed, type of IOL implanted, time between surgeries, surgical complications, and visual outcomes.

RESULTS

The study comprised medical records of 109 eyes. The mean time between the primary cataract surgery and IOL exchange was 1657 days. Dislocation of an in-the-bag posterior chamber IOL (27.5%), intolerance of a multifocal IOL (18.3%), and uveitis-glaucoma-hyphema syndrome (11.9%) were the most frequent indications for IOL exchange. The final IOL position after exchange was most frequently in the capsular bag (43.1%), anterior chamber (25.7%), or sulcus (22%). The final visual acuity at 1 month was 20/40 or better in 78.9% of cases. Of those not achieving this level of acuity, pathology not related to exchange surgery was identified in 48% of cases. The most frequent complications after IOL exchange surgery were posterior capsule opacification (13.8%), cystoid macular edema (10.1%), and high astigmatism (>1.5 diopters) (8.3%).

CONCLUSIONS

The most frequent indication for IOL exchange surgery was dislocated IOLs; the second most frequent indication was patient dissatisfaction after multifocal IOL implantation. The increased ability to place an intracapsular IOL with few intraoperative complications and largely treatable postoperative complications enhances the effectiveness of IOL exchange surgery and patient satisfaction.

FINANCIAL DISCLOSURE

Neither author has a financial or proprietary interest in any material or method mentioned.

Long-term Outcome of Pars Plana Vitrectomy and Sutured Scleral-Fixated Posterior Chamber Intraocular Lens Implantation or Repositioning

PURPOSE

To assess the long-term stability of sutured scleral-fixated posterior chamber intraocular lenses (PCIOLs) performed in combination with pars plana vitrectomy.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

Retrospective single-surgeon study of 118 eyes of 111 patients seen at Retina Consultants of Hawaii, who underwent sutured scleral fixation of at least 1 haptic of a posterior chamber intraocular lens with 10-0 polypropylene combined with a pars plana vitrectomy. The fixation knot-tying technique required 2 separate 10-0 polypropylene sutures tied into 1 combined knot-1 suture closed the fixation sclerotomy and created the scleral fixation, and 1 suture looped together around the haptic of the PCIOL, securing the haptic to the scleral fixation site. The primary outcomes were position of the PCIOL at last follow-up, dislocation of either 1 or both haptics of the PCIOL, and breakage of the 10-0 polypropylene fixation suture.

RESULTS

PCIOLs remained well stabilized and positioned at last follow-up in 116 of 118 eyes (98.3%), with a mean follow-up of 6.0 years. The maximum stable follow-up with 2 intact fixation sutures was 24.75 years. There were 4 cases of redislocation (3.4%), but 2 cases were owing to unstable residual capsular support. There was 1 case of suture breakage in 214 fixation sutures (0.47%) and 1 case of haptic breakage.

CONCLUSIONS

Scleral fixation sutures with 10-0 polypropylene provide excellent long-term fixation of PCIOLs, with a less than 0.5% incidence of suture breakage and documented suture stability for up to 24+ years.

Glaucoma and Intraocular Pressure in Patients Operated for Late In-the-bag Intraocular Lens Dislocation: A Randomized Clinical Trial

PURPOSE

To compare intraocular pressure (IOP) and IOP-lowering treatment requirements in patients with late in-the-bag intraocular lens (IOL) dislocation operated with 2 different methods, and to assess whether an IOP decrease after surgery can be expected.

DESIGN

Prospective, randomized, parallel-group clinical trial.

METHODS

In our university clinic, 104 patients (eyes) were randomly assigned to IOL repositioning by scleral suturing (n = 54) or IOL exchange with a retropupillar iris-claw lens (n = 50). The main outcome measure was 6-month postoperative IOP change.

RESULTS

Overall IOP was 18.0 ± 6.2 mm Hg before surgery and 15.7 ± 4.8 mm Hg 6 months after surgery (P < .001). IOP changed by -1.2 ± 5.8 mm Hg (P = .18) in the Repositioning group and -3.8 ± 6.4 mm Hg (P < .001) in the Exchange group (group difference: P = .05). Before surgery, 62 patients had either preexisting glaucoma (n = 39) or high IOP (≥22 mm Hg) with suspected glaucoma (n = 23), of whom several required preoperative IOP-lowering treatment. In the postoperative period, 28% and 21% of the patients in each operation group, respectively, required IOP-lowering treatment with glaucoma medications added, adjunctive laser trabeculoplasty, cyclodiode laser, or filtering surgery. Only 0 and 3 patients, respectively, discontinued their IOP-lowering medication.

CONCLUSIONS

This trial showed an IOP decrease after late in-the-bag IOL dislocation surgery that seemed to be more pronounced with IOL exchange. However, associated high IOP was not resolved by dislocation surgery in many patients, and increased IOP-lowering treatment in the postoperative course was commonly required.

Visual outcome and complications of various techniques of secondary intraocular lens

BACKGROUND/AIMS:

The purpose of this study was to compare and evaluate the visual outcome and complications of various techniques of secondary intraocular lens (IOL) (i.e., anterior chamber IOL [ACIOL], suture-fixated posterior chamber IOL [PCIOL], and glue-fixated PCIOL).

STUDY DESIGN AND SETTING:

This was a randomized, prospective, interventional, comparative, clinical trial study.

SUBJECTS AND METHODS:

Patients of either sex having aphakia and lacking posterior capsular support were included in the study, and patients having corneal or scleral pathology, optic atrophy, uncontrolled glaucoma, retinal detachment, and other retinal pathology were excluded from the study. The patients were divided into three groups after comprehensive ophthalmological examination – Group A (secondary ACIOL) included 44 patients, Group B (secondary scleral-fixated sutured PCIOL) included 32 patients, and Group C (fibrin glue-fixated sutured PCIOL) included 34 patients.

RESULTS:

A total of 110 patients were included in this study, of which 59 (53.63%) were males and 51 (46.37%) were females. The best-corrected visual acuity (VA) after 6 weeks was in the range of 20/60–20/40 in 36.4% of Group A and 40.6% of Group B patients. In Group C, 52.9% of patients had best-corrected VA in the range of 20/30–20/20. The overall complications were less in glued PCIOL group.

CONCLUSION:

It can be concluded that fibrin glue-assisted PCIOL implantation provides better visual outcome with minimal complications in eyes with deficient capsular support.

Late In-the-Bag Intraocular Lens Dislocation: A Randomized Clinical Trial Comparing Lens Repositioning and Lens Exchange

PURPOSE

To compare the efficacy and safety of 2 operation methods for late in-the-bag intraocular lens (IOL) dislocation.

DESIGN

Prospective, randomized, parallel-group surgical trial.

PARTICIPANTS

Patients referred to Oslo University Hospital (tertiary referral center).

METHODS

We randomly assigned 104 patients (104 eyes) either to IOL repositioning by scleral suturing (n = 54) or to IOL exchange with retropupillary fixation of an iris-claw IOL (n = 50). One surgeon performed all operations. Patients were evaluated comprehensively before surgery, and most patients (82%) attended an examination 6 months after surgery.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA) 6 months after surgery.

RESULTS

The mean postoperative BCVA was 0.24±0.29 logarithm of the minimum angle of resolution (logMAR) units (range, -0.18 to 1.16 logMAR) in the repositioning group and 0.35±0.54 logMAR (range, -0.20 to 3.0 logMAR) in the exchange group (P = 0.23). A BCVA of 20/40 or better (Snellen) was reached by 61% and 62% of the patients, respectively (P = 0.99). The mean postoperative corneal cylinder was 1.2±1.0 and 1.2±0.8 diopters, respectively (P = 0.84), and the postoperative endothelial cell density changes were -3±10% (P = 0.07) and -10±14% (P = 0.001), respectively (group difference, P = 0.04). Repositioning had a longer mean surgical time than exchange (P < 0.001). There were 2 (4%) and 0 cases of perioperative fluid misdirection syndrome, respectively. Postoperative complications were intraocular pressure (IOP) increase (n = 12), cystoid macular edema (CME; n = 3), and nonarteritic anterior ischemic optic neuropathy (n = 1) in the repositioning group, and IOP increase (n = 9), pupillary block (n = 1), choroidal effusion (n = 2), CME (n = 4), and redislocation (n = 1) in the exchange group.

CONCLUSIONS

We found satisfactory and not significantly different outcomes for BCVA 6 months after surgery in the 2 groups. Both operation methods seemed safe, with low frequencies of serious perioperative and postoperative complications. However, some of the observed differences in complications should be taken into consideration when selecting the most suitable method in clinical practice.

Surgical management of spontaneous in-the-bag intraocular lens and capsular tension ring complex dislocation

We describe a technique to manage late spontaneous intraocular lens (IOL) and capsular tension ring (CTR) dislocation within the intact capsular bag. The subluxated IOL and CTR complex can be positioned in a closed chamber and fixed to the pars plana at both 3 and 9 o’clock quadrants with the presented ab externo direct scleral suturation technique which provides an easy, safe and effective surgical option for such cases.

27-GAUGE NEEDLE-ASSISTED TECHNIQUE FOR REPOSITIONING A DISLOCATED INTRAOCULAR LENS

BACKGROUND

Several techniques for the reposition of a posterior chamber intraocular lens (IOL) posterior dislocating into the vitreous cavity have been developed. However, most of these methods are complicated or include externalizing part of the IOL from a corneal or scleral wound. We here describe a 27-gauge needle-assisted technique for management of a dislocated posterior chamber IOL.

METHODS

This is a retrospective, noncomparative, interventional case series that discusses the results of 27-gauge needle-assisted reposition of the posterior chamber IOL with transscleral sulcus fixation in 5 consecutive cases with an IOL dislocated into vitreous cavity. These patients underwent IOL reposition with the above-mentioned technique between April 2013 and October 2014 and were followed up for at least two months thereafter.

RESULTS

The IOLs of the five cases were stable with proper centrations. The postoperative best-corrected visual acuity ranged from 20/30 to 20/20.

CONCLUSION

The technique of 27-gauge needle-assisted reposition of the posterior chamber IOL with transscleral fixation is effective for reposition of a dislocated IOL. This technique provides good IOL fixation without creating a large corneal wound or scleral flap.

Iris fixation of unstable anterior chamber intraocular lenses

Cataract surgeons are sometimes challenged with a patient who has an unstable anterior chamber intraocular lens (AC IOL). Over time, an unstable AC IOL can lead to significant complications. This problem is most often addressed with an IOL exchange using an appropriately sized AC IOL or a posterior chamber IOL with iris or scleral fixation. We present a technique of 2-point iris fixation of unstable AC IOLs as a simpler and less traumatic alternative.

FINANCIAL DISCLOSURE

Neither author has a financial or proprietary interest in any material or method mentioned.

Intraocular lens exchange-removing the optic intact

Current practice for intraocular lens (IOL) exchange is to cut the optic of the posterior chamber intraocular lens (PCIOL) prior to removing it. Great care must be taken during this maneuver to avoid a posterior capsular tear. Removing the haptics from the fibrosed capsule can also be hazardous, as it may result in zonular stress and dehiscence. A technique is described for performing foldable (one-piece acrylic) IOL removal without cutting the optic. Careful visco-dissection of the haptics with a low viscosity ophthalmic viscosurgical device (OVD) in the fibrosed peripheral capsular tunnel avoids zonular or capsular stress. Internal wound enlargement permits foldable IOL removal in one piece, whilst preserving a self-sealing sutureless corneal wound. This technique may enhance the safety and efficacy of foldable IOL exchange.