Sutureless scleral fixation of intraocular lenses

A New Technique with Scleral Grooves for Sutureless Scleral Fixation of the Carlevale Intraocular Lens

INTRODUCTION

A novel technique is described employing scleral grooves to facilitate sutureless scleral fixation of the Carlevale intraocular lens (CIL). We describe its use in a series of 47 patients with aphakia.

METHODS

A retrospective study of all patients with aphakia who underwent CIL implantation with the new technique by a single surgeon during 1 year. The novelty of this technique consists in the creation of two partial-thickness linear sclerotomies (grooves), 180° apart, 2 mm from and parallel to the limbus. In the middle of each groove a full-thickness sclerotomy is performed to facilitate externalization of the CIL anchors. The groove allows the anchor to plug the full-thickness sclerotomy and to rest within the sclera without protrusion. Reported outcomes include pre-operative/post-operative visual acuity, post-operative spherical equivalent and surgical complications. Follow-up was a minimum of 6 months.

RESULTS

Forty-eight eyes of 47 patients with aphakia with a mean age of 74 years (range 31-90 years) are included. The commonest causes of aphakia were intraocular lens (IOL) subluxation,with or without exfoliation (54.2%), complicated cataract surgery (29.2%), crystalline lens luxation (6.3%) and trauma (4.1%). All CILs inserted with the new technique stayed successfully in situ during follow-up. Median pre-operative best-corrected visual acuity (0.75 logMAR; range 0.1-2.7) significantly improved to 0.5 logMAR post-operatively (p < 0.001). Moreover, 78% and 65% of the operated cases were within 1.0 and 0.5 diopters, respectively, from intended refraction. The most common complications were transient cystoid macular oedema (8.3%) and transient intraocular pressure rise (8.3%), all of which resolved within 2 months.

CONCLUSIONS

The proposed modification of sutureless scleral fixation of the CIL appears safe and effective. In our experience it is less time consuming and easier to perform than previous techniques and may therefore offer a useful future option.

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.

Current Evidence for a New Surgical Technique for Scleral Fixation: The Implantation of a Carlevale Lens, a Systematic Review

Background: The Carlevale lens (FIL SSF, Soleko IOL Division, Italy) is a new lens for suture-less scleral fixation. This paper aimed to systematically review articles on this lens, the surgical techniques used for its implantation, complications and outcomes. Methods: This systematic review was performed following the PRISMA guidelines. The search string used was "Carlevale" AND "scleral fixation" from inception until March 2024. For completeness, either case-control studies, case reports or case series written in English were included. The authors used the Newcastle-Ottawa scale for the case-control studies and the JBI Critical Appraisal Checklist for case reports and case series. Results: Twenty-nine articles were included. Scleral fixation with Carlevale lens can be performed by creating scleral flaps or, alternatively, by using scleral pockets. The two sclerotomies must be diametrically opposed, and are preferably created by 25-gauge trocars. A pars plana vitrectomy should be performed every time, and the design of the lens should be suitable for self-anchoring to the sclera; the most accredited strategy to achieve this is to avoid scleral sutures. There were only a few intraoperative and postoperative complications reported; vitreous hemorrhages were the most frequent intraoperative events, while the most relevant postoperative complications were vitreous hemorrhages, cystoid macular oedema and transient variations in the intraocular pressure. Excellent results have been obtained in terms of BCVA, IOL centration and stability, mean intraocular pressure, postoperative spherical equivalent, separation between anterior and posterior chamber and the distance of the IOL from anterior chamber structures. Conclusions: The foldable hydrophilic design of the Carlevale lens has shown good effectiveness, IOL stability and few intra and post-operative complications.

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.

Comparison of three techniques for simultaneous intraocular lens implantation in subluxated cataract surgery: Transconjunctival intrascleral, Z-suture knotless transscleral, and Cionni capsular tension ring assisted

PURPOSE

To evaluate and compare the clinical outcomes of three different methods of intraocular lens (IOL) implantation in the surgery of subluxated cataracts.

METHODS

In this retrospective, comparative, clinical interventional study, the medical records of patients who underwent IOL implantation with sutureless 27-gauge needle-assisted transconjunctival intrascleral (Group 1), Z-suture knotless transscleral (Group 2), and Cionni capsular tension ring (Cionni-CTR) assisted (Group 3) simultaneously with subluxated cataract extraction between June 2010 and June 2022 were evaluated. Demographic characteristics, follow-up times, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical and cylindrical refractive values, and spherical equivalent (SE) values of three groups were compared. Intraoperative and postoperative complications were recorded.

RESULTS

There were 20 eyes in Group 1, 35 eyes in Group 2, and 40 eyes in Group 3. In all groups, statistically significant improvement was observed in postoperative UDVA and CDVA compared to preoperative values (each p < 0.05). There was no statistical difference between the groups in postoperative UDVA and CDVA values. (p = 0.130, p = 0.167 respectively). No significant difference was observed between the groups in terms of postoperative spherical, cylindrical, and SE values (each p > 0.05).

CONCLUSION

The study suggests that three different IOL implantation techniques for simultaneous IOL implantation in subluxated cataract surgery have similar effects on visual and refractive outcomes.

Effect of sutureless scleral fixed intraocular lens implantation on aphakic eyes: a system review and meta-analysis

BACKGROUND

Sutureless scleral fixed intraocular lens implantation (SF-IOL) has become one of the mainstream schemes in clinical treatment of aphakic eyes because of its advantages, such as avoiding dislocation of intraocular lens or subluxation caused by suture degradation or fracture and significant improvement of postoperative visual acuity. However, a consensus on the relative effectiveness and safety of this operation and other methods is still lacking. This study aimed to compare the efficacy and safety of sutureless SF-IOL with other methods. Aphakia means that the lens leaves the normal position and loses its original function, including absence or complete dislocation and subluxation of the lens which could cause anisometropic amblyopia, strabismus, and loss of binocular function in children and adolescents. For adults, the loss of the lens could lead to high hyperopia and affect vision. Above all this disease can seriously affect the quality of life of patients.

METHODS

Literature about sutureless SF-IOL in PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, China Technical Journal VIP database, and Wanfang database published from 2000 to 2022 was reviewed. The weighted average difference was calculated by RevMan5.3 software for analysis. Two researchers independently selected the study and used the Cochrane collaboration tool to assess the risk of errors. Cochrane bias risk tool was used to evaluate the quality of evidence. This study is registered on PROSPERO (CRD42022363282).

RESULTS

The postoperative IOL-related astigmatism of sutureless SF-IOL was lower than that of suture SF-IOL, and there was statistical difference when we compared the absolute postoperative spherical equivalent after sutureless SF-IOL and suture SF-IOL. Indicating that the degree of refractive error after sutureless SF-IOL was lower. Meanwhile, the operation time of sutureless SF-IOL was shorter than that of suture SF-IOL. The subgroup analysis showed that the absolute postoperative spherical equivalent and astigmatism values in Yamane technique were lower than those in suture SF-IOL.

CONCLUSION

Sutureless SF-IOL has the advantages of stable refraction, short operation time, and less postoperative complications. However, high-quality literature to compare these technologies is lacking. Some long-term follow-up longitudinal prospective studies are needed to confirm the findings.

Outcomes of three-piece rigid scleral fixated intraocular lens implantation in subjects with deficient posterior capsule following complications in manual small incision cataract surgery

Objective

To evaluate the surgical visual outcomes of three-piece rigid scleral fixated intraocular lens (SFIOL) implantation in subjects with deficient posterior capsule following complications of cataract extraction.

Design

Retrospective 4-year cohort study.

Participants

Data from 174 eyes that underwent SFIOL combined with pars plana vitrectomy (PPV) between January 2018 and March 2022 and follow-up exams were included.

Methods

Demographic characteristics including primary indications for surgery, history of trauma, laterality, baseline and best-corrected visual acuity (BCVA), refraction as spherical equivalent (SE), intraocular pressure (IOP), duration of follow-up, and complications were analyzed.

Results

The mean preoperative BCVA was 1.38 ± 0.46 logarithm of the minimum angle of resolution (logMAR), which improved significantly to 0.37 ± 0.22 logMAR. The baseline refractive status measured in spherical equivalent (SE) was 4.1 ± 6.2 Diopters (D), and the postoperative status was -0.4 ± 0.97 D. Early postoperative complications included hypotony (n = 1; 0.57%, vitreous hemorrhage (n = 3; 1.72%), elevated IOP (n = 8; 4.59%), mild dilated pupil (n = 1; 0.57%) and corneal edema (n = 16; 9.19%). Late complications included in this study were retinal detachment (n = 1; 0.57%), cystoid macular edema (CME) (n = 1; 0.57%), primary glaucoma (n = 1; 0.57%), secondary glaucoma (n = 13; 7.47%), zonular dehiscence (n = 3; 1.72%), retinal pigment epithelium (RPE) changes (n = 3; 1.72%), choroidal coloboma (n = 2; 1.14%), posterior dislocation of posterior chamber IOL (PCIOL) (n = 1; 0.57%), corneal decompensation (n = 1; 0.57%), retinal hemorrhage (n = 1; 0.57%), macular hole (n = 1; 0.57%), chronic uveitis (n = 1; 0.57%), mild non-proliferative diabetic retinopathy (NPDR) (n = 3; 1.72%), and mild NPDR with diabetic macular edema (DME) (n = 1; 0.57%).

Conclusion

Integrating IOL implantation with vitrectomy various posterior segment complications were resolved in the same setting without attempting a second surgery.

LONG-TERM ANALYSIS OF INTRASCLERAL FIXATION OF INTRAOCULAR LENS: Trocar-Cannula-Based Sutureless Intrascleral Fixation Versus Sutured Scleral Fixation

PURPOSE

To compare the long-term outcomes of sutureless intrascleral fixation of the intraocular lens versus sutured scleral fixation.

METHODS

The authors retrospectively analyzed the medical records of patients who underwent intrascleral fixation of the intraocular lens using two different techniques: trocar-cannula-based sutureless fixation and sutured scleral fixation. Clinical outcomes were compared before and 1-, 3-, 6-, and 12-month follow-ups after the operation.

RESULTS

A total of 51 patients were followed over a 12-month period after the operation, including 28 eyes in the sutureless group and 23 eyes in the sutured group. Best-corrected visual acuity and spherical equivalent values reached targeted values faster in the sutureless scleral fixation of the intraocular lens. However, no significant difference was observed between the two groups. For intraocular lens capture, there was a statistically significant difference observed in the incidence of postoperative complications, which was demonstrated by one eye in the sutureless group and seven in the sutured group ( P = 0.009). To exclude the effect of corneal astigmatism, surgically induced astigmatism was calculated based on the astigmatism value 1 year after surgery. It was found that the sutureless technique significantly reduced the occurrence of astigmatism (2.43 ± 1.42 vs. 1.65 ± 0.94, P = 0.031).

CONCLUSION

In a 1-year follow-up period, the trocar-cannula-based sutureless technique was reliable and effective. Sutureless fixation was associated with fewer postoperative complications and lower surgically induced astigmatism values than those with sutured fixation.

Intrascleral anchoring knot on the double suture without peritomy for fixation of intraocular lens

A new minimally invasive technique for universal fixation of any posterior chamber intraocular lens (IOL), iris prosthesis or capsular tension device (CTD), both for rescuing in case of dislocation and for secondary implantation, is described. It uses intrascleral anchoring knot on the reinforced double 9-0 polypropylene suture without conjunctival opening or scleral dissection. The technique was applied for scleral fixation of the S-shaped monoblock acrylic IOL dislocated into the vitreous cavity in 1 eye, and decentered IOL-CTD-capsular bag complexes in 3 eyes. In none of the cases, complications including knot slippage, suture exposure or hypotony were observed. All patients were followed up for 6 months. The uncorrected distance visual acuity was significantly improved and the IOLs positions remained stable. The described technique might be a simple, effective and safe alternative to flanged scleral fixation approaches.

Novel Sutureless Scleral Fixated IOL for Inadequate or Absent Capsular Support

Purpose. To evaluate the clinical outcome and safety profile of a new sutureless scleral fixation (SSF) technique using a single-piece foldable acrylic Carlevale intraocular lens. Methods. In this case study, 27 eyes of 27 patients were implanted with an SSF single-piece IOL because of inadequate or absent capsular support. The hand-shake technique used during surgery was combined with the creation of scleral pockets in order to secure the IOL haptics. The BCVA was evaluated in the 1st and 6th month in every patient and in the 12th and 24th months, when possible. Also, we evaluated the improvement achieved in spherical equivalent values from baseline to the 6th month after the procedure. Intraoperative and postoperative complications were assessed. Results. The mean age was 69.1 ± 14.9 years, and the mean follow-up was 13.6 ± 4.8 months. Indications of scleral-fixated IOL included dislocated posterior chamber IOL (40.7%), dislocated anterior chamber IOL (11.1%), subluxated traumatic cataract (18.5%), subluxated nontraumatic cataract (18.5%), and aphakia (11.1%). Concurrent PPV was performed on eight of the eyes (32%). The mean preoperative logMAR BCVA increased from 0.85 ± 0.59 baseline to 0.44 ± 0.30 one month after surgery $\left(p<0.01\right)$ and 0.36 ± 0.34 $\left(p<0.003\right)$ six months after surgery. The baseline refractive status expressed in SE was 4.3 ± 6.4 D, and the postoperative status was −0.5 ± 0.99 D. Postoperative complications included vitreous hemorrhage (7.4%), hypotony (7.4%), transient IOP elevation (3.7%), and postoperative cystoid macular oedema (3.7%). The IOL was very well centered and stable in every case during the follow-up period. Conclusion. The use of the SSF technique with implantation of a single-piece foldable acrylic Carlevale IOL seems to be a safe and effective alternative method that provides good preliminary results in cases where capsular support is inadequate or absent. Long-term stability results would be required to evaluate the benefit of this novel surgical approach in order to compare it with other existing methods.

Two-year results of a novel sutureless scleral fixation surgery with the haptic hook technique

PURPOSE

In this study, we evaluated the visual results and complication rates of the novel technique of sutureless scleral fixated intraocular lens (SFIOL) surgery in patients without capsular support.

METHODS

In this retrospective study, patients who did not have adequate capsular support and who underwent sutureless SFIOL between 2013 and 2017 at the University of Health Science Dr. Lütfi Kirdar Kartal Training and Research Hospital's Eye Clinic were included. Preoperative and postoperative best corrected visual acuity (BCVA), perioperative and postoperative complications, surgical indications, previous surgeries, and surgical procedures were evaluated.

RESULTS

The study included 131 eyes of 162 patients who underwent sutureless SFIOL surgery. Thirty-one patients were excluded from the study because of missing data. The mean age of the patients was 61.5 ± 23.2 years, 72 of whom were female, and the mean follow-up period was 24.3 ± 11.4 months. When all the patients were evaluated together, the preoperative mean BCVA was 1.11 ± 1.01, 0.86 ± 0.76 in the first month, 0.71 ± 0.69 in the third month, and 0.60 ± 0.50 in the second year after surgery according to logMAR.

CONCLUSION

The 2-year results of our study demonstrate that the haptic hook technique for sutureless SFIOL surgery is effective and safe in aphakia rehabilitation. However, haptic hooks and their associated future complications must be monitored for a longer period of time to reach a definite conclusion.

Long-term Outcomes of Fibrin Glue-Assisted Intrascleral Haptic Fixation of Posterior Chamber Intraocular Lenses in Children

OBJECTIVES

To evaluate the long-term outcomes of intrascleral haptic fixation of posterior chamber intraocular lens (PCIOL) with fibrin glue in children.

METHODS

This is a retrospective case study conducted in a tertiary eye institute in North India. A total of 118 eyes of 82 children who underwent glued intrascleral haptic fixation of PCIOLs were retrospectively analyzed. Detailed analysis of the indication for surgery and ocular and systemic associations was performed. The outcome measures included intraoperative complications, final visual and refractive outcomes, and postoperative complications.

RESULTS

The mean age of the patients was 10.16±3.94 years. Fifty-one patients (62.2%) were male and 31 (37.8%) were female. The mean follow-up period was 31.28±13.22 months. The mean preoperative corrected distance visual acuity was 1.18±0.63 Logarithm of Mean angle of resolution (logMAR) which improved to 0.60±0.58 logMAR postoperatively at 6 weeks (P<0.001). The mean preoperative and 6 weeks postoperative endothelial cell density were 3,176.08±318.6 and 2,936±289.9 cells/mm2, respectively (P=0.23). In the immediate postoperative period, corneal edema (19 eyes; 16.1%), decentered IOL/tilt (3 eyes; 2.54%), vitreous hemorrhage (3 eyes; 2.54%), optic capture (4 eyes; 3.38%), and hypotony (2 eyes; 1.69%) were seen. In the late postoperative period (>6 weeks), retinal detachment was observed in two eyes that had associated Marfan syndrome. Cystoid macular edema was seen in four eyes (3.38%), and glaucoma was seen in five eyes (4.23%).

CONCLUSIONS

Fibrin glue-assisted intrascleral haptic fixation of a PCIOL is a safe and effective method to manage aphakia with inadequate capsular support in children.

Evaluation of anterior segment structures with Scheimpflug camera in patients undergoing sutureless scleral fixation by modified Yamane technique

PURPOSE

To evaluate anterior segment parameters in patients undergoing sutureless scleral fixation intraocular lens implantation with the modified Yamane technique (SSF-IOL-MY) by using Scheimpflug camera system.

METHODS

Each group of 25 patients was included for aphakia undergoing SSF-IOL-MY and for senile cataract undergoing uneventful phacoemulsification and intraocular lens implantation (Phaco+IOL). Anterior chamber depth (ACD), iridocorneal angle (ICA), anterior chamber volume (ACV) and keratometric values were evaluated by Scheimpflug camera (Sirius, CSO, Italy) system.

RESULTS

It was seen that the ACD, ICA and ACV display wider structures in patients with SSF-IOL-MY group compared to Phaco+IOL group. However, the ACD (p = 0.828) and ICA (p = 0.219) have not a statistically significant difference, while ACV (p = 0.007) has a statistically significant difference. In terms of keratometric values of the patients, there was no statistically difference in K1, K2 and Kmax values (p = 0.348, p = 0.106, p =0.269, respectively). Although there was no statistically significant difference between the groups in terms of anterior corneal astigmatism, posterior corneal astigmatism was statistically higher in the Phaco+IOL group (p = 0.192, p = 0.031, respectively).

CONCLUSION

SSF-IOL-MY surgery affects anterior segment parameters similar to the Phaco+IOL method, which is the gold standard in cataract surgery. In this surgery, it was approached to the gold standard method in terms of IOL position with the ACD, ACV and ICA values and the results of the corneal incision with the keratometric values.

Biomechanical Testing of Flanged Polypropylene Sutures in Scleral Fixation

OBJECTIVE

To optimize the flanged belt-loop technique of scleral fixation through biomechanical testing and report clinical outcomes of resultant modifications.

DESIGN

Experimental study.

METHODS

The force to disinsert flanged polypropylene suture from human cadaveric sclera was assessed using a tensile testing machine and compared to the breaking strengths of 9-0 and 10-0 polypropylene. The effects of modifying suture gauge (5-0, 6-0, 7-0, or 8-0), amount of suture cauterized (0.5 or 1.0 mm), and sclerotomy size (27, 30, 32, 33 gauge) were investigated. Belt-loop intrascleral fixation using 6-0 and 7-0 polypropylene with 30 and 32 gauge needles, respectively, was performed in 4 patients. Main outcome measures were flanged suture disinsertion forces in cadaveric sclera.

RESULTS

The average force to disinsert a flange created by melting 1.0 mm of 5-0, 6-0, 7-0, and 8-0 polypropylene suture from human cadaveric sclera via 27, 30, 32, and 33 gauge needle sclerotomies was 3.0 ± 0.5 N, 2.1 ± 0.3 N, 0.9 ± 0.2 N, and 0.4 ± 0.1 N, respectively. The disinsertion forces for flanges formed by melting 0.5 mm of the same gauges were 72%-79% lower (P < .001). In comparison, the breaking strengths of 9-0 and 10-0 polypropylene were 0.91 ± 0.4 N and 0.52 ± 0.03 N. Belt-loop fixation using 6-0 and 7-0 polypropylene with 30 and 32 gauge sclerotomies demonstrated good outcomes at 6 months.

CONCLUSIONS

The flanged belt-loop technique is a biomechanically sound method of scleral fixation using 1.0 mm flanges of 5-0 to 7-0 polypropylene paired with 27, 30, and 32 gauge sclerotomies. In contrast, 8-0 polypropylene and 0.5 mm flanges of any suture gauge will likely be unstable with this technique.

The SWISS IOL Technique (Small-Width Incision Scleral Suture): A Mini-Invasive Technique

Purpose

To evaluate the outcomes and safety of a minimally invasive technique for sutured IOL scleral fixation in case of compromised capsular and iris support.

Materials and Methods

In this retrospective study, we explain our mini-invasive technique and assess the outcomes in terms of visual acuity, pre- or postoperative complications, and IOL position (Sensar AR40e, AMO) in a case series of three patients.

Results

The expected best corrected visual acuity could be achieved after one month. Surgeries were uneventful with a stable eye. No postoperative complications occurred except for one patient who had a conjunctival disinsertion. Neither postoperative hypotony nor raised IOP was found. Additionally, no patient experienced corneal edema at one week control, IOL dislocation, vitreous hemorrhage, or new pupil's irregularity.

Conclusions

In conclusion, each scleral technique has its own advantages and its inherent postoperative complications. To date, there is no evidence of superiority of any single technique. By improving our scleral sutured lens techniques, we could improve peroperative ocular stability, potentially decrease postoperative complication rate, and offer a rapid recovery with a stable visual acuity within a month.

Glued intraocular lens in eyes with deficient capsules: retrospective analysis of long-term effects

PURPOSE

To assess the long-term (6-12 years) results and complications of glued transscleral-fixated intraocular lens (IOL).

SETTING

Dr. Agarwal's Eye Center, Chennai, India.

DESIGN

Retrospective case series.

METHODS

Eyes with glued IOL of more than 5-year follow-up were evaluated. Visual acuity (logarithm of the minimum angle of resolution [logMAR]), IOL tilt, corneal topography, corneal endothelial cell density, intraocular pressure, central corneal thickness, central foveal thickness, and ocular residual astigmatism (ORA) were evaluated.

RESULTS

Overall, 91 eyes (63 patients) with mean postoperative 8.2 ± 2.3 years were analyzed. The duration was 10 to 12 years in 31 eyes (34%), 9 years in 14 eyes (15.3%), and 6 to 9 years in 46 eyes (50.5%). No subscleral haptic was visible in 50% eyes. Mild, moderate, and severe grade of haptic visibility was noted in 33.5%, 9.4%, and 7%, respectively. The corrected distance visual acuity (CDVA) was 0.50 ± 0.50 logMAR. Clinically, no tilt was seen in 87 eyes (95.6%), whereas detectable tilt was seen in 4 eyes (4.3%). The optical coherence tomography microtilt was 0.8 ± 1.7 and 0.4 ± 1.2 degrees in 90- and 180-degree axes, respectively. The mean iris vault was 0.45 mm, and the mean ORA was 1.10 ± 1.00 diopter. Complications were glaucoma (7.6%), IOL luxation (4.4%), retinal detachment (3.2%), macular edema (4.3%), corneal decompensation (3.2%), uveitis (2.1%), and uveitis-glaucoma-hyphema syndrome (1%). Haptic reposition (3.2%), retinal detachment surgery (3.2%) keratoplasty (1%), pupilloplasty (2.1%), and IOL explantation (1%) were the second surgeries performed.

CONCLUSIONS

Glued IOL has shown good anatomical and functional stability with minimal incidence of vision-threatening complications on long-term.

A Biomechanical Study of Flanged Intrascleral Haptic Fixation of Three-Piece Intraocular Lenses

PURPOSE

Flanged intrascleral haptic fixation (FISHF) is a useful method for securing intraocular lenses (IOLs) in eyes without capsular support. Biomechanical studies were conducted to support the use of this technique.

DESIGN

Laboratory investigation.

METHODS

Haptics of 3-piece IOLs were passed through cadaveric human sclera using 30- and 27-gauge needles. Flanges were created by melting 1.0 mm from the haptic ends using cautery. The forces required to remove the flanged haptic from the sclera and disinsert the haptic from the optic were measured using a mechanical tester and a custom-fabricated mount.

RESULTS

The mean FISHF dislocation force using 30-gauge needles was greatest with the CT Lucia 602 (2.04 ± 0.24 newtons [N]) compared to the LI61AO (0.93 ± 0.41 N; P = .001), ZA9003 (0.70 ± 0.34 N; P = <.001), and MA60AC (0.27 ± 0.19 N; P <.001). Using 27-gauge needles with the CT Lucia resulted in a lower dislocation force (0.56 ± 0.36 N; P <.001). The FISHF dislocation force was correlated with the flange-to-needle diameter ratio (r = 0.975). The FISHF dislocation forces of the CT Lucia and LI61AO using 30-gauge needles were not significantly different from their haptic-optic disinsertion forces (P = .79 and .27, respectively). There were no differences in flange diameters between 1.0 mm and 2.0 mm haptic melt lengths across the IOLs (P = .15-.85).

CONCLUSIONS

These data strongly support the biomechanical stability of FISHF with the polyvinylidene fluoride haptics of the CT Lucia using small diameter instruments for the creation of an intrascleral tunnel. 1.0 mm of haptic may be the optimal melt length.

Outcomes of a new suture technique for the treatment of dislocated intraocular lenses: locked loop on the haptic

PURPOSE

To evaluate surgical and refractive outcomes of a new sutured scleral fixation technique in the management of subluxated intraocular lenses (IOLs).

METHODS

Nineteen eyes treated with the new scleral fixation technique were included. The mean corrected distance visual acuity (CDVA), postoperative refraction error, mean endothelial cell count (ECC), and complications were recorded. All patients were evaluated immediately postoperatively, at 1 and 7 days, and then at 1, 3, and 6 months.

RESULTS

The mean duration of follow-up of the patients was 10 months (range, 6-15 months). The mean CDVA was 0.41 ± 0.1 logMAR (logarithm of minimum angle of resolution) preoperatively and was 0.08 ± 0.07 logMAR postoperatively. The mean astigmatism was - 2.22 ± 1.86 D preoperative and was - 0.86 ± 0.58 D postoperative. The mean preoperative and postoperative ECC was 2455 ± 288 and 2352 ± 288, respectively. One patient (5.26%) experienced vitreous hemorrhage, and two (10.52%) experienced intraocular pressure elevation. IOL tilt and decentralization, conjunctival erosion, and cystoid macular edema were not observed in any eyes during follow-up.

CONCLUSION

This new IOL repositioning technique can be applied in a short surgical time and provides a stable IOL centration on long-term follow-up.

Sutureless intrascleral fixation using a uniquely designed intraocular lens

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

Anterior chamber intraocular lens - An effective alternative in traumatic and surgical aphakia in the era of scleral-fixated intraocular lens

Purpose:

To evaluate outcomes of anterior chamber intraocular lens (ACIOL) implantation with vitrectomy in eyes with surgical or traumatic aphakia, and subluxated or dislocated lens.

Methods:

In this retrospective study, we evaluated patients who underwent pars plans vitrectomy with ACIOL implantation from April 2016 to March 2019. Patients with minimum follow-up period of 1 year and operated by single surgeon were included. Ophthalmic history, indication for surgery, BCVA, IOP, slit-lamp examination, and fundus assessment findings were noted. Postoperatively best-corrected visual acuity (BCVA), intraocular pressure (IOP) and complications if any were noted.

Results:

Ninety eyes of 88 patients were included in the study. The mean age of the patients was 60.2 ± 10.2 yrs. Majority (75.6%) were males and 24.4% were females. Indications for pars-plana vitrectomy (PPV) with ACIOL implantation were nucleus drop in 16.6%, IOL drop in 25.5%, large posterior capsular rupture (PCR) with vitreous disturbance or zonular dehiscence (ZD) during cataract surgery in 33.3%, more than 180° subluxation of lens in 10% and traumatic lens or intraocular lens (IOL) drop in 14.4% cases. Preoperative and postoperative mean Log MAR visual acuity was 1.59 ± 0.44 and 0.36 ± 0.33 respectively, with few complications like cystoid macular edema (CME) in 8.8%, persistently raised IOP in 4.4%, persistent uveitis in 2.2%, retinal detachment (RD) in 2.2%, and tilted IOL in 1.1% cases.

Conclusion:

Out of different options available for secondary IOL implantation in patients with poor capsular support ACIOL has the advantages of cost-effectiveness, small learning curve, faster surgical time with a lesser rate of complications like IOL tilt, vitreous hemorrhage, and suture erosion as compared to scleral-fixated IOL (SF-IOL). Comparable visual outcome can be obtained by proper patient selection in these cases.

Secondary Sutureless Posterior Chamber Lens Implantation with Two Specifically Designed IOLs: Iris Claw Lens versus Sutureless Trans-Scleral Plugs Fixated Lens

Background. The management of patients with aphakia and/or lack of capsular support remains debated. The sutureless posterior chamber IOL (PCIOL) fixation is a very useful surgical option. The purpose of the study was to compare the early outcomes as well as post-operative best corrected visual acuity, refractive errors and complications of two different techniques of sutureless PCIOL secondary implantation. Methods. Patients who underwent secondary implantation from December 2019 to January 2021 in the Department of Ophthalmology of Creteil Hospital, and in the Granville Ophthalmology Center, were retrospectively included. Eyes implanted with the iris claw lens (Artisan Aphakia IOL model 205, Ophtec BV, Groningen, The Netherlands) were included in group 1, and eyes implanted with a newly developed sutureless trans-scleral plugs fixated lens (STSPFL, Carlevale lens, Soleko, Pontecorvo, Italy) were included in group 2. Results. Twenty-two eyes of 22 patients were enrolled in group 1, and twenty eyes of 20 patients in group 2. No difference was found in visual acuity between two groups (0.35 +/− 0.29 logmar for group 1 and 0.23 +/− 0.51 logmar for group 2) (p = 0.15) at mean post-operative follow up (6.19 +/− 3.44 months for group 1 and 6.42 +/− 3.96 months for group 2) (p = 0.13). Both the mean refractive error (MRE) and induced astigmatism (IA) were greater in group 1 compared to group 2, respectively: the MRE was 0.99 +/− 0.57 vs. 0.46 +/− 0.36 (p < 0.01), and IA was 1.72 +/− 0.96 vs. 0.72 +/− 0.52 (p < 0.01). Conclusions. No significant differences in terms of the recovery of visual acuity were found between the two groups. Group 2 (STPFL) gives better results in our sample due to less post-operative induced astigmatism and less refractive error.

Refractive outcome of trocar-assisted sutureless scleral fixation with 3-piece intraocular lenses

PURPOSE

Intraocular lens (IOL) implantation with a trocar-assisted sutureless scleral fixation technique is a relatively new IOL implantation approach for aphakic eyes. During this surgery, the intrascleral position of the haptics can change the location of the IOL optic and may alter the refractive outcome. This study aimed to evaluate the refractive outcome of this surgery.

METHODS

The files of 22 patients who had undergone IOL implantation with the trocar-assisted sutureless scleral fixation technique were retrospectively reviewed, and the patients were invited for final examination. IOL power was calculated with optical biometry (Lenstar LS900). IOL power calculations were performed according to formulas designed for in-the-bag IOL implantation. The final refractive error was determined with an autorefractometer (Topcon KR-1/RM-1).

RESULTS

This study included 14 patients (8 male, 6 female, mean age: 62.7 ± 18.7). There were no significant differences between the preoperative and postoperative corneal astigmatism values (p = 0.16). There were also no significant differences between the postoperative corneal and total astigmatism values (p = 0.44), confirming the absence of significant IOL tilt. The difference between the implanted IOLs and the calculated IOL power for emmetropia was 0.09 D ± 0.49 D (p = 0.52). Although emmetropia was targeted, the refractive outcome shifted to hyperopia (+ 0.85 D ± 1.15 D) and was significantly different from the refractive status calculated with optical biometry (p = 0.034).

CONCLUSIONS

The intrascleral fixation of IOLs results in increased posterior positioning of the IOL optic and can induce approximately 0.85 D of hyperopia if proper adjustments are not performed during IOL power calculations.

COMPARISON OF SCLERAL FIXATION OF INTRAOCULAR LENS: Sutureless Intrascleral Fixation Versus Conventional Sutured Scleral Fixation

PURPOSE

To compare the clinical outcomes of sutured scleral and sutureless intrascleral fixations of the intraocular lens.

METHODS

Medical records of patients who underwent sutureless intrascleral fixation (sutureless group) and the conventional sutured scleral fixation (sutured group) were retrospectively reviewed. Patient demographics and the clinical outcomes of the two techniques were compared before and 1, 3, and 6 months after surgery.

RESULTS

Seventy patients were followed up for 6 months after the surgery: 25 patients in the sutureless group (25 eyes) and 45 in the sutured group (45 eyes). Surgery time was shorter in the sutureless group than that in the sutured group (73.00 ± 15.68 vs. 107.39 ± 25.30 minutes, P < 0.001). The visual acuity gradually improved throughout the postoperative period in both groups, and a faster visual acuity recovery was observed in the sutureless group. The cylindrical error at 6 months after the surgery was significantly lower in the sutureless group than that in the sutured group (-1.33 ± 0.55 vs. -2.29 ± 1.19 diopter, P < 0.001).

CONCLUSION

Sutureless intrascleral fixation is an effective and reliable surgical technique that provides more favorable visual and refractive outcomes than the conventional sutured scleral fixation method.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONLCUSION

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

Scleral Fixation of Carlevale Intraocular Lens in Children: A Novel Tool in Correcting Aphakia With No Capsular Support

BACKGROUND AND OBJECTIVE

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

PATIENTS AND METHODS

This is a retrospective, noncomparative, interventional case series of five eyes of five consecutive patients who underwent three-port pars plana vitrectomy and scleral fixation of the IOL. Inclusion criteria were at least 6 months of follow-up in children who underwent vitrectomy and IOL placement for aphakia and inadequate capsular support. Patients were excluded from the analysis if there was a previous open globe injury or any other ocular comorbidity such as macular pathology or previous surgery for retinal detachment, glaucoma, corneal transplantation, or strabismus.

RESULTS

The median follow-up period was 9 months (range: 7-13 months). The median age was 8 years (range: 2-10 years), and the male-to-female ratio was 5 to 0. Mean postoperative best-corrected visual acuity (VA) at the last follow-up visit was 20/32 (0.26 ± 0.32 logMAR [mean ± standard deviation]), improving from a mean baseline uncorrected VA of 20/800 (1.6 ± 0.7 logMAR), a statistically significant change (P = .003). The uncorrected postoperative VA was 20/63 (0.54 ± 0.37 logMAR). No significant postoperative complications were noted and all patients had good IOL position at the end of the follow-up without IOL capture. The mean tilt in four eyes (the 2-year-old was excluded from the analysis) was 2.1 ± 1.9 degrees. None of the patients required reoperation.

CONLCUSIONS

The present study represents the first to date in evaluating the use of a scleral-fixated IOL in patients with aphakia and in pediatric patients with inadequate capsular support. The technique is safe and provides excellent postoperative IOL fixation without IOL capture in any of the patients studied. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:94-101.].

A Systematic Review on Three Major Types of Scleral-Fixated Intraocular Lens Implantation

PURPOSE

We performed a systematic review on 3 major types of scleral-fixated intraocular lens (SFIOL) implantations and conducted subgroup analyses on pediatric population and subjects with Marfan syndrome.

DESIGN

Systematic review.

METHODS

We performed a search in PubMed, Ovid MEDLINE, and Embase for English language articles with keywords "(sutured intraocular lens) OR (SFIOL) OR (sutureless intraocular lens) OR (glued intraocular lens) OR (intrascleral intraocular lens) OR (SFIOL)" through October 16, 2019. Articles reporting individual outcomes after SFIOL were included in this systematic review. Recorded outcome measures included intraoperative and postoperative complications, endothelial cell changes, and intraocular lens-related outcomes.

RESULTS

Our search yielded 217 papers. After removing duplicated and irrelevant reports, we included 57 articles involving 2624 eyes. The mean age at operation was 51.47 ± 25.62 years. Sutured SFIOL was most commonly reported in all subjects with Marfan syndrome and 92.87% of pediatric patients. The pooled intraoperative complication rate was 6.65%. Minor anterior chamber hemorrhage was the most common intraoperative (1.92%) and postoperative complication (13.93%). Optic capture was the top intraocular lens (IOL)-related complication (4.47%). The overall mean endothelial cell loss was 8.95% at 16.77 ± 11.04 months. Overall 11.99% of SFIOLs were decentred with a mean distance of 0.49 ± 0.40 mm and a mean degree of tilt by 4.11 ± 3.03°.

CONCLUSIONS

Glued SFIOL had the fewest IOL-related complications and the lowest endothelial cell loss. Sutured SFIOL carried the highest IOL-related complications, whereas sutureless, glueless SFIOL was associated with the greatest endothelial cell loss.

Novel use of an adjustable single 8-0 polypropylene suture of scleral fixation without conjunctival dissection

Background

This report serves to describe the use of a novel adjustable single 8–0 polypropylene suture for scleral fixation without conjunctival dissection, and to describe related clinical outcomes associated with this approach.

Methods

In this study, we retrospectively reviewed 28 eyes from 27 patients that underwent scleral fixation of the intraocular lens (IOL) without conjunctival dissection using an adjustable single 8–0 polypropylene suture at the Beijing Tongren Eye Center between April 2018 and April 2019. For this surgical approach, a 23-gauge infusion cannula was set, after which two Hoffmann scleral pockets were created. Next, 8–0 polypropylene sutures were inserted into the eye guided by 10–0 polypropylene sutures of a long straight needle. The 8–0 suture was then used to fix the haptic IOs. Finally, these 8–0 polypropylene sutures were removed from the scleral pockets, and knots were tightened with the adjustable single suture. Primary outcomes included visual acuity and postoperative complication incidence.

Results

For this study, outcomes for 28 eyes from 27 patients (9 female, 18 male) were assessed. Patients had a mean age of 54 ± 15.11 years-old and were followed for an average of 10.18 ± 2.76 months postoperatively. Uncorrected visual acuity in these patients improved significantly from a preoperative value of 1.269 ± 0.464 logMAR to a 3-month postoperative value of 0.409 ± 0.413 logMAR (p = 0.000). The majority of postoperative complications in these patients were temporary and self-limiting, including corneal edema (35.71%), hypotony (14.29%), elevated intraocular pressure (28.58%), and mild hyphema (7.14%). No evidence of exposure or erosion of the trimmed suture end was detected in any patients. An ultrasound biomicroscope was able to readily detect the IOL and all sutures, and IOLs were found to be well-centered without any dislocation, tilting, or subluxation upon follow-up.

Conclusions

An adjustable single 8–0 polypropylene suture can reliably and effectively be used for scleral fixation without conjunctival dissection for the treatment of patients with aphakia or inadequate posterior capsule support. The novel procedure described herein may therefore be an effective means of minimizing the risk of suture-related complications in patients undergoing scleral-fixated IOL implantation.

Trial registration

Retrospective case series study, not applicable. NCT04476264.

Efficacy of 25G vitrectomy combined with intrascleral intraocular lens implantation

We investigated the clinical efficacy and safety of 25-gauge (G) vitrectomy combined with intrascleral intraocular lens (IOL) implantation. A 25G vitrectomy combined with intrascleral IOL implantation was performed on 39 patients diagnosed with lens dislocation, IOL dislocation, or aphakia. Changes in visual acuity, intraocular pressure (IOP), number of corneal endothelial cells, location of IOL, anatomic success of IOL, recurrence rate of IOL dislocation, and complications were analyzed. One week postoperatively, the IOL was in the centered position in all patients (100%), and 1 month postoperatively, it was centered in 36 patients (92.3%). IOL haptics were exposed under the conjunctiva in one patient (2.6%). Reimplantation of IOL for IOL dislocation was required in two patients (5.1%). Three to six months postoperatively, the IOLs were in the optimum position in 36 patients (92.3%). There were significant differences between the average logarithm of minimal angle of resolution (logMAR) visual acuity at 1 week, 1 month, 3 months, and 6 months postoperatively and that before surgery (P < .05). The average IOP at 1 week, 1 month, 3 months, and 6 months postoperatively was significantly lower than the preoperative IOP (P < .05). A 25G vitrectomy combined with intrascleral IOL implantation is effective and safe for the treatment of eyes without capsular support.

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

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

Use of Techniques for Scleral and Iris Fixation in Secondary Implantation of Intraocular Lenses

Scleral and iris fixation of intraocular lenses (IOL) are useful in the treatment of surgical or traumatic aphakia, luxation, and subluxation of IOL if the patient does not present appropriate capsular support. However, there is no consensus in the literature about which of these 2 methods is safer and better. The authors performed a literature review searching the main postoperative outcomes obtained with the use of each surgical method. Scleral and iris fixation of IOL are efficient in correction of the patients' visual acuity, even though each technique presents distinct complications which depend especially on the experience of the surgeon with the performed surgical method. It is important to understand that individuals submitted to scleral or iris fixation present previous preoperative complications in their eyes. Besides, both procedures are very complex, involving intense manipulation of the eye globe. The success rate of these surgical techniques is highly variable and has a close relation to the preoperative conditions of the patient's eye and the improvement of the surgeon's learning curve.

Scleral fixation of intraocular lenses

PURPOSE OF REVIEW

To review current, effective and more popular techniques for scleral fixation of intraocular lens (IOLs) and IOL-capsular bag complex.

RECENT FINDINGS

Scleral fixation of IOLs became popular, originally with sutured scleral fixated IOLs and later the Scharioth technique of intrascleral haptic fixation. This was further developed as the Glued IOL technique which enjoys widespread adoption all over the world. Recently the Yamane technique has also become popular and is being widely adopted as well.

SUMMARY

Scleral fixated IOLs have evolved in the last 2 decades with technical modifications, extended indications and improvised instrumentation. Though sutured and sutureless techniques have been growing equally, the sutureless scleral fixation techniques have attracted special interest. Reduced suture-related complications, technical ease and high-quality functional outcomes may be possible reasons. Sutureless capsular bag fixation also has distinct advantages.

[Morphofunctional changes and complications after out-of-the-bag intraocular lens implantation]

The article reviews morphofunctional changes and complications after using modern methods of out-of-the-bag implantation of the intraocular lens (IOL). Literature data shows that the smallest morphofunctional changes in intraocular structures and the best results are obtained after retropupillary implantation of an iris-claw lens and transscleral fixation of posterior chamber IOL.

[Methods of out-of-the-bag intraocular lens implantation]

The article reviews the main modern methods of out-of-the-bag IOL implantation. Literature data shows that the most pressing question to date is comparative assessment of retropupillary iris-claw lens implantation and trans-scleral posterior chamber IOL fixation.

Observational study of intraocular lens tilt in sutureless intrascleral fixation versus standard transscleral suture fixation determined by ultrasound biomicroscopy

Background

The position of the intraocular lens (IOL) is a major factor that affects the final visual acuity after cataract surgery. However, no prospective study has compared the IOL positions associated with the sutureless intrascleral technique and the standard transscleral suturing technique. The current study compared the IOL positions in the two techniques using ultrasound biomicroscopy (UBM) in vivo.

Methods

Twenty-one eyes of 21 patients were included in this observational study conducted between February and May 2015. Eleven patients underwent the sutureless intrascleral technique, and 10 patients underwent transscleral fixation with suturing. Ophthalmologic examination and UBM were performed in all patients. Optic tilt was measured in relation to the iris plane. The haptic location was defined. Mann-Whitney test and multiple linear regression were used to analyze the vertical and horizontal gradients. Significant differences were considered when p ≤ 0.05.

Results

The most common indication for scleral fixation was a complication during phacoemulsification (81.81% in the sutureless group and 60% in the suture group). The mean vertical and horizontal tilts were, respectively, 0.24 ± 0.21 and 0.25 ± 0.19 mm in the sutureless group and 0.14 ± 0.17 and 0.23 ± 0.16 mm in the suture group. No significant differences were seen in the vertical tilt and horizontal tilt (p = 0.888 and p = 0.148, respectively) between the groups. Gender (p = 0.835), age (p = 0.888), follow-up time (p = 0.915), and surgical duration (p = 0.094) were not associated with optic tilt. Of the 22 haptics in the sutureless group, 21 (95.45%) were in the intrascleral tunnel; of the 20 haptics in the suture group, 13 (65%) were posterior to the ciliary body, four (20%) anterior to the ciliary body, and three (15%) in the ciliary sulcus.

Conclusion

This study showed that there are no significant differences in the IOL positions between the two techniques.

Refractive Outcomes after Pars Plana Vitrectomy and Scleral Fixated Intraocular Lens with Gore-Tex Suture

PURPOSE

To evaluate refractive outcomes after combined pars plana vitrectomy (PPV) and scleral fixation of an intraocular lens (IOL) using Gore-Tex suture.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Fifty-five eyes from 53 patients who underwent PPV with a Gore-Tex sutured IOL from June 2013 through December 2017.

METHODS

Patients who underwent combined PPV and scleral fixation of an IOL with Gore-Tex suture were identified. All eyes underwent scleral fixation of either an Akreos A060 or enVista MX60 IOL and were fixated either 2 mm or 3 mm posterior to the limbus. Postoperative manifest refractions were performed at least 3 months after surgery and were compared with preoperative predicted target refraction based on in-the-bag IOL calculations. Subgroup analyses based on sclerotomy placement and IOL models were performed.

MAIN OUTCOME MEASURES

Postoperative manifest refraction and difference with sclerotomy placement and IOL model.

RESULTS

The mean postoperative spherical equivalent (SEQ) was -0.99±1.00 diopters (D). The mean difference in SEQ (ΔSEQ) from preoperative predicted target was -0.64±1.00 D. The IOL was fixated 2 mm posterior to the limbus in 14 eyes and 3 mm in 41 eyes. Within these 2 subgroups, the mean postoperative SEQ was -1.53±1.35 D for fixation 2 mm posterior to the limbus and -0.82±0.83 D for fixation 3 mm posterior to the limbus (P = 0.09). The mean ΔSEQ was -0.43±0.71 D for fixation 3 mm posterior to the limbus and -1.35±1.32 D for fixation 2 mm posterior to the limbus (P = 0.03). The mean amount of surgically induced astigmatism in the overall cohort was 0.77±0.65 D. The mean ΔSEQ and induced astigmatism were similar between IOL models.

CONCLUSIONS

After combined PPV and Gore-Tex-sutured IOL implantation, mean postoperative refractive outcomes were more myopic when the IOL was fixated 2 mm from the limbus compared with 3 mm from the limbus. No significant difference was found between IOL models. Based on these results, future implant power calculations may be adjusted to approximate preoperative target refraction more accurately.

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

PURPOSE

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

STUDY DESIGN

Retrospective cohort study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Anatomy of the ciliary sulcus and the optimum site of needle passage for intraocular lens suture fixation in the living eye

PURPOSE

To determine the relationship of the anatomic position of tissue surrounding the ciliary sulcus using ultrasound biomicroscopy (UBM) for measurement of ciliary sulcus parameters and the surrounding tissue after intracapsular cataract extraction (ICCE) and determine the correct suture site for intraocular lens (IOL) suture fixation.

SETTING

Sugiura Eye Clinic, Asahi General Hospital, Shizouka-ken, Japan.

DESIGN

Prospective case series.

METHODS

Using UBM, the angle of the ciliary sulcus and several areas of the tissue surrounding the ciliary sulcus were measured from 8 orientations in eyes after ICCE. These measurements and endoscopic observation of the ciliary sulcus indicated the optimum points of needle insertion and needle emergence on the sclera for IOL suture fixation. Endoscopic observation of the ciliary sulcus also showed its shape.

RESULTS

The shape of the surrounding tissue of the ciliary sulcus was measured in 16 eyes after ICCE, and endoscopy was used to observe the ciliary sulcus during surgery in 150 eyes. For ab interno ciliary sulcus suture fixation, the correct point of needle emergence on the sclera was 2.5 mm from the posterior surgical limbus when a straight needle was used. For ab externo pars plana suture fixation, the correct point of needle insertion on the sclera was 3.0 mm from the posterior surgical limbus. Endoscopic observation showed that the lower surface of the ciliary sulcus was formed by the fusion of neighboring ciliary processes.

CONCLUSION

Knowing the detailed shape of ciliary sulcus will allow for more precise IOL suture fixation.

Reinforced scleral fixation of foldable intraocular lens by double sutures: comparison with intrascleral intraocular lens fixation

PURPOSE

The purpose of this study is to describe a new technique for small-incision scleral fixation of intraocular lens (IOL) using double 10-0 polypropylene sutures, and to report the outcomes of IOL position compared with intrascleral IOL fixation at 12-month follow-up.

STUDY DESIGN

A retrospective comparative study.

METHOD

This new technique, called double sutured scleral fixated-IOL (DSF-IOL), was created to help with long-term knots strengthening by applying double sutures to each IOL haptic using an augmented Clove-hitch knot instead of the conventional knots tied by single suture. The tilt and decenter of IOL were measured by Scheimpflug camera and other refractive outcomes were compared between two groups at 12-month follow-up.

RESULTS

This study consisted of 26 eyes (54.2%) from the DSF-IOL group, and 22 eyes (45.8%) from the intrascleral fixated IOL (ISF-IOL) group. No significant differences of mean absolute degree of IOL tilt (2.90 ± 0.77 vs 2.82 ± 0.72; p = 0.633) and IOL decenter (151.90 ± 59.80 vs 175.0 ± 73.14 microns; p = 0.265) were found between the two groups. Post-operative LogMAR visual acuity was not statistically different between the two groups (0.32 ± 0.17 vs 0.41 ± 0.19, p = 0.089). Early post-operative hypotony was only present in the ISF-IOL group (13.6%).

CONCLUSION

This study shows that DSF-IOL is as effective as ISF-IOL. This technique can be a simpler approach to optimize small-incision scleral fixation of IOL without the complications associated with intrascleral IOL fixation.

[Study of the results scleral-fixated intraocular lenses in the absence of capsular support]

INTRODUCTION

In the absence of sufficient capsular support, scleral fixation of the intraocular lens is an interesting alternative. The goal is to evaluate this implantation technique when traditional implantation is impossible.

PATIENTS AND METHODS

This is an observational, retrospective, monocentric study at the Amiens university medical center between August 2013 and March 2016. Patients all underwent scleral fixation of a three-piece implant without suturing of the haptics, after posterior vitrectomy. All patients requiring implantation in the absence of stable capsular support were included. Patients with adequate iris or capsular support were excluded from our study.

RESULTS

Eighteen patients were included, with an average age of 69.3±16.9 years. The surgical indications were: complicated surgery, trauma and endothelial decompensation. The preoperative mean corrected visual acuity was 1.2±0.4 LogMAR while the postoperative acuity was 0.7±0.5 LogMAR. The mean postoperative corneal astigmatism was 1.9±1.9 diopters. The main complications observed were ocular hypertension, macular edema, retinal detachment, iris incarceration and exteriorization of the haptic.

DISCUSSION

There are two alternatives when faced with lack of a sufficient capsular support: scleral fixation or iris fixation. Our technique is the only one achievable in the presence of iris atrophy. Furthermore, it induces less astigmatism and enables the repositioning of a three-piece implant dislocated into the vitreous.

CONCLUSION

Scleral fixation is a technique allowing both a satisfactory and a lasting functional result and is to be considered when faced with a lack of sufficient capsular support.

Glued intrascleral haptic fixation of an intraocular lens

Glued intrascleral haptic fixation of an intraocular lens (glued IOL) has evolved as a technique with various modifications that are adopted and practiced by several surgeons. With adequate and appropriate haptic tuck, glued IOL imparts a stable IOL fixation and is a secured method of secondary IOL placement with no pseudophacodonesis.

Retrospective Study of Visual Outcomes and Complications After Sutureless, Flapless, and Glueless Intrascleral Fixation of Posterior Chamber Intraocular Lens in Children and Young Adults

PURPOSE

To evaluate the visual outcomes and complications after sutureless, flapless, and glueless intrascleral fixation of a posterior chamber intraocular lens (IOL) in patients between the ages of 5 and 20 years.

METHODS

Children with gross subluxated lenses and aphakia following intracapsular cataract extraction with inadequate posterior capsular support underwent intrascleral fixation of a standard three-piece posterior chamber IOL without sutures, flaps, or glue. A retrospective study of 15 eyes of 11 patients with a mean follow-up period of 6 months was performed. The main outcome measures were improvement in visual acuity (best corrected [BCVA] and uncorrected [UCVA]) and early and late postoperative complications.

RESULTS

Preoperative to postoperative mean UCVA changed from 1.34 ± 0.35 to 0.36 ± 0.18 logarithm of the minimum angle of resolution (logMAR), respectively (P < .001). Preoperative to postoperative mean BCVA changed from 0.69 ± 0.37 to 0.19 ± 0.19 logMAR, respectively (P < .001). Two patients showed early postoperative complications within 1 week. One patient presented with vitreous hemorrhage and the other with hyphema on postoperative day 1. Both patients were treated conservatively and recovered by the first follow-up visit. None of the patients showed late postoperative complications during the 6-month follow-up period. The final visual outcome between the complication (n = 2) and no complication (n = 13) groups showed no statistically significant difference (P = .91). The final visual outcome between the eyes with primary and secondary implantation was similar with no statistically significant difference (P = .857).

CONCLUSIONS

The technique of flapless, glueless, and sutureless scleral fixation of a three-piece IOL has shown significant improvement in visual acuity and does not cause significant complications postoperatively. [J Pediatr Ophthalmol Strabismus. 2017;54(6):381-386.].

Intrascleral IOL Fixation

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

Sutureless intrascleral intraocular lens fixation with lamellar dissection of scleral tunnel

Purpose

To report the results of sutureless scleral fixation of a posterior chamber intraocular lens (IOL) by using our developed simple technique.

Methods

We retrospectively reviewed the medical records of 48 eyes of 47 patients who underwent sutureless intrascleral IOL fixation by using our modified technique. A 25-gauge microvitreoretinal knife was used to perform sclerotomies and create limbus-parallel scleral tunnels with lamellar dissection in which the haptics were fixed.

Results

The IOLs were fixed and centered well. The mean follow-up period was 26.7 months. Postoperative complications included smooth vitreous hemorrhage in four eyes (8.3%), cystoid macular edema in two eyes (4.2%), and iris capture of the IOL in two eyes (4.2%). No other complications, such as breakage of the IOL, spontaneous IOL dislocation, or retinal detachment, were detected during the follow-up period.

Conclusion

The lamellar dissection of the limbus-parallel scleral tunnel can simplify the forceps-assisted introduction of the haptics into the scleral tunnel, and this technique seemed to be safe.