Pathologic comparison of asymmetric or sulcus fixation of 3-piece intraocular lenses with square versus round anterior optic edges

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

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

Capsular Waves: A Warning Indicator for Potentially Malpositioned Intraocular Lenses

Purpose

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

Setting

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

Design

Focused, observational case series.

Methods

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

Findings

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

Conclusion

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

Safety and efficacy in pediatric secondary intraocular lens implantation, in-the-bag versus sulcus implantation: a multicenter, single-blinded randomized controlled trial

BACKGROUND

Treatment of pediatric cataract remains challenging because of the extremely high incidence of postoperative adverse events (AEs), especially the AEs related to the locations of secondary implanted intraocular lens (IOL). There are two common locations for secondary IOL implantation in pediatric aphakic eyes: ciliary sulcus or in-the-bag implantation. However, there are currently no large, prospective studies comparing complication rates and visual prognosis of in-the-bag versus ciliarysulcus secondary IOL implantation in pediatric patients. Whether or how much secondary in-the-bag IOL implantation benefits the pediatric patients more than sulcus implantation and deserves to be performed routinely by surgeons remains to be elucidated. Here, we describe the protocol of a randomized controlled trial (RCT) designed to evaluate the safety and efficacy of two approaches of IOL implantation in pediatric aphakia.

METHODS

The study is a multicenter, single-blinded RCT with 10 years of follow-up. Overall, a minimum of 286 eyes (approximately 228 participants assuming 75% have two study eyes) will be recruited. This study will be carried out in four eye clinics across China. Consecutive eligible patients are randomized to undergo either secondary in-the-bag IOL implantation or secondary sulcus IOL implantation. Participants with two eyes eligible will receive the same treatment. The primary outcomes are IOL decentration and the incidence of glaucoma-related AEs. The secondary outcomes include the incidence of other AEs, IOL tilt, visual acuity, and ocular refractive power. Analysis of the primary and secondary outcomes is to be based on the intention-to-treat and per-protocol analysis. Statistical analyses will include the χ² test or Fisher's exact test for the primary outcome, mixed model and generalized estimated equation (GEE) model for the secondary outcome, Kaplan-Meier survival curves for the cumulative probability of glaucoma-related AEs over time in each group.

DISCUSSION

To the best of our knowledge, this study is the first RCT to evaluate the safety and efficacy of secondary IOL implantation in pediatric aphakia. The results will provide high-quality evidence for the clinical guidelines for the treatment of pediatric aphakia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05136950. Registered on 1 November 2021.

A Case of Pigment Dispersion Syndrome after Placement of Sulcus Intraocular Lens with 7-mm Optic Diameter after Posterior Capsule Rupture

A 48-year-old woman diagnosed with primary angle closure suspect (PACS) in the right eye underwent cataract surgery, and a 7-mm optic diameter intraocular lens (IOL) was placed in the ciliary sulcus after intraoperative posterior capsule rupture. The patient developed uveitis and blurred vision the next day. The IOL was fixed between the iris and the anterior capsule. Irregularly shaped pupils due to posterior synechia and pigmentation on the IOL surface were observed. In the Scheimpflug image, the IOL on the anterior capsule was observed and the anterior chamber depth was 2.92 mm. A diagnosis of pigment dispersion syndrome and elevated intraocular pressure due to sulcus IOL placement was made. The patient underwent intrascleral IOL fixation surgery using an already inserted IOL to reposition the IOL under the anterior capsule. After 1 week, the blurred vision, anterior chamber inflammation, and IOL surface pigmentation were resolved. The right eye IOP was 15 mm Hg and the pupil became a regular circle. Scheimpflug images showed the IOL located behind the anterior capsule and an anterior chamber depth of 3.88 mm. Because the patient had a slightly shorter axial length of 22.89 mm and PACS, pigment dispersion may have occurred due to friction between the iris and the shape of the optic edge with a large optic diameter. In cases of posterior capsule rupture with short axial length and PACS, the use of a 7-mm optic diameter IOL in the sulcus should be avoided, or intrascleral IOL fixation should be selected as the surgical technique.

In-the-Bag Versus Ciliary Sulcus Secondary Intraocular Lens Implantation for Pediatric Aphakia: A Prospective Comparative Study

PURPOSE

To compare outcomes of in-the-bag vs ciliary sulcus secondary intraocular lens (IOL) implantation for pediatric aphakia.

DESIGN

Prospective interventional case series.

METHODS

This institutional study was conducted in 202 children (355 aphakic eyes) diagnosed as having congenital cataracts and who underwent cataract extraction before age 24 months. Pediatric aphakic eyes underwent in-the-bag or ciliary sulcus secondary IOL implantation according to the amount of residual lens capsule and were monitored for 3 years postoperatively. The main outcome measures were adverse events (AEs), IOL tilt and decentration, and best corrected visual acuity (BCVA) in the operative eye.

RESULTS

A total of 144 eyes (40.6%, 89 children) received in-the-bag IOL implantation (capsular group), and 211 eyes (59.4%, 132 children) underwent ciliary sulcus IOL implantation (sulcus group). Kaplan-Meier curves showed that the time-dependent incidence of glaucoma-related AEs (GRAEs) (P = .005) and any AEs (P = .002) were higher in the sulcus group. In-the-bag IOL implantation was a strong protective factor against GRAE (hazard ratio, 0.08; 95% CI, 0.01-0.53; P = .009) and any AEs (hazard ratio, 0.21; 95% CI, 0.08-0.57; P = .002). Clinically significant IOL decentration (>0.4 mm) was more common in the sulcus group compared with the capsular group (vertical decentration: 29.8% vs 15.7%, P = .005; horizontal decentration: 30.3% vs 9.35%, P < .001). BCVA in the capsular group was better than that in the sulcus group (logMAR, 0.56 vs 0.67, P = .014).

CONCLUSIONS

Compared with ciliary sulcus secondary IOL implantation, in-the-bag IOL implantation reduced AEs and yielded better IOL centration and BCVA for pediatric aphakia.

Force of lifelong crystalline lens growth: chronic traumatic mechanical insult to the choroid

PURPOSE

To calculate the forces applied to the uvea and retina as a result of lifelong crystalline lens growth.

DESIGN

Retrospective study.

SETTING

MRI Research, Inc., Middleburg Heights, Ohio; Institute of Ophthalmology and Visual Science UMDNJ-New Jersey Medical School, Newark, New Jersey; USC Psychology University of Southern California, Los Angeles.

METHODS

Magnetic resonance images were acquired from 15 phakic/pseudophakic eye pairs in patients with cataract (ages 46 to 83 years). Choroidal lengths were measured. The forces required to produce differences between phakic/pseudophakic choroidal lengths were calculated.

RESULTS

The length of the choroid is greater in the phakic eye compared with the corresponding pseudophakic eye (n = 15), and this difference increases with age (P = .00006; power = 0.99). The corresponding choroidal strain also increases with age (P = .00003, power = 0.99) as do the forces required to produce such a change in choroidal length (P = .000008, power = 0.99).

CONCLUSIONS

The authors theorize that lifelong crystalline lens growth applies a chronic, traumatic, mechanical insult to the uvea and retina. This previously unknown, ever-increasing, force appears to stretch the choroidal tissue and may be an intraocular pressure-independent modifiable risk factor for retinal disease. Implications exist for understanding the pathophysiology of retinal diseases in the aging eye that are often comorbid with cataracts, for example, glaucoma, macular degeneration, and diabetic retinopathy.

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

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

Diagonal haptic capture of a plate intraocular lens with 4 haptics

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Purpose

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

Methods

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

Results

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

Conclusions

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