Techniques of intraocular lens suspension in the absence of capsular/zonular support

Z-suture scleral fixation intraocular lenses: A refractive and safety report

PURPOSE

Scleral fixation of intraocular lenses constitutes a surgical option in cases where there is inadequate capsular support or zonular insufficiency. Knotless techniques, such as the z-suture technique, avoid suture-related complications, such as conjunctival erosion or exposure. The purpose of this study was to evaluate the visual outcomes and postoperative complications of patients who underwent scleral z-suture fixation of the Akreos AO® intraocular lenses.

METHODS

A retrospective, observational study was conducted, including 22 eyes of 20 patients who underwent Akreos AO® intraocular lenses using the z- suture scleral fixation technique.

RESULTS

The mean age of the patients was 55,64 ± 28,47 years old, and the mean follow-up time was 25,64 months. The most common indication for surgery was previous complicated cataract surgey. The mean postoperative spherical equivalent was +0,058D ± 0,79D, with values ranging from - 1,50D to +1,00D. Mean best-corrected visual acuity was 0,178 ± 0,15 logMAR. Intraocular pressure was 15,07 ± 2,56 mmHg on the day after surgery, and 16 ± 2,15 mmHg 1 month after. No suture-related complications were observed in any patient postoperatively. One patient had a slight inferonasal lens dislocation and another patient had a severe case of herpetic keratitis posoperatively.

DISCUSSION

The knotless z-suture technique appears to be a reliable and safe way to fix an intraocular lens in the sclera, regardless of the patient's age. Our results show good visual results and predictable refractive outcomes. Decades of follow-up may be necessary to assess the long-term risk of lens dislocation.

Refractive outcomes of Carlevale IOLs compared to Artisan iris-claw IOLs considering the type of incision

PURPOSE

To compare the refractive outcomes and the complications of implantation surgery by the Carlevale IOL to the Artisan iris-claw IOL.

METHODS

Retrospective comparative study of consecutive surgical cases between 2019 and 2021 in our tertiary centre in Paris, France.

RESULTS

We included 142 eyes in the Artisan group and 63 in the Carlevale group. Post-operative astigmatism at one month was 2.3 ± 1.6 D in the Carlevale group, 3.3 ± 2.5 D in the Artisan group with corneal incisions, and 1.8 ± 1.4 D in the Artisan group with scleral incisions (p = 0.015). Surgery duration was higher (p = 0.007) with the Carlevale IOL (70.8 ± 31.3 min) than with the Artisan IOL (58.3 ± 23.2 min). The complication rates were similar at one month between the two groups (25.4% in Artisan, 27% in Carlevale). The mean follow-up was longer in the Artisan group (234.5 days vs. 77 days, p < 0.001).

CONCLUSION

Artisan iris-claw IOL seems to induce higher astigmatism than Carlevale sutureless scleral-fixated IOL at one month when injected through a corneal incision, but not when injected through a scleral incision. Therefore cataract surgeons should avoid wide corneal incisions in implantation surgery whenever possible.

Refining delivery and positioning: A modified approach to FIL SSF intraocular lens implantation using the "full reverse" technique

PURPOSE

To present a modified surgical technique for implantation of the sutureless scleral-fixated hydrophilic intraocular lens (FIL SSF).

METHODS

Single surgeon retrospective case series and review of surgical videos with step-by-step technique analysis. Uncorrected and best corrected visual acuity (UCVA and BCVA), refractive error (spherical equivalent), full clinical examination with intraocular pressure (IOP) measurement, endothelial cell density on corneal specular microscopy and macular optical coherence tomography (OCT) were recorded at baseline, 1, 4 and 8 weeks postoperatively.

RESULTS

The FIL SSF IOLs were successfully implanted using the so-called "full reverse" technique, having the lens loaded in the injector in an upside-down fashion, as opposed to IOL technical specifications. In all cases, the FIL SSF IOL was properly placed in the ciliary sulcus, well-centered and without signs of tilt. Follow up figures at 2 months are consistent with published data, confirming the potential benefits of the new implantation technique.

CONCLUSION

In our preliminary experience, the "full reverse" technique of the FIL SSF IOL has proven effective in preventing incorrect IOL orientation in 100% of cases. However, larger prospective controlled studies and longer follow up are required to either support or disprove our results.

Safety, efficacy, and clinical outcomes of transconjunctival intrascleral fixation of an intraocular lens

BACKGROUND

Implantation of intraocular lens in the capsular bag has become the standard of care in aphakic state. However, in the absence of capsular support, several techniques and intraocular lenses are available. Our study aims to report the safety, efficacy, and clinical outcomes of transconjunctival intrascleral intraocular lens fixation with Yamane's double-needle technique and flanged haptics.

METHODS

Prospective, observational study with some retrospective data collection. The study enrolled 13 patients (16 eyes) who underwent transconjunctival intrascleral fixation of an intraocular lens with Yamane's technique between June 2017 and April 2019 at Dhahran Eye Specialist Hospital and King Fahd University Hospital. All patients underwent preoperative and postoperative comprehensive evaluation, including uncorrected and best-corrected vision, intraocular pressure, slit-lamp examination, dilated fundus examination, and ultrasound biomicroscopy. We excluded patients with visually significant coexistent pathology such as retinal diseases, glaucoma, follow-up less than three months, and combined surgery such as keratoplasty.

RESULTS

The mean preoperative uncorrected visual acuity was 1.50 logMAR, and it improved to 0.60 logMAR. The mean preoperative best-corrected visual acuity was 0.70 logMAR, and it improved to 0.40 logMAR. The median safety index was 2.0, and the median efficacy index was 1.58. The postoperative complications included iris capture by the intraocular lens in one eye (7.7%), haptic extrusion in one eye (7.7%), and transient cornea edema in one eye (7.7%). There were no detected reports during the follow-up period of postoperative retinal detachment, choroidal detachment, elevation of the intraocular pressure (> 25 mmHg), hypotony, hyphema, vitreous hemorrhage, or endophthalmitis.

CONCLUSIONS

The transconjunctival intrascleral fixation of an intraocular lens is safe and effective with a short learning curve and was not associated with significant intraoperative or postoperative complications.

Anterior Chamber Intraocular Lens Implantation Versus Four-Flanged Scleral Fixation Technique for Patients With Loss of Capsular Support During Routine Cataract Surgery

PURPOSE

To compare the outcomes of anterior chamber intraocular lens (AC-IOL) implantation versus the four-flanged scleral fixation technique in eyes with loss of capsular support during routine cataract surgery.

METHODS

This was a retrospective cohort study of all patients in whom an IOL was implanted either during or after short-term aphakia due to loss of capsular and sulcus support in a routine cataract surgery with at least 6 months of follow-up time between 2015 and 2023 in a tertiary medical center in Israel. Two different IOL implantation techniques were compared: the implantation of an angle-supported ACIOL and four-flanged scleral fixation. Main outcome measures included postoperative complications such as pseudophakic bullous keratopathy, loss of intraocular pressure control and glaucoma, IOL subluxation, and retinal detachment.

RESULTS

Sixty-five eyes of 65 patients were included in the study, 33 eyes in the AC-IOL group and 32 eyes in the flange group. Follow-up time was 29.92 ± 20.02 months in the AC-IOL group and 20.17 ± 15.56 months in the flange group (P = .087). Pseudophakic bullous keratopathy was observed in 10 (30.3%) patients in the AC-IOL group and in 1 (3.1%) patient in the flange group (P = .04). This association remained significant using survival analysis (P = .006). In 4 (12.1%) patients in the AC-IOL group, a glaucoma filtering procedure was performed to control the intraocular pressure compared with none in the flange group (P = .042).

CONCLUSIONS

In the setting of loss of capsular support during routine cataract surgery, four-flanged scleral fixation showed an overall lower rate of complications and significantly reduced rate of subsequent surgical interventions. [J Refract Surg. 2024;40(8):e520-e526.].

Influence of Sutureless Scleral Fixation Techniques With 3-Piece Intraocular Lenses on Dislocation Force

PURPOSE

To compare 4 different secondary intraocular lens (IOL) fixation techniques regarding the least required force to dislocate a scleral fixated 3-piece IOL in human corneoscleral donor tissue.

DESIGN

Experimental laboratory investigation.

METHODS

The least required dislocation force (LRDF) of 4 different secondary IOL fixation techniques, namely, the techniques using transscleral tunnels (TTs; as described by Scharioth), glued haptics (GHs; Agarwal), flanged haptics (FHs; Yamane), and bent haptic ends (BH; Behera/Bolz), were investigated using 40 three-piece IOLs (Sensar AR40) fixated to human scleral tissue. The main outcome of the study, dislocation force between different techniques, was measured with a tensiometer.

RESULTS

The force needed to dislocate the haptics was highest with the FH technique and was significantly higher than with all the other techniques (GH vs FH: -1.02±0.02 N, P < .001; TT vs FH: -1.08±0.21 N, P < .001; BH vs FH: -1.00±0.25 N, P = .044). There was no significant difference regarding the dislocation force between the other techniques: GH vs TT (-0.06±0.100 N, P = .988), GH vs BH (-0.02±0.03 N, P = .60), TT vs BH (-0.08±0.04 N, P > .99).

CONCLUSIONS

The FH technique as described by Yamane proved to be the strongest form of secondary IOL fixation regarding dislocation force in this in vitro study. The other fixation techniques showed significantly less resistance to axial traction.

Long-Term Surgical Outcomes of Scleral Flap versus Scleral Pocket Technique for Sutureless Intrascleral One-Piece Lens Fixation

Objectives: This study compared long-term surgical outcomes of the scleral flap versus scleral pocket technique for sutureless intrascleral one-piece intraocular lens (IOL) fixation. Methods: A retrospective comparative study was conducted at a single center, involving consecutive patients undergoing sutureless intrascleral one-piece IOL implantation, between January 2020 and May 2022. Eyes were divided into two groups based on the surgical technique: group 1 underwent scleral flap (n = 64), and group 2 received scleral pocket technique (n = 59). Visual acuity, refractive outcomes, and complications were assessed over a minimum 24-month follow-up period. Results: Both groups showed improvements in best-corrected visual acuity (BCVA), increasing from 0.84 ± 0.56 logMAR at baseline to 0.39 ± 0.23 logMAR (p = 0.042) at 24 months in group 1 and from 0.91 ± 0.63 logMAR at baseline to 0.45 ± 0.38 logMAR (p = 0.039) at 24 months in group 2. No significant differences in BCVA were observed between the groups at baseline (p = 0.991), 12 (p = 0.496) and 24 months (p = 0.557). Mean spherical equivalent (-0.73 ± 1.32 D in group 1 and -0.92 ± 0.99 D in group 2, p = 0.447), refractive prediction error (-0.21 ± 1.1 D in group 1 and -0.35 ± 1.8 D in group 2, p = 0.377), and surgically induced astigmatism (0.74 ± 0.89 D in group 1 and 0.85 ± 0.76 in group 2, p = 0.651) were comparable between the two groups. An IOL tilt of 5.5 ± 1.8 and 5.8 ± 2.0 degrees (p = 0.867) and an IOL decentration of 0.41 ± 0.21 mm and 0.29 ± 0.11 mm (p = 0.955) were obtained, respectively, in group 1 and group 2 at 24 months. Mean endothelial cell density remained stable at 24 months in both groups (p = 0.832 in group 1 and p = 0.443 in group 2), and it was 1747.20 ± 588.03 cells/mm2 in group 1 and 1883.71 ± 621.29 cells/mm2 in group 2 (p = 0.327) at baseline, 1545.36 ± 442.3 cells/mm2 in group 1 and 1417.44 ± 623.40 cells/mm2 in group 2 (p = 0.483) at 24 months. No cases of endophthalmitis were observed. Conclusions: The scleral pocket technique for sutureless intrascleral one-piece IOL fixation is comparable to the traditional scleral flap technique in terms of long-term visual outcomes and safety. The scleral pocket technique offers a simplified approach and a viable option even for less experienced surgeons.

Long-Term Postoperative Outcomes Following Cionni Ring and In-the-Bag Intraocular Lens Implantation in Eyes With Subluxated Lenses

PURPOSE

Evaluate long-term outcomes following Cionni modified capsule tension ring (MCTR) and in-the-bag intraocular lens (IOL) implantation in subluxated lenses.

DESIGN

Retrospective case series.

METHODS

Forty-one eyes of 31 patients from Raghudeep Eye Hospital, India, with subluxated lenses who had completed a minimum of 5 years' postoperative follow-up were included. Lens extraction, capsular bag fixation with MCTR using 9-0 polypropylene suture, and in-the-bag IOL implantation were performed in all eyes. Corrected distance visual acuity (CDVA), IOL centration, posterior capsule opacification, glaucoma, and retinal complications were documented at final follow-up.

RESULTS

The mean age of the cohort was 20.48 ± 16.46 (SD) years. Twenty-four eyes (58%) were below 15 years of age at the time of surgery. Marfan syndrome accounted for 37% cases. Mean follow-up was 9.89 ± 3.81 (SD) years. Thirty-two eyes (74%) had a CDVA of ≥0.3 logMAR at final follow-up. IOL decentration was noted in 7 eyes (17%), requiring a secondary surgery. The mean duration from primary surgery to resurgery was 8.79 years. Seventeen eyes (41%) required a laser capsulotomy, 88% of which were pediatric eyes. Retinal detachment occurred in 4 eyes (10%), 3 of which had Marfan syndrome.

CONCLUSION

Capsular bag fixation with an MCTR using 9-0 polypropylene and in-the-bag IOL implantation had good long-term visual outcomes with an acceptable rate of serious postoperative complications in eyes with subluxated lenses. This approach allows preservation of the natural compartments of the eye and placement of an IOL in its most physiological position. However, considering a 17% rate of IOL decentration requiring surgical intervention, long-term stability with nonbiodegradable suture materials such as polytetrafluoroethylene as well as decentration rates following sutured or sutureless scleral fixation should be compared.

Long term surgical results and safety profile of the novel CM T Flex scleral fixated intraocular lens

PURPOSE

To report the long term visual outcomes and complications with use of the novel CM-T Flex scleral fixated intraocular lens (CMT-SFIOL).

MATERIALS AND METHODS

116 eyes that underwent CMT-SFIOL were reviewed and 57 eyes with CMT-SFIOL that completed a 2-year follow-up were included. Main outcome measures noted were best-corrected visual acuity (BCVA) and complications. Postoperatively, follow-ups were done at 1 week (1w), 1 month (1 m), 1 year (1y) and 2-year (2y) intervals.

RESULTS

40 (70.17%) of 57 eyes received CMT-SFIOL for surgical aphakia. Mean follow up was 39.77 ± 8.44 months. BCVA for distance & near improved from 1.26 ± 0.84 to 0.76 ± 0.77, 0.50 ± 0.72 and 0.51 ± 0.73 & 1.28 ± 0.58 to 0.98 ± 0.49, 0.92 ± 0.44 and 0.89 ± 0.40 at 1 m, 1y and 2y respectively (p < 0.001 for all). At 1w, 10 eyes (17.54%) had corneal edema (CE) and 8 eyes (14.03%) had anterior chamber (AC) reaction. Two eyes (3.50%) had IOP > 30 mm Hg and 1 eye (1.75%) had vitreous hemorrhage (VH). At 1 m, 3 eyes (5.26%) had CE and 5 eyes (8.77%) had AC reaction. Two eyes (3.50%) had IOP > 30 mm Hg and 1 eye (1.75%) had VH. Cystoid macular edema was noted in 3 eyes (5.26%). At 1y and 2y, 2 eyes (3.5%) and 1 eye (1.75%), had CE. No decentration, dislocation, haptic exposure or retinal detachment was noted. No eyes required resurgery.

CONCLUSION

CM-T Flex SFIOL is an effective method to correct aphakia, with reliable and safe long-term results.

Aphakia treatment with sutureless scleral fixation or retropupillary iris-claw intraocular lens implantation: visual acuity, anterior segment and keratometry outcomes

PURPOSE

Evaluation of anterior segment parameters using the Scheimpflug corneal topography 1 year after surgery in patients who underwent sutureless scleral fixation intraocular lens (SFIOL) implantation using the modified Yamane technique and retropupillary iris-claw intraocular lens (RPIOL) implantation.

METHODS

A total of 60 eyes from 57 patients who underwent sutureless SFIOL implantation and 57 eyes from 52 patients who underwent RPIOL implantation were included. Anterior chamber depth (ACD), anterior chamber angle (ACA), anterior chamber volume (ACV), anterior-posterior corneal astigmatism, and keratometric values were assessed using the Scheimpflug corneal topography (Pentacam HR, Germany).

RESULTS

There was no statistically significant difference in postoperative UCVA and BCVA between the sutureless SFIOL and the RPIOL group (p = 0.236, p = 0.293, respectively). While there was no statistically significant difference in postoperative IOP between the two groups (p = 0.223), a statistically significant decrease in IOP was observed in both groups (p < 0.001). While there was no statistical difference between the sutureless SFIOL group and the RPIOL group in terms of spherical value (p = 0.441) and spherical equivalence (p = 0.237), there was a statistically significant difference in cylindrical value (p < 0.001). While there was a statistical difference in anterior astigmatism (p < 0.001), there was no statistical difference in posterior astigmatism (p = 0.405). There was no statistical difference in terms of ACV, ACD, and ACA between the sutureless SFIOL and the RPIOL group (p = 0.812, p = 0.770, p = 0.401, respectively).

CONCLUSION

In this study, although there was a statistical difference in cylindrical value and anterior corneal astigmatism between the sutureless SFIOL and RPIOL groups, vision was not affected. According to this study, sutureless SFIOL and RPIOL are two successful methods in terms of visual acuity, anterior segment, and keratometry outcomes in aphakic patients after phacoemulsification.

Background factors determining the time to intraocular lens dislocation

PURPOSE

To clarify the characteristics of intraocular lens (IOL) dislocation requiring IOL suture or intraocular scleral fixation.

METHODS

This retrospective consecutive case series included 21 eyes (21 patients) who required sutured or sutureless intrascleral IOL fixation following IOL extraction owing to IOL dislocation at the outpatient clinic in the Department of Ophthalmology, Saitama Red Cross Hospital, Japan, between January and December 2019. Medical records were retrospectively reviewed for background diseases, location of the dislocated IOL (intracapsular/extracapsular), insertion of a capsular tension ring (CTR), and the period from IOL insertion to dislocation.

RESULTS

We included 21 eyes of 21 patients who required IOL suture or intrascleral fixation for IOL dislocation at our clinic from January to December 2019 were included. The most common background disease was pseudoexfoliation syndrome (four cases), followed by atopic dermatitis, dysplasia/dehiscence of the zonule, post-retinal detachment surgery, high myopia, and uveitis (three cases each). At the time of dislocation, the IOLs were either intracapsular (16 cases, including 3 cases with CTR insertion) or extracapsular (5 cases). The time from IOL insertion to IOL dislocation was 13.7 ± 8.1 years (maximum: 31.3 years, minimum: 1.7 years).

CONCLUSIONS

In this study, all 21 cases represented late IOL dislocations occurring after 3 months postoperatively. Among these late IOL dislocation cases, IOL dislocation occurred in a short-medium period of time, especially in those with CTR insertion and weakness/dehiscence of the zonule, with an average of 3 to 5 years postoperatively. We propose referring to these cases as intermediate-term IOL dislocation.

Clinical Outcomes in Scleral Fixation Secondary Intraocular Lens with Yamane versus Suture Techniques: A Systematic Review and Meta-Analysis

Background: The purpose of the study is to compare the visual outcomes and complications of sutured scleral fixation (SSF), a traditional and conservative surgical approach, and the newer and faster Yamane technique for secondary intraocular lens placement. Methods: A literature search was performed on PubMed, Embase, and Scopus on studies published between 1 July 2017 to 29 September 2023. Outcomes analyzed included the final best corrected visual acuity (BCVA) between 3 and 12 months to assess the effectiveness of the procedure, post-operative month (POM) 1 BCVA to assess the speed of visual recovery, endothelial cell count (ECC), absolute refractive error, surgical duration, and complication rates. Additional subgroup analyses were performed based on surgeon experience with the technique. Single-surgeon studies had an average of 26 procedures performed, whereas multiple-surgeon studies averaged only 9 procedures performed; these were then used to delineate surgeon experience. A sample-size weighted mean difference (MD) meta-analysis was performed across all variables using RevMan 5.4.1; p < 0.05 was considered statistically significant. Results: Thirteen studies with 737 eyes were included: 406 eyes were included in the SSF group, and 331 eyes were included in the Yamane group. There was no significant difference in the final BCVA between groups in both the single-surgeon versus multiple-surgeon studies (MD = -0.01, 95% CI: [-0.06, 0.04], p = 0.73). In the single-surgeon studies, the BCVA at POM1 was significantly improved in the Yamane group compared to SSF (MD = -0.10, 95% CI: [-0.16, -0.04], p = 0.002). In the multiple-surgeon studies, there was no significant difference in BCVA at POM1 (MD = -0.06, 95% CI: [-0.16, 0.04], p = 0.23). The Yamane group had a shorter surgical duration than SSF in both single-surgeon and multiple-surgeon studies (MD = -24.68, 95% CI: [-35.90, -13.46], p < 0.0001). The ECC, refractive error, and complication rates did not significantly differ amongst all groups. Conclusions: The Yamane technique demonstrated similar long-term visual outcomes and complication rates to the traditional SSF. Visual recovery was significantly faster in the Yamane group in the single-surgeon studies. The operative times were shorter across all Yamane groups. Based on these findings, it is advisable to consider the Yamane technique as a viable, and perhaps preferable, option for patients requiring secondary IOL placement, alongside traditional SSF methods.

Zonular dialysis and cataract surgery: results from a UK tertiary eye care referral centre

OBJECTIVE

Zonular dialysis (ZD), referred to as the presence of a deficient zonular support for the lenticular capsule, might be the result of several causes and be detected only at the time of cataract surgery. The aim of this study was to evaluate pre-, intra-, and postoperative features of eyes with ZD regardless of the etiology detected during cataract surgery.

METHODS

A single-centre retrospective observational cohort study was performed at Moorfields Eye Hospital (NHS Foundation Trust, London, U.K.) to identify patients who underwent cataract surgery whose procedure was intraoperatively described as being complicated by ZD between January 1, 2014, and August 22, 2019. Patient characteristics, intraoperative clinical findings, visual and refractive outcomes, and postoperative complications were recorded.

RESULTS

ZD was identified intraoperatively in 447 eyes. In most cases (213 of 223; 96.8%), patients underwent a phacoemulsification procedure, not requiring any conversion to intracapsular or extracapsular extraction technique. Intraoperative complications increased to 46.2% (103 of 223), with no significant correlation with ZD width. Capsular tension rings (CTRs) were implanted in 43.4% of patients (97 of 223). The use of CTRs correlated with better postoperative visual and refractive outcomes.

CONCLUSIONS

ZD is a serious complication of cataract surgery requiring prompt intraoperative diagnosis and proper management. While it tends to worsen cataract surgery outcomes, the implantation of CTRs during the surgical procedure seems to be associated with better postoperative visual and refractive results.

Repositioned versus exchanged flanged intraocular lens fixation for intraocular lens dislocation

This study aimed to compare the outcomes of flanged intraocular lens (IOL) fixation with new IOL exchange after dislocated IOL removal and repositioned dislocated IOL in patients with IOL dislocation. Eighty-nine eyes that underwent flanged IOL fixation were retrospectively included, with 51 eyes in the exchanged IOL group and 38 eyes in the repositioned IOL group. In both groups, best-corrected visual acuity (BCVA) improved at 1, 3, 6, and 12 months postoperatively and did not differ between the two groups at any of these time points. However, at 1 week postoperatively, BCVA in the repositioned IOL group improved compared with baseline, whereas that in the exchanged IOL group did not. Moreover, there were lesser changes in the corneal endothelial cell density (ECD) and corneal astigmatism in the repositioned IOL group than in the exchanged IOL group. The IOL positions, including IOL tilt and IOL decentration, were not different between the groups. Flanged IOL fixation with new IOL exchange and with repositioned dislocated IOL for patients with IOL dislocation had similar visual outcomes and IOL position. However, the latter had a smaller corneal ECD decrease and astigmatic change. This technique was effective in treating IOL dislocation while minimizing corneal injury.

Ten-year results of scleral-fixated intraocular lens implantation: outcomes of ab externo scleral fixation with 10-0 polypropylene suture

PURPOSE

To describe long-term visual and anatomical outcomes of sutured scleral-fixated intraocular lens (SF IOL) implantation.

SETTING

Tertiary eyecare hospital in India.

DESIGN

Retrospective interventional noncomparative study.

METHODS

Postoperative change in corrected distance visual acuity (CDVA) and occurrence of complications were assessed from the patient medical records. Long-term SF IOL survival rates and factors affecting the occurrence of postoperative IOL-related complications were assessed. Patients with postoperative follow-up less than 10 years or incomplete medical records were excluded.

RESULTS

64 eyes of 53 patients were included. Follow-up duration was 11.4 ± 1.2 years. Mean preoperative CDVA was 0.71 ± 0.43 logMAR (Snellen equivalent: 6/30), and mean CDVA at the final visit was 0.52 ± 0.49 logMAR (Snellen equivalent: 6/18) (P < .01). 48% cases had CDVA of 6/12 or better at the last follow-up. 58% cases had coexistent ocular pathology affecting the final visual outcome. IOL and suture-related complications were the commonest and included IOL decentration (17% cases), IOL drop (14%), and suture exposure (6%). The probability of IOL survival (postoperative period without IOL-related complications) was 90.6% at 8 years and 81.2% at 10 years (Kaplan-Meier analysis). Occurrence of postoperative IOL-related complications was unaffected by patient sex, age, indication for surgery (trauma or other), previous intraocular surgery, or technique of scleral fixation (2-point or 4-point) (multivariate regression analysis).

CONCLUSIONS

Although sutured SF IOL implantation is viable with favorable long-term visual outcomes, there is a risk of postoperative IOL-related complications. Occurrence of postoperative IOL-related complications is unaffected by patient and ocular factors.

Six-point scleral fixation of a three-looped haptics one-piece posterior chamber intraocular lens by a single suture

To evaluate a novel technique for six-point scleral fixation of a three-looped haptics posterior chamber intraocular lens (PCIOL) by a single suture. Nine eyes of nine patients were studied from September 2021 to March 2023. All patients had undergone vitrectomy. Only a single 9-0 polypropylene suture was used for scleral fixation. The three looped haptics were fixed at 12, 4, and 8 o'clock with six-point scleral fixation. The entire procedure took about 30 min. Among the nine patients, eight (88.8%) eyes had a significant improvement in best-corrected visual acuity, whereas one (11.2%) eye showed no change. No intraoperative or postoperative complications were observed. By ultrasonic biomicroscopy examination, intraocular lenses were well positioned and stable with no tilt in the horizontal and vertical axis. The method of six-point scleral fixation of a three-looped haptics PCIOL by a single suture is safe and effective.

Long-term outcomes of iris-sutured subluxated intraocular lenses

PURPOSE

This study evaluated the long-term outcomes of managing posterior chamber intra-ocular lens (IOL) (PCIOL) subluxation through pars plana vitrectomy (PPV) with IOL iris suturing.

SETTINGS AND DESIGN

Retrospective chart review.

METHODS

Patients who underwent PPV with iris-sutured IOL (IS-IOL) for IOL subluxation between January 2008 and April 2021 at a tertiary center with a minimum of 6 months of follow-up were included. The patients were divided into two groups: those who had prior PPV and those who had not undergone the procedure.

RESULTS

A total of 54 patients underwent iris suturing of a subluxated IOL. Among them, 36 (66%) had previously undergone PPV, while 18 patients (33%) had not. The etiology of PCIOL subluxation was uncertain in 20 (37.0%), prior PPV in 17 (32%), and following complicated cataract surgery in 11 (20%) cases. The mean time between original IOL insertion and IS-IOL was 6.1 ± 7.0 years. The mean follow-up duration was 46.8 ± 39.7 months. The mean post-operative best corrected visual acuity (BCVA) was logMAR 0.43 ± 0.52 at final follow-up, a significant improvement from pre-operative BCVA. Vision was significantly better in the group with no prior PPV (logMAR 0.54 ± 0.59 vs. 0.21 ± 0.23 at final follow-up, P = 0.026). At final follow-up, 34 (63%) eyes had BCVA of 20/40 or better. The most common complication was cystoid macular edema, attributed to the IS-IOL in 13 (21.4%) eyes, 11 (68.6%) of which resolved or improved.

CONCLUSIONS

The management of posterior chamber IOL subluxations with PPV and iris suturing of the subluxated IOL is a safe technique that provides excellent long-term visual outcomes.

A meta-analysis of sutureless scleral-fixated intraocular lens versus retropupillary iris claw intraocular lens for the management of aphakia

This study compared the visual outcomes and complications between sutureless scleral-fixated intraocular lens and iris claw intraocular lens implantation in aphakia without adequate capsule and/or zonule support. Studies comparing the clinical outcomes of scleral-fixated intraocular lens and iris claw intraocular lens implantation published until April 2022 were retrieved from the PubMed, EMBASE, Cochrane Library, and Google Scholar databases. The outcomes included postoperative final visual acuity, surgical time, surgery-induced astigmatism, and complications. The weighted mean difference and odds ratio were calculated. Two randomized controlled trials and five cohort studies, including 244 and 290 eyes in the scleral-fixated intraocular lens group and iris claw group, respectively, were included. Scleral-fixated intraocular lens implantation results in a better postoperative final corrected distance visual acuity compared with iris claw intraocular lens implantation; however, it is more time-consuming. Scleral-fixated intraocular lens implantation seems to have lesser incidences of surgery-induced astigmatism. Furthermore, both procedures have a similar complication rate. Therefore, based on current best evidence, these two procedures should be considered according to patient's conditions.

[Transscleral fixation of intraocular lens in the treatment of lens subluxation in children]

Congenital subluxation of the lens as a complication of Marfan syndrome, Weill-Marchesani syndrome, microspherophakia, etc. leads to the development of amblyopia and requires timely surgical treatment with removal of the subluxated lens and implantation of an artificial intraocular lens (IOL). IOL implantation in children with pathology of the ligamentous apparatus of the lens remains an urgent problem of ophthalmic surgery due to the lack of a consensus regarding the IOL fixation method among practitioners.

PURPOSE

This study evaluated the effectiveness and safety of IOL implantation with transscleral fixation using the knotless Z-suture technique in pediatric patients with congenital lens subluxation.

MATERIAL AND METHODS

The study included 24 children (36 eyes) with grade III congenital subluxation of the lens who underwent phacoaspiration of the subluxated lens with IOL implantation with transscleral fixation using the knotless Z-suture performed in the Kazakh Research Institute of Eye Diseases in Almaty in the period from 2017 to 2021. The average observation period was 31.7±11.3 months (2.0 to 4.5 years). The stability of the IOL position, the state of the intrascleral sutures, visual acuity after surgery, the presence and severity of complications in the long-term period were evaluated.

RESULTS

All patients (100%) had a significant improvement in visual acuity after surgery. No intraoperative complications were registered in any of the cases. Postoperative complications were noted in 8.3% of cases (n=3). The final functional outcome of surgical treatment depended on the presence of concomitant pathology, the main cause of low vision was the development of refractive amblyopia due to refractive errors.

CONCLUSIONS

The presented technique of transscleral fixation of IOL has proven to be reliable, which is especially important for pediatric patients considering their high physical activity and expected lifespan.

Application of the suture needle retrograde threading method in scleral fixation of intraocular lenses

BACKGROUND

Here we described a new threading technique for the universal fixation of any posterior chamber intraocular lens (IOL).

METHODS

Twenty-seven eyes of 27 patients whose surgery done by Surgeon A with the needle-guided method or the suture needle retrograde threading (SNRT) method for intrascleral IOL fixation were enrolled in the first group. Thirty-four eyes of 34 patients whose surgery done by Surgeon A, Surgeon B or Surgeon C with the SNRT method for intrascleral IOL fixation were grouped into three sub-groups by surgeon. Information regarding age, sex, best-available visual acuity (BCVA), intraocular pressure (IOP), past ophthalmological history, threading time (from puncturing to externalizing suture) and complications during and after the surgery were gathered.

RESULTS

The analysis showed that the threading time was less in the SNRT group than needle-guided group by Surgeon A. There was one eye with suture needle slipping from the guide needle when guiding out of the eye. The threading procedure was completed one time without suture ruptures or loop slippage in the SNRT group operated by Surgeon A. And using the SNRT method, Surgeon A, Surgeon B, and Surgeon C did not show any significant difference in threading time. No complications (e.g., vitreous hemorrhage, hyphemia, retinal detachment, suprachoroidal hemorrhage, or hypotony) were observed during surgery or postoperatively in all cases. No leakage occurred at the site of the puncture after the operation.

CONCLUSIONS

The described technique appears to be a safe, simple, easy-to-learn, and universal surgical method, which is suitable for various types of IOLs.

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.

Long term outcomes of Yamane technique in various indications

INTRODUCTION

To describe the clinical and refractive outcomes of Yamane transconjunctival sutureless intrascleral intraocular lens (SIS IOL) fixation technique in aphakic and dislocated IOLs.

METHODS

The aphakic and IOL dispositioned patients who underwent Yamane surgery in Bozyaka Research and Training Hospital were evaluated retrospectively. The demographic data, preoperative & postoperative best-corrected visual acuity (BCVA), spherical equivalent (SE), indication for surgery, additional surgical interventions, complications, the final status of retina, and central macular thickness (CMT) through spectral-domain optic coherence tomography (SD-OCT) were recorded.

RESULTS

A total of 30 eyes of 30 patients were evaluated. The indication for surgery was aphakia in 24 patients, lens dislocation in 1 patient, and IOL dislocation in 5 patients. The mean age of participants was 64.17 ± 14.69 years, and the mean follow-up was 46.07 ± 7.96 months. The mean BCVA was improved from 0.25 ± 0.22 (-0.94 ± 0.83 log MAR) to 0.49 ± 0.24 in decimals (-0.37 ± 0.27 log MAR) (p:0.041). The mean subjective refraction improved from 10.06 ± 3.10 to -1.45 ± 0.73 D in the final visit (p < 0.05). The mean of cylindrical refraction was -1.22 ± 1.03 D in the postoperative period. At the time surgery, 36.6% of patients required at least one additional surgical procedure. During follow-up period, two (6.7%) out of 30 of patients had retinal detachment, two of the patients (6.7%) occured epiretinal membrane, one of the patients (3.3%) had cystoid macular edema.

CONCLUSION

Yamane SIS IOL fixation technique is an effective and reliable surgical option in complicated cases that require additional surgical interventions in long-term follow-up.

Preferred surgical techniques for secondary intraocular lens implantation in adults with aphakia

AIM

To identify the current surgical management of aphakia and the outcomes and complications of each technique.

METHODS

This cross-sectional study included ophthalmic surgeons with at least one-year experience in surgery for aphakia. A study questionnaire was formulated to collect data in Saudi Arabia and other regional countries. The questionnaire included 22 questions on demographics, preferred surgical techniques, complications and the factors related to surgeon decision and the choice for managing aphakia.

RESULTS

The study included 145 participants (111; 76.6% were males) with mean age of 46.7 ± 11.5 years. The mean duration of cataract surgery experience was 17.6 ± 11.1 years. Most participants (86.2%) were trained in cataract surgery. Scleral fixation of intraocular lens (SFIOL) was the most commonly preferred technique, followed by iris fixation IOL, and anterior chamber IOL (75.2%, 9%, and 15.9%, respectively). The main determinants for selection of a surgical technique were simplicity (56.6%), surgical instrument availability (48.3%), and training on the technique (47.6%). The most frequent postoperative complications were pupil distortion, high intraocular pressure (IOP), pupillary capture of the IOL, and IOL decentration.

CONCLUSIONS

SFIOL is the preferred surgical technique for managing aphakia. The decision to choose one technique over another is complex and is based on several factors, including technical difficulty, previous training, anatomical variations, ocular comorbidities, and the potential complications. The most frequent complications after surgical correction of aphakia are pupil distortion, high IOP, pupillary capture of the IOL, and decentered IOLs.

MODIFIED SUTURELESS INTRASCLERAL FIXATION TECHNIQUE FOR SECONDARY INTRAOCULAR LENS IMPLANTATION: A Pilot Study

BACKGROUND/PURPOSE

To demonstrate possible complications of a new intraocular lens for sutureless secondary scleral implantation and modifications of the surgical technique to optimize outcomes.

METHODS

A retrospective study of 16 eyes (16 patients) who underwent a secondary intraocular lens implantation using the Carlevale intraocular lens (Soleko, Italy) with two anchor haptics for intrascleral implantation (mean follow-up 2.2 months).

RESULTS

The visual acuity did not improve statistically significantly postoperatively ( P = 0.601). Seven (44%) patients suffered from postoperative hypotonia (intraocular pressure <5 mmHg) during the first three postoperative days.

CONCLUSION

Owing to the early postoperative hypotony, we decided to modify the surgical technique. We present several suggestions to optimize the technique and outcome such as positioning the sclerotomies at the 2 and 8 o'clock positions, using 27 G trocars alone and suturing the frown incisions using self-resorbing sutures.

FIL SSF intraocular lens opacification after pars plana vitrectomy with gas tamponade for traumatic lens luxation and retinal detachment: a case report and literature review

BACKGROUND

To report a case of sutureless scleral-fixated hydrophilic intraocular lens (FIL SSF IOL, Soleko, Italy) opacification following pars plana vitrectomy surgery using sulfur hexafluoride (SF6) for traumatic lens luxation associated with retinal detachment.

CASE PRESENTATION

A 77-year-old woman was referred to our emergency department after blunt trauma in her right eye. At the ophthalmic evaluation, visual acuity was hand movement, biomicroscopy showed pseudoexfoliation syndrome and a traumatic lens luxation in the vitreous chamber. The patient underwent pars plana vitrectomy, subluxated cataract explantation, and FIL SSF IOL implant. During surgery, an inferior retinal detachment was encountered, requiring 20% SF6 gas tamponade. No adverse events were encountered. One month postoperatively, visual acuity (BCVA) improved to 0,3 logMAR. At the 3-month follow-up, the patient presented with BCVA of 0,5 logMAR, and biomicroscopy showed a minimal IOL opacification. Six months postoperatively, BCVA decreased to 1.0 logMAR, and diffuse, IOL opacification was noted at slit lamp examination. The patient refused any other surgical intervention for IOL exchange.

CONCLUSIONS

Although hydrophilic IOL opacification gas related is known, to the best of our knowledge, this is the first case reported in the literature of FIL SSF IOL opacification after pars plana vitrectomy with gas tamponade for retinal detachment.

Clinical Experience of Two Sutureless Intrascleral Fixation Techniques for Secondary Intraocular Lens Implantation

INTRODUCTION

The aim of this study was to evaluate the outcome of the modified Carlevale intraocular lens (IOL) fixation technique, using two different vitrectomy ports (23- vs. 27-gauge) as anchor fixation.

METHODS

Retrospective, consecutive study of 282 eyes (282 patients) who underwent a secondary IOL implantation using the Carlevale IOL (Soleko IOL Division, Italy) with two anchor haptics for intrascleral implantation with either 23- or 27-gauge (G) port.

RESULTS

Transient post-operative ocular hypotonia (intraocular pressure ≤5 mm Hg) was observed less in the 27-G group (13 vs. 4 patients, p = 0.057) three requiring additional tunnel sutures (2 cases for 23-G; 1 case 27-G). Post-operative vitreous haemorrhage was recorded more often in the 23-G group (8 vs. 1 patient, p = 0.034), but all cases in both groups resolved without intervention. Visual acuity did improve post-operatively in the two groups. No post-operative complications such as retinal detachment, endophthalmitis, and IOL-dislocation tilt were observed in the follow-up.

CONCLUSION

The 27-G modified technique for sutureless intrascleral implantation is simple and effective and causes less post-operative hypotony.

Improving Effective Lens Position Prediction for Transscleral Fixation of Intraocular Lens Among Congenital Ectopia Lentis Patients

PURPOSE

To introduce a method of predicting effective lens position (ELP) among congenital ectopia lentis (CEL) patients undergoing transscleral fixation of intraocular lens (IOL), and evaluate its effect on improving refractive outcome by utilizing the Sanders-Retzlaff-Kraff / theoretical (SRK/T) formula.

DESIGN

Retrospective cross-sectional study.

METHODS

A training set (93 eyes) and validation set (25 eyes) was included. Z value as the distance between the iris plane and a hypothetic postoperative IOL position was introduced in this study. The Z-modified ELP consisted of corneal height (Ch) and Z (ELP = Ch + Z), and Ch was calculated by keratometry (Km) and white-to-white (WTW). The value of Z was identified by linear regression formula with the involvement of axial length (AL), Km, WTW, age, and gender. The comparison of mean (MAE) and mediate absolute error (MedAE) among Z-modified SRK/T formula, SRK/T, Holladay I, and Hoffer Q formula was performed to evaluate the performance of Z-modified SRK/T formula.

RESULTS

Z value was associated with AL, K, WTW, and age (Z = offset + 15.1093 × lg (AL) + 0.0953899 × Km - 0.3910268 × WTW + 0.0164197 × Age - 19.34804). The Z-modified ELP has good accuracy with no difference to back-calculated ELP. The accuracy of Z-modified SRK/T formula was better than other formulas (P < .001) as the MAE was 0.24 ± 0.19 diopter (D) and MedAE was 0.22 D (95% CI: 0.01-0.57 D). Sixty-four percent of eyes had a refractive error smaller than ±0.25 D, and none of the subjects had a prediction error greater than ±0.75 D.

CONCLUSIONS

ELP of CEL can be accurately predicted by AL, Km, WTW, and age. Z-modified SRK/T formula improved on the current formula by improving predicting accuracy of ELP and may serve as a promising formula for CEL patients with transscleral fixation of IOL.

Scleral flaps, pars plana vitrectomy and gore-tex sutured posterior chamber intraocular lens placement: a case series and review of literature

Introduction

Cataract surgery is one of the most common surgical procedures performed worldwide. Intraocular lens (IOL) implants are placed routinely in the capsular bag after successful cataract extraction. However, in the absence of adequate capsular support, IOL may be placed in the anterior chamber, fixated to the iris or fixated to the sclera. The purpose of this study is to report the clinical outcomes and safety profile of a trans-scleral sutured intraocular lens (IOL) technique using scleral flaps, vitrectomy, and Gore-Tex suture to place posterior chamber IOL.

Methods

Retrospective, interventional case series of eyes undergoing scleral fixation of an IOL using Gore-Tex suture with concurrent vitrectomy. Ocular examination with the logarithm of the minimum angle of resolution visual acuity (logMAR BCVA), tonometry, and slit-lamp biomicroscopy was performed on all patients at 1, 3, 6, and 12 months after the operation. All post-operative complications were recorded.

Results

Twenty-five eyes of 25 patients were included. Mean logMAR BCVA improved from 0.43 ± 0.36 (20\40 Snellen equivalent) preoperatively to 0.13 ± 0.18 (20\25 Snellen equivalent) postoperatively at 12 months (p<0.01). Indications included surgical aphakia (16) and dislocated lens implant (9). No cases of IOL opacification, suprachoroidal haemorrhage, post-operative endophthalmitis, IOL dislocation, Gore-Tex exposure, or retinal detachment were observed during the follow-up period.

Conclusion

Ab externo scleral fixation of IOLs with Gore-Tex suture plus scleral flap is well tolerated and associated with a very low rate of suture exposition. Moreover, our study confirms excellent refractive outcomes after surgery.

Scleral fixation of a novel modified, injected canine intraocular lens by haptic capture, in 17 dogs

INTRODUCTION

The aims of lens removal surgery are to re-establish or preserve both a clear visual axis and emmetropic vision. Trans-scleral intraocular lens (IOL) fixation has been described in cases where lens capsule instability precludes the insertion of a prosthetic intraocular lens into the lens capsule. Previous techniques have necessitated enlargement of the corneal incision to accommodate either a rigid polymethylmethacrylate IOL or an acrylic foldable IOL inserted using forceps. This paper reports the modification of an endocapsular IOL to be used as an injectable suture-fixated IOL introduced through a 2.8 mm corneal incision.

MATERIALS AND METHODS

All cases underwent lens extraction by phacoemulsification followed by removal of the unstable lens capsule. A PFI X4 IOL (Medicontur) was modified to create four open-loop haptics. The IOL was injected into the anterior chamber, each haptic was captured in a loop of suture introduced ab externo, and the lens was sutured with four-point fixation.

RESULTS

The results from 20 eyes in 17 dogs are reported. Over an average follow-up time of 14.5 months, vision was retained in 16/20 eyes. Vision was lost in four eyes due to corneal ulceration and ocular hypertension (1/20), retinal detachment (2/20), and Progressive Retinal Atrophy (1/20).

CONCLUSIONS

The modified PFI X4 proved suitable for injection and scleral fixation through a 2.8 mm corneal incision, with a success rate comparable to previously published techniques.

Refractive outcome and lens power calculation after intrascleral intraocular lens fixation: a comparison of three-piece and one-piece intrascleral fixation technique

PURPOSE

To evaluate the refractive prediction error of common intraocular lens (IOL) power calculation formulae in patients who underwent intrascleral IOL fixation using two different techniques.

METHODS

This is a prospective, randomized, longitudinal, single-site, single-surgeon study. Patients who underwent intrascleral IOL implantation using the Yamane or the Carlevale technique were followed up for a period of six months postoperatively. Refraction was measured using the best-corrected visual acuity at 4 m (EDTRS chart). Lens decentration, tilt and effective lens position (ELP) were assessed using an anterior segment optical coherence tomography (AS-OCT). The prediction error (PE) and the absolute error (AE) were evaluated for the SRK/T, Hollayday1 and Hoffer Q formula. Subsequently, correlations between the PE and axial length, keratometry, white to white and ELP were assessed.

RESULTS

In total, 53 eyes of 53 patients were included in the study. Twenty-four eyes of 24 patients were in the Yamane group (YG) and 29 eyes of 29 patients were in the Carlevale group (CG). In the YG, the Holladay 1 and Hoffer Q formulae resulted in a hyperopic PE (0.02 ± 0.56 D, and 0.13 ± 0.64 D, respectively) while in the SRK/T formula the PE was slightly myopic (- 0.16 ± 0.56 D). In the CG, SRK/T and Holladay 1 formulae led to a myopic PE (- 0.1 ± 0.80 D and - 0.04 ± 0.74 D, respectively), Hoffer Q to a hyperopic PE (0.04 ± 0.75 D). There was no difference between the PE of the same formulae across both groups (P > 0.05). In both groups the AE differed significantly from zero in each evaluated formula. The AE error was within ± 0.50 D in 45%-71% and was within ± 1.00 D in 72%-92% of eyes depending on the formula and surgical method used. No significant differences were found between formulae within and across groups (P > 0.05). Intraocular lens tilt was lower in the CG (6.45 ± 2.03°) compared to the YG (7.67 ± 3.70°) (P < 0.001). Lens decentration was higher in the YG (0.57 ± 0.37 mm) than in the CG (0.38 ± 0.21 mm), though the difference was not statistically significant (P = 0.9996).

CONCLUSIONS

Refractive predictability was similar in both groups. IOL tilt was better in the CG, however this did not influence the refractive predictability. Though not significant, Holladay 1 formula seemed to be more probable than the SRK/T and Hoffer Q formulae. However, significant outliers were observed in all three different formulae and therefore remain a challenging task in secondary fixated IOLs.

The lens capsule significantly affects the viscoelastic properties of the lens as quantified by optical coherence elastography

The crystalline lens is a transparent, biconvex structure that has its curvature and refractive power modulated to focus light onto the retina. This intrinsic morphological adjustment of the lens to fulfill changing visual demands is achieved by the coordinated interaction between the lens and its suspension system, which includes the lens capsule. Thus, characterizing the influence of the lens capsule on the whole lens’s biomechanical properties is important for understanding the physiological process of accommodation and early diagnosis and treatment of lenticular diseases. In this study, we assessed the viscoelastic properties of the lens using phase-sensitive optical coherence elastography (PhS-OCE) coupled with acoustic radiation force (ARF) excitation. The elastic wave propagation induced by ARF excitation, which was focused on the surface of the lens, was tracked with phase-sensitive optical coherence tomography. Experiments were conducted on eight freshly excised porcine lenses before and after the capsular bag was dissected away. Results showed that the group velocity of the surface elastic wave, V, in the lens with the capsule intact (V=2.55±0.23 m/s) was significantly higher (p &lt; 0.001) than after the capsule was removed (V=1.19±0.25 m/s). Similarly, the viscoelastic assessment using a model that utilizes the dispersion of a surface wave showed that both Young’s modulus, E, and shear viscosity coefficient, η, of the encapsulated lens (E=8.14±1.10 kPa,η=0.89±0.093 Pa∙s) were significantly higher than that of the decapsulated lens (E=3.10±0.43 kPa,η=0.28±0.021 Pa∙s). These findings, together with the geometrical change upon removal of the capsule, indicate that the capsule plays a critical role in determining the viscoelastic properties of the crystalline lens.

Surgical correction of corneal opacity and aniridia with penetrating keratoplasty and a new iris prosthesis implant

PURPOSE

This study is to describe the clinical outcome of penetrating keratoplasty combined with implantation of a novel intraocular lens with an artificial iris, aided by continuous vitreous chamber infusion, in patients with severe aniridia and corneal alterations.

METHODS

This was a prospective single-center case series study involving five patients with corneal alterations and aniridia. All subjects underwent simultaneous penetrating keratoplasty and implantation of a new intraocular lens with an artificial iris with the assistance of infusion into the vitreous chamber to regulate intraocular pressure during the surgical procedure. Visual acuity, corneal endothelial cell density, and intraocular pressure assessments were performed in the postoperative period. The final cosmetic outcome of the iris prosthesis placement was also evaluated.

RESULTS

In all cases, increased visual acuity and a good aesthetic result were observed in all affected eyes except one in which, despite the excellent aesthetic outcome, the eye was very hypotonic as it had high myopia and had undergone several previous surgeries.

CONCLUSION

The single surgical procedure combining implantation of an intraocular lens-iris prosthesis with penetrating keratoplasty is an effective technique for the simultaneous treatment of aphakia and aniridia. However, larger series with longer-term follow-up are needed to definitively establish the benefits of this technique.

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.

Surgical management of aphakia

Despite the safety and efficacy of cataract surgery, intraoperative complications can hamper the ability to place an intraocular lens in the capsular bag. With vast numbers of cataract surgeries performed daily, complications occur often enough that every ophthalmologist should be equipped with techniques to manage aphakia. Medical management of aphakia used to be commonplace but these techniques have their disadvantages including thick bulky lenses, poor cosmesis, and aniseikonia. Surgical management of aphakia overcomes these disadvantages and offers patients the possibility of a spectacle and contact lens-free lifestyle. This article reviews the various options of surgical management of aphakia and their advantages and disadvantages. Comparison of outcomes between techniques and a protocol for deciding between techniques is presented.

Treatment of long-term endophthalmitis developing after intraocular lens implantation in children: a retrospective study

Background

To discussed the risk factor and the management of vitrectomy for long-term endophthalmitis developing after intraocular lens (IOL) implantation in children.

Methods

We retrospectively investigated the clinical characteristics and surgical outcomes of long-term endophthalmitis developing after IOL implantation in children.

Results

Four eyes of four children were included in the study. The mean time to endophthalmitis development after IOL implantation was 3.0 ± 0.8 years. The corneal or scleral sutures may have been caused the infection. All 4 patients underwent vitrectomy and received intravitreal antibiotics with or without IOL removal. At the last follow-up, the outcomes were satisfactory; the fundus was clear, the retina remained attached, the visual acuity improved, and there were no severe complications.

Conclusions

The use of scleral sutures and the exposure of conceal sutures may induce the onset of long-term endophthalmitis after IOL implantation. Complete vitrectomy and appropriate use of antibiotics are effective in the treatment of long-term endophthalmitis developing after IOL implantation in children.

A Comparison of Visual Quality and Contrast Sensitivity between Patients with Scleral-Fixated and In-Bag Intraocular Lenses

Purpose: To analyze visual quality and contrast sensitivity in patients after intraocular lens (IOL) implantation with sutured scleral fixation. Setting: Chang Gung Memorial Hospital, Taoyuan, Taiwan. Design: Retrospective observational study. Methods: Data on the refractive outcome, visual acuity, and subjective visual symptoms in patients with scleral-fixated or in-bag IOL implantation were collected from September 2019 to March 2020. We also investigated patients’ postoperative higher-order aberrations (HOAs) and dysphotopsia using a wavefront aberrometer and glaretester, respectively. The following values were compared: corrected distance visual acuity, spherical equivalent, root mean square values for aberrations, and contrast sensitivity. Results: A total of 23 eyes implanted with scleral-fixated IOL and 74 eyes with in-bag IOL were studied. The mean postoperative spherical equivalent and logarithm of the minimum angle of resolution after scleral fixation were −1.09 ± 3.32 D and 0.20 ± 0.17, respectively. The ocular HOAs were higher in the scleral-fixation group than in the in-bag group (p = 0.001). Contrast sensitivity was negatively associated with age, and it was similar between the two groups after controlling for the age effect. Conclusions: Ocular HOAs and refractive errors were higher in the scleral-fixation group than in the in-bag group. However, no significant difference was noted in contrast sensitivity between advanced scleral fixation and in-bag IOL implantation.

Long-term outcomes of transsclerally sutured intraocular lens correctly fixed in the ciliary sulcus

Objective

To report the long-term postoperative outcomes of transsclerally sutured intraocular lenses (IOLs), in which the haptics were correctly fixated into the ciliary sulcus using an auxiliary device and endoscope.

Methods and analysis

Data were collected from eyes that were followed up for at least 12 months after ciliary sulcus suture fixation of an IOL using an auxiliary device for securely placing the IOL haptics to the ciliary sulcus, which was confirmed using intraoperative endoscopy in all cases. The corrected distance visual acuity (CDVA), refractive error, anterior chamber depth (ACD), IOL decentration and tilt, corneal endothelial cell density (CECD) and postoperative complications were recorded. ACD and IOL deviations were compared with those of normal controls after standard cataract surgery.

Results

A total of 146 eyes of 142 patients were included, with a mean follow-up period of 56.0±35.3 (range 12–174) months. Postoperative CDVA from 1 month to 8 years and final CDVA were significantly better, and the mean refraction error, ACD and CECD decline rate were −0.71±0.75 dioptre, 4.01±0.37 mm and −7.4%±16.0%, respectively. Compared with normal controls, ACD was not significantly different but the tilt and decentration were significantly different. The main postoperative complications included vitreous haemorrhage (24.0％), suture thread exposure (19.2%) and corectopia (18.5%). There were no cases of IOL dislocation due to suture breakage or postoperative endophthalmitis

Conclusion

Long-term postoperative outcomes were favorable with good CDVA and without IOL dislocation and endophthalmitis. The significance and value of fixing haptics to the ciliary sulcus should be re-evaluated.

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.

Intraocular Lens Fixation Technique Without Corneal Incision in Minimally Invasive Vitrectomized Eyes

INTRODUCTION

To introduce a modified technique for primary/secondary intraocular lens (IOL) fixation without corneal incision in vitrectomized eyes.

METHODS

Consecutive case series who had undergone previous or concomitant pars plana vitrectomy (PPV) to have primary/secondary IOL fixation were prospectively included. A self-sealing scleral incision was made underneath the superior scleral flap, through which the IOL was inserted into the anterior chamber. The suture tied with the IOL passed through the sclera to fix the IOL in the ciliary sulcus. Patients were followed up for at least 3 months. Main outcomes were best corrected visual acuity (BCVA), intraocular pressure (IOP), surgically induced astigmatism (SIA), and intraoperative and postoperative complications.

RESULTS

A total of 31 patients were included in the study. The mean follow-up time was 5.35 ± 4.14 months. The BCVA (log MAR unit) improved from 0.97 ± 0.58 preoperative to 0.42 ± 0.36 postoperative (P < 0.001). Mean IOP remained unchanged (preoperative IOP 14.03 ± 2.90 mmHg, postoperative IOP 13.26 ± 3.46 mmHg, P = 0.130). The mean SIA was 0.91 ± 0.76 diopters. No obvious intraoperative and postoperative complications were observed.

CONCLUSION

This method has favorable postoperative visual recovery and IOP control. This modified method could be taken into account as an option by surgeons in vitreoretinal surgery.

Outcomes of four-point suture fixated and two-point sutureless posterior chamber IOLs combined with pars plana vitrectomy

Background

While each scleral fixation method has its own advantages, there is a lack of strong evidence to suggest a superior technique. Advances in cataract surgery expand patient eligibility for successful cataract extraction, benefitting a growing population of pseudophakic patients. However, implantation of secondary intraocular lens (IOL) with compromised anterior or posterior capsule is a more challenging task. Each method of scleral fixation has its own advantages and none of them has strong evidence to be superior. This paper describes postsurgical outcomes of two scleral intraocular(IOL) fixation techniques combined with pars plana vitrectomy(PPV) from a single tertiary referral eye center.

Methods

Patients underwent PPV and IOL implantation with either four-point sutured scleral fixation (Akreos AO60(AK); n = 24) or two-point sutureless flanged intrascleral fixation (CT Lucia(CTL); n = 7). Reports include IOL and sclerotomy placement, fixation techniques, and IOL model.

Results

Thirty-one eyes of thirty patients were analyzed. Average change in vision from baseline measurement was LogMAR − 0.68 ± 0.66 and − 0.90 ± 0.63 for AK and CTL groups, respectively. Average postoperative refractive error was − 0.3 ± 1.03 D (AK) and 0.4 ± 0.60 D (CTL). No opacification cases of Akreos lens were found in this study with the longest follow up of 53 months.

Conclusions

Both methods of implantation (sutured and sutureless) could provide good visual and refractive outcomes. Minimal complication rates were reported despite including patients with multiple comorbidities, making both techniques an attractive choice for secondary IOL implantation.

Intrascleral Knotless Zigzag Suture Fixation of Four-Haptic Hydrophilic Acrylic Foldable IOL: Clinical Outcomes

Background

The main options for intraocular lens (IOL) placement without capsular bag support and/or zonular weakness are iris-fixated IOL and scleral-fixated IOL (SFIOL).

Purpose

To describe the surgical technique and the outcomes of intrascleral knotless zigzag suture fixation of Akreos AO60 foldable IOL.

Methods

Retrospective cohort study of consecutive cases.

Results

Ninety-nine eyes of 92 patients were retrospectively studied. The mean age was 72.1±15.2 years (range 18–94), and the median follow-up duration was 19.5 months (range 3–81). The best-corrected visual acuity improved from a mean±SD of 1.34±0.70 logarithm of the minimum angle of resolution (logMAR) units at baseline to 0.49±0.56 logMAR at the end of follow-up (p<0.001). The mean±SD final SE was −1.24±1.82 diopters. The mean±SD prediction error was −0.51±1.16 diopters. The overall perioperative complications rate was 44.4% (n=44). The rate of complications requiring invasive treatment was 19.2% (n=19). The most common perioperative complications were ocular hypertension (OHT, 20.2%, n=20), and cystoid macular edema (CME, 15.2%, n=15). The rate of IOL dislocation was 7% (n=7).

Conclusion

This knotless technique avoids the risks of haptics fixation but is more prone to IOL dislocation in cases of suture deterioration. Past ophthalmic history needs to be carefully considered in candidates who underwent SFIOL implantation.

A comparative study of knotless versus knotted transscleral suture-fixated intraocular lens implantation

Purpose:

To compare functional outcomes and complication rates of two scleral fixated intraocular lens implantation (SFIOL) techniques.

Methods:

In this retrospective study, there were 30 eyes of 30 patients who underwent SFIOL implantation for dislocation of the IOL or crystalline lens. Group 1 (n = 17) comprised patients who received scleral-fixated polymethylmethacrylate (PMMA) IOL implantation through a self-sealing sclerocorneal tunnel with the suture burial technique, and group 2 (n = 13) comprised patients who received scleral-fixated foldable acrylic IOL implantation with a cartridge using a self-sealing clear corneal incision (CCI) with knotless Z-suture technique between 2014 and 2019. Surgical outcomes concerning safety, efficiency, visual function, induced astigmatism with vector analysis, and complications were compared.

Results:

The indications were dislocated crystalline lens (n = 5/30), dislocated IOL (n = 17/30), and dropped nucleus (n = 8/30). The mean follow-up time was 50.65 ± 14.02 months in group 1 and 15.69 ± 3.71 months in group 2 (P < 0.001). The postoperative visual acuity improvement was statistically significant in both groups (P < 0.001). Surgically induced astigmatism was significantly higher in group 1 (2.68 ± 1.04 D) compared with group 2 (1.6 ± 1.0 D) at month 12 (P = 0.001). Postoperative complications included suture exposure (n = 1 in group 1) and cystoid macular edema (n = 1 in group 1; n = 1 in group 2).

Conclusion:

Both SFIOL techniques are safe and effective in the absence of adequate capsular support. However, the knotless Z-suture technique appears to be superior to the suture burial technique with regard to suture exposure-related complications. In addition, self-sealing CCI appears to be superior to self-sealing sclerocorneal tunnel with regard to surgically induced astigmatism.

Descemet Stripping Endothelial Keratoplasty in Microcornea for Pseudophakic Bullous Keratopathy With Anterior Chamber Intraocular Lens

To report a case of bilateral pseudophakic bullous keratopathy (PBK) in a patient having bilateral microcornea with pre-existing anterior chamber intraocular lens (ACIOL) who underwent Descemet stripping endothelial keratoplasty (DSEK) with a successful postoperative visual outcome. A 36-year-old female, diagnosed with microcornea and congenital cataract in both eyes underwent lens aspiration sequentially followed by ACIOL implantation in both eyes. The patient reported to our centre and was diagnosed with bilateral PBK with ACIOL with microcornea. She also had associated secondary glaucoma, postoperative chronic uveitis, and hyphaema, which were controlled with medical management first and taken into consideration while planning DSEK. The patient underwent manual DSEK without intraocular lens exchange under local anaesthesia in both eyes sequentially with a good visual recovery postoperatively in both eyes. Descemet stripping automated endothelial keratoplasty (DSAEK)/DSEK seems a viable option in patients with microcornea who develop PBK following cataract surgery with retained ACIOL where there is absence of capsular support as well as deficiency of iris tissue.

Angle-supported intraocular lens versus scleral-sutured posterior chamber intraocular lens in post-cataract surgery aphakic patients: two-year follow-up cost-effectiveness analysis

PURPOSE

To compare visual, anatomical and economical outcomes of patients with secondary anterior chamber intraocular lens (AC-IOL) implantation and secondary scleral fixated intraocular lens (SF-IOL) implantation.

METHODS

In this retrospective observational study, 38 aphakic patients after complicated phacoemulsification divided in two groups, AC-IOL group (17 patients receiving AC-IOL implantation) and SF-IOL group (21 patients receiving SF-IOL implantation). Corrected distance visual acuity (CDVA), patient reported visual outcome (VF-14) and endothelial cell density (ECD) were measured at baseline and two-year follow-up. Complication rate was registered. The global cost of each procedure and the incremental cost-effectiveness ratio (ICER) were calculated.

RESULTS

No statistically significant difference was found in CDVA (logMAR 0.24 ± 0.17 vs. 0.32 ± 0.26, p = 0.27), VF-14 (68 ± 18 vs. 61 ± 20, p = 0.24), ECD (1456.48 ± 525.15 vs. 1341.71 ± 374.33, p = 0.48) and overall complication rate (p = 0.79) postoperatively between the SF-IOL group and the AC-IOL group. The ECD loss rate was significantly higher in the AC-IOL group (15.5% vs. 3.5%, p = 0.004). The average global cost of the two procedures was higher in the SF-IOL group (p < 0.005) and ICER showed an additional payment of 693 € for each patient in SF-IOL group against a saving of 186 endothelial cells 2 years postoperatively.

CONCLUSION

AC IOL and SF-IOL implantation showed similar outcomes in terms of visual function and safety profile. Higher ECD loss was found in AC-IOL group. The global cost of implantation was significantly lower for AC-IOL, but the ICER seems to justify the SF-IOL implantation in patients with low ECD.

Corneal endothelial cell damage after scleral fixation of intraocular lens surgery

PURPOSE

To analyze corneal endothelial cell damage after scleral fixation of intraocular lens (SFIOL) surgery.

STUDY DESIGN

Retrospective study.

METHODS

Medical records of consecutive eyes undergoing SFIOL surgery performed by a single surgeon were reviewed between January 2011 and June 2019. The patients were classified into three groups according to surgical methods: Group I, re-fixating the existing intraocular lens (IOL) or fixating a new IOL in an aphakic eye; Group II, removing the existing IOL and fixating a new IOL; and Group III, phacoemulsification and fixating a new IOL simultaneously. Preoperative and postoperative specular microscopy (SM) status were compared. Changes in SM were compared among the three groups.

RESULTS

Ninety-four eyes were included. Thirty-four eyes in Group I, 39 in Group II, and 21 in Group III. The endothelial cell density (ECD) loss in Group I was 1.5%, less than the ECD loss of 14.3% (p < 0.001) in Group II and 15.4% (p = 0.005), in Group III. In no eye was there an ECD decrease to < 1000/mm² following the surgical procedure.

CONCLUSIONS

ECD loss was related to IOL removal or phacoemulsification rather than SFIOL surgery. SFIOL using the existing IOL should be considered preferential in eyes with low ECD and dislocated IOL.