Trocar-assisted sutureless intrascleral posterior chamber foldable intra-ocular lens fixation

Clinical outcomes of iris fixation and sutureless scleral fixation of dislocated foldable posterior chamber intraocular lenses

PURPOSE

Explore the visual outcome and complications of iris fixation intraocular lenses (IFIOL) and sutureless scleral-fixated intraocular lenses (SSFIOL) in the surgical management of patients without exchanging dislocated posterior chamber intraocular lenses (PCIOLs) in the vitreous.

METHODS

Retrospectively, 14 IFIOL and 15 SSFIOL reimplantations for dislocated PCIOLs were analyzed. Mean follow-up of reIFIOL group and reSSFIOL group: 11.3±2.0 (range: 9-15) months and 11.8±2.2 (range: 9-16) months, respectively. Preoperative and postoperative outcomes, operative indications, and complications were evaluated.

RESULTS

Primary surgical indications were pseudoexfoliation (PXE) (21.4%), post-cataract surgery (PCS) (35.7%), trauma (42.8%) in the reIFIOL group, and PXE (26.6%), PCS (40%) trauma (33.3%) in reSSFIOL group, respectively. At the latest follow-up, there was an improvement in best-corrected visual acuity (BCVA) (0.053±0.051 to 0.53±0.13, P<0.0001) in reIFIOL group and (0.05±0.02 to 0.64±0.16, P<0.0001) in reSSFIOL group. Postoperative complications of reIFIOL group and reSSFIOL group included corneal edema (14.2%; nil), IOP elevation (21.4%; 7.1%), bullous keratopathy (14.2%; nil), anterior uveitis (35.7%; 13.3%), cystoid macular edema (CME) (21.4%; 7.1%), pupil ovalization (21.4%; nil), broken haptic (none; 13.3%), IOL exchange (nil; 13.3%), and vitreous hemorrhage (nil; 14.2%).

CONCLUSIONS

Self-dislocated IOL reimplantation may enable much earlier visual rehabilitation in the reSSFIOL group than in the reIFIOL group. Moreover, the 27G trocar-assisted reSSFIOL technique takes a shorter operation time and relatively lower complication rates. However, further prospective studies with larger series and longer follow-up periods are required.

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.

Novel trocar assisted intraocular lens and capsular bag complex fixation

PURPOSE

To describe the innovative technique of trocar-assisted intraocular lens (IOL) and capsular bag complex fixation.

METHODS

In this technique, initial pupil dilatation is achieved either with intracameral adrenaline or with the help of iris hooks. Automated anterior vitrectomy is performed in cases with vitreous prolapse. A 25 G trocar cannula is placed at the limbus through a paracentesis opposite the zonular dialysis area. The cannula lumen act as a guide to pass the double-arm polypropylene suture attached to the needle. This prevents any inadvertent corneal injury and acts as a perpendicular tract to pass the needle through IOL capsular bag complex.

RESULTS

We performed this technique in 9 cases with an excellent outcome with a minimum of 3 months of follow-up. All patients had well-centred IOL. There was no incidence of corneal injury, Descemet membrane detachment, iris trauma, IOL tilt, decentration, dislocation, vitreous prolapse or retinal detachment. All patients achieved excellent visual acuity ranging from 6/12-6/6 postoperatively.

CONCLUSION

The novel trocar-assisted IOL bag complex fixation technique is very effective and allows smooth IOL fixation in technically challenging cases with IOL subluxation. The trocar acts as a guide to prevent injury to the surrounding tissue, and IOL fixation is achieved with minimal manipulations in the anterior chamber. It also prevents the need for IOL explantation in these cases.

CONTRIBUTION FACTORS OF EFFECTIVE LENS POSITION, TILT, AND DECENTRATION DURING FLANGED SCLERAL FIXATION OF INTRAOCULAR LENS: A Model Eye Study

PURPOSE

The authors aimed to elucidate the factors related to effective lens position, tilt, and decentration of scleral fixed intraocular lenses (IOLs) with a flanged haptic technique in an artificial eye model using anterior segment optical coherence tomography.

METHODS

Two bent 27-gauge needles were passed through a 1.0- or 2.0-mm scleral tunnel, 2.0 mm posterior to the limbus and 180° apart. Both haptics of a three-piece IOL were docked with guide needles and externalized. Factors related to the IOL position were analyzed using anterior segment optical coherence tomography and a stereomicroscope.

RESULTS

The 1.0-mm scleral tunnel induced a significantly longer effective lens position than the 2.0-mm tunnel and suture fixation ( P < 0.05 and P < 0.01, respectively). Discrepancy in scleral tunnel length induced higher decentration of the optic to the opposite side of the haptic-embedded shorter tunnel and tilt perpendicular to the fixed axis than that in the scleral tunnel of the same length ( P < 0.001 and P < 0.05, respectively). If the scleral fixation points of both haptics are not exactly 180° apart, the IOL may become decentered and tilted ( P < 0.01 and P < 0.05, respectively).

CONCLUSION

In the flanged haptic technique, the length, balance, and position of both scleral tunnels determine IOL effective lens position, tilt, and decentration.

Modified Carlevale Intraocular Lens Fixation Technique: Two Vitrectomy Ports As Lens Plug Fixation Sites

PURPOSE

To describe and evaluate the effectiveness of the modified Carlevale intraocular lens (IOL) fixation technique, using two vitrectomy ports as lens plug fixation sites.

MATERIALS AND METHODS

This prospective, consecutive, interventional study examined 60 eyes in 60 patients, who underwent 25- or 23-gauge vitrectomy for an IOL subluxation/luxation, lens dislocation, or aphakia, with Carlevale IOL implantation.

RESULTS

Postoperatively, transient ocular hypotension was observed in four eyes. The mean refractive prediction error was -0.27 ± 0.78 diopters. No postoperative complications, such as retinal detachment, endophthalmitis, or IOL dislocation, were observed in the 4-month follow-up.

CONCLUSION

This new technique may be simple, fast, and effective because of fewer scleral wounds and fewer postoperative complications.

A comparative study of transscleral sutured intraocular lens fixation and sutureless flanged intraocular lens fixation

BACKGROUND

To compare the intraocular lens (IOL) tilt and decentration and visual outcomes of transscleral sutured IOL fixation and sutureless flanged IOL fixation. To investigate the influence of IOL tilt and decentration on internal higher-order aberrations (HOAs) in these two techniques.

METHODS

Patients who received transscleral sutured or sutureless flanged IOL fixation procedures were included in this prospective, non-randomized, comparative study. Corrected distance visual acuity (CDVA) was measured at baseline and at every postoperative visit for 12 months. IOL tilt and decentration were measured using a second-generation anterior segment optical coherence tomography (Casia2) and internal HOAs were measured using iTrace Visual Function Analyzer at 3 months postoperatively.

RESULTS

The study included 27 eyes from the transscleral sutured IOL fixation group and 26 eyes from the sutureless flanged IOL fixation group. There was no significant difference in CDVA between the two groups at all time points. The two groups did not differ in refractive difference from the predicted value, corneal endothelial cell loss, IOL tilt, IOL decentration, internal astigmatism or internal HOAs. Vertical IOL decentration significantly correlated with total internal optical aberration (r = 0.288, P = 0.036), total internal HOA (r = 0.440, P = 0.001), internal coma (r = 0.348, P = 0.001), vertical internal coma (r = 0.388, P = 0.004), average height of modulation transfer function (r = - 0.364, P = 0.007) and Strehl ratio (r = - 0.297, P = 0.031). Horizontal IOL decentration significantly correlated with horizontal internal coma (r = 0.312, P = 0.023).

CONCLUSIONS

Transscleral sutured IOL fixation and sutureless flanged IOL fixation had similar IOL positions and visual outcomes. IOL decentrations correlated with internal HOAs and thus should be avoided.

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

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

Intraocular lens implantation in the absence of capsular support

In the absence of capsular support, it is not always possible to safely place an intraocular lens (IOL) in the capsular bag at the time of surgery. Several techniques have thus been developed to enable safe placement of a secondary IOL outside the capsular bag. These techniques include placement of anterior chamber IOLs, iris-fixated IOLs (sutured, iris-claw), and scleral-fixated IOLs (sutured, sutureless). Secondary IOL placement can take place at the time of the initial surgery or in a second surgery. Each technique has its own unique advantages, as well as its potential complications. At this time, comparison studies have found no secondary IOL technique to be superior in terms of visual acuity or rate of complications. Additional comparison studies with longer follow-up times are needed to confirm these findings. The decision on which secondary IOL technique to perform depends on numerous factors including surgeon experience and comfort, as well as patient comorbidities.

Endoscope-Assisted Sutureless Intrascleral Haptic Fixation of a Posterior Chamber Intraocular Lens

Purpose:

In eyes with compromised capsule support, sutureless scleral fixation is a popular method of placing a posterior chamber intraocular lens (PCIOL). We describe an endoscope-assisted sutureless technique for intrascleral fixation of a 3-piece PCIOL.

Methods:

Eyes of patients who had endoscope-assisted scleral-fixated intraocular lens (SFIOL) implantation were examined retrospectively. The technique comprised direct capture of the IOL haptic with a forceps through a pars plana sclerotomy with subsequent haptic fixation into scleral tunnels created with a 26-gauge needle. The endoscope was used to visualize haptic positioning under the iris and ensure proper centration of the IOL.

Results:

Thirteen eyes of 13 patients were examined. The mean age of the patients was 68.2 years (range, 38-87 years), and the mean follow-up was 13.6 months (range, 5-23 months). The indications for surgery were a subluxated IOL (6 eyes), postoperative aphakia (5 eyes), and a subluxated cataract (2 eyes). The mean best-corrected visual acuity ± SD improved significantly from 1.2 ± 0.6 logMAR preoperatively to 0.6 ± 0.7 logMAR at last the follow-up (paired Welch t test; t10 = 2.69; P = .023). IOL stability and centration were maintained in all patients.

Conclusions:

Endoscopic visualization during sutureless SFIOL implantation helped improve haptic localization, minimize intraoperative complications, and achieve excellent IOL centration.

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.

Punch and rescue technique for scleral fixation of dislocated single-piece intraocular lenses

In-the-bag intraocular lens (IOL) dislocation is a well-known complication after cataract surgery. As the number of cataract surgeries performed annually continues to increase, so will the incidence of IOL dislocations requiring surgical correction. Described is a new technique for rescue and refixation of a single-piece acrylic IOL. In this method, a new instrument called the IOL punch is used to create a hole at the optic-haptic junction or along the border of the optic, which acts as an anchor point for centration and subsequent scleral fixation of a dislocated IOL. The IOL punch allows for precise intraocular manipulation of the IOL and is less invasive compared with popular scleral fixation methods. This innovative technique may decrease the risk for postoperative complications and allows patients to maintain or recover previous uncorrected visual acuity by circumventing the need for IOL explantation or exchange.

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.

Modified Yamane technique with a 26-gauge needle: single corneal incision and simplified haptic insertion

A modified Yamane technique with a 26-gauge needle for aphakia correction is described. Single corneal or corneoscleral incision is set at 12 o'clock. The 26-gauge needles are used to make 2 angled incisions parallel to the limbus to fix the haptics of a 3-piece intraocular lens. The modifications provide an easier and safer way of haptic insertion into the needle tip and decreases the possibility of bending or breaking the haptic.

A Modified Intrascleral Intraocular Lens Fixation Technique Using 27-Gauge Blunted Needles with Fewer Intraocular Manipulations

A new method for intraocular lens (IOL) fixation in the scleral tunnel using two common 27G blunted needles and an ultrathin 30G needle with fewer intraocular manipulations was developed. Half-depth scleral flaps were prepared, and vertically angled sclerotomies were performed under each scleral flap, 2 mm from the limbs with a 20G microblade or a 26G needle. Two bent 27G blunted needles connected the sclerotomy and corneoscleral incisions. One haptic was inserted into this bent 27G blunted needle extraocularly and extruded through the sclerotomy site. Each haptic was inserted into the lumen of the preplaced ultrathin 30G needle and buried into the scleral tunnel. In this retrospective study, we reviewed the outcomes of this new technique in patients with at least 3 months' follow-up data. Iris capture of the IOL was not observed in any case, and IOL repositioning was not performed either. Astigmatism induced by intraocular aberration was almost as same as that with other methods. Our technique can be performed in any operation room without any extra instruments. This trial is registered with UMIN000044350.

Minimally Invasive Surgery for Intraocular Lens Removal and Intrascleral Intraocular Lens Fixation with Trabeculectomy in a Patient with Dislocated Intraocular Lens and Elevated Intraocular Pressure

A 88-year-old female who was being treated for end-stage pseudoexfoliation syndrome was referred to our hospital for treatment of dislocated intraocular lens (IOL) and the elevated intraocular pressure (IOP) and in the right eye (RE). At the first visit to our hospital, best-corrected visual acuity (BCVA) was 0.2 in the RE and 0.02 in the left eye (LE). IOP was 47 mm Hg in the RE and 21 mm Hg in the LE. Slit-lamp examination showed no abnormalities in anterior segments and dislocated IOL in the RE. Fundus photograph showed optic disc pallor in both eyes. We performed the combined therapy of flanged intrascleral IOL fixation with the double-needle technique and trabeculectomy. Throughout the follow-up period, BCVA slightly improved from 0.2 to 0.4 in the RE. The angle of tilt of the IOL was 6.6, 7.9, and 8.7° as measured by swept-source optical coherence tomography at 1, 4, and 6 months after the surgery, respectively. The IOP remained less than 10 mm Hg without having to administer any other glaucoma medications. Furthermore, any complications associated with the surgery were not confirmed.

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.

27-gauge trocar-assisted sutureless intraocular lens fixation

Backgrounds

However there have been numerous investigations of intrascleral intraocular lens (IOL) fixation techniques, there is room for improvement in terms of simplifying complicated techniques and reducing the high levels of skill required. This study aimed to report a novel technique for sutureless intrascleral fixation of the IOL using retinal forceps with a 27-gauge trocar.

Methods

Nineteen eyes of 18 patients underwent intrascleral fixation of the IOL from July 2018 to September 2019 were enrolled in this study. A 27-gauge trocar formed 3-mm scleral tunnels positioned at 4 and 10 o’clock, 2 mm from the corneal limbus. We used a 3-piece IOL haptic grasped by a 27-gauge retinal forceps and pulled from the 27-gauge trocar. The IOL was fixed by making a flange. Main outcome measures were visual acuity, corneal endothelial cell density, IOL tilt, decentration, predicted error of refraction and complications.

Results

The 19 eyes were followed up for 1 month. The mean pre- and postoperative logMAR uncorrected visual acuity (UCVA) was 1.06 ± 0.63 and 0.40 ± 0.26, respectively (p < 0.01), while the mean pre- and postoperative logMAR best corrected visual acuity (BCVA) was 0.27 ± 0.51 and 0.06 ± 0.15, respectively (p = 0.09). The mean corneal endothelial cell density was 2406 ± 625 to 2004 ± 759 cells/mm² at 1 month (p = 0.13). The mean IOL tilt was 3.52 ± 3.00°, and the mean IOL decentration was 0.39 ± 0.39 mm. There was no correlation among IOL tilt, decentration and BCVA (p > 0.05). The mean prediction error of the target refraction was − 0.03 ± 0.93 D. The complications were vitreous hemorrhage (3 eyes), hyphema (1 eye), IOP elevation (1 eye), iris capture of the IOL (1 eye) and hypotony (2 eyes). No IOL dislocation occurred.

Conclusions

IOL intrascleral fixation with a flange achieved good IOL fixation and visual outcome in the scleral tunnels created with the 27-gauge trocar.

Influence of sclerotomy size on intraocular lens tilt after intrascleral intraocular lens fixation

PURPOSE

To determine whether differences in sclerotomy size during intrascleral intraocular lens (IOL) fixation influence IOL tilt and visual acuity after surgery.

SETTING

University of Fukui Hospital and Japanese Red Cross Fukui Hospital, Japan.

DESIGN

Retrospective case series.

METHODS

The study reviewed the records of patients who had intrascleral IOL fixation with transconjunctival 25-gauge pars plana vitrectomy and a follow-up longer than 6 months. The preoperative and postoperative visual outcomes, degree of IOL tilt, and intraoperative and postoperative complications were statistically compared between the sclerotomy groups.

RESULTS

The study included 65 eyes (60 patients). Postoperatively, the maximum degree of IOL tilt was significantly smaller in the 24-gauge sclerotomy group than in the 30-gauge sclerotomy group (P = .003). The degree of IOL tilt was significantly correlated with the amount of postoperative IOL astigmatism (total astigmatism - corneal astigmatism) (P = .0001, R² = 0.23). There were no statistically significant differences in the preoperative or postoperative corrected distance visual acuity (CDVA) or the complication rate between the sclerotomy groups.

CONCLUSION

A smaller sclerotomy for intrascleral IOL fixation was associated with greater IOL tilt and IOL astigmatism after surgery; however, this did not clinically or significantly affect the postoperative CDVA.

Sekundäre Linsenimplantation: chirurgische Techniken und Ergebnisse

Es stehen verschiedene alternative chirurgische Optionen zur Verfügung, um eine sekundäre Intraokularlinse (IOL) in Augen mit unzureichender Kapselunterstützung zu implantieren. Erfolgreiche Techniken umfassen die Implantation einer irisfixierten IOL (IFIOL), einer kammerwinkelgestützten Vorderkammerlinse (ACIOL) oder verschiedene Variationen zur Sklerafixierung (SFIOL). Jede dieser Methoden hat sich als sicher und effektiv erwiesen, weist jedoch verfahrensspezifische Einschränkungen auf. Jüngste Studien zeigen, dass die Entwicklung neuer chirurgischer Techniken diesen Patienten weiterhin sichere und reproduzierbare Behandlungsmöglichkeiten bietet. Obwohl die Implantation von sekundären IOLs ohne Kapselunterstützung von vielen Faktoren, einschließlich der Präferenz des Chirurgen, abhängt, sind nahtlose sklerafixierende Techniken für die chirurgische Gemeinschaft von wachsendem Interesse. Das Bestreben nach kürzeren und weniger traumatischen Operationen sowie nach reproduzierbaren und funktionell guten Ergebnissen, fördert dabei die Entwicklung von neuen Operationstechniken, Intraokularlinsen und Instrumenten. Diese Übersichtsarbeit gibt einen Einblick in alte und neue Behandlungsmethoden zur Korrektur von Aphakie mit sekundären Intraokularlinsen

[Clinical Outcomes of Endoscope-Assisted 30-Gauge Single-Needle Technique for Intrascleral Intraocular Lens Fixation]

INTRODUCTION

We have developed an endoscope-assisted single-needle technique, which is an improvement of Yamane's double-needle technique of the intrascleral intraocular lens (IOL) fixation techniques. In this surgical procedure, the IOL is manipulated in the vitreous cavity, and the IOL haptic is externalized from the eye one by one with the aid of an ophthalmic endoscope. The purpose of this study was to report the postoperative visual function and safety of this new technique.

METHODS

Overall, 19 consecutive eyes (16 patients; mean age, 75.1 ± 9.6 years; mean follow-up period, 5.7 months) that underwent intrascleral IOL fixation surgery with our new technique were included in the study. Manifest refraction, uncorrected/corrected visual acuity, and corneal endothelial cell density were measured before and after surgery. Tilt and decentration of IOL were analyzed using anterior segment optical coherence tomography.

RESULTS

The mean absolute prediction error (spherical equivalent) was 0.82 ± 0.52. The mean postoperative best-corrected visual acuity had significantly improved at the final visits (p = 0.02). No significant differences in the mean corneal endothelial cell density were observed between the first (2,232 ± 751 cells/mm2) and final (2,099 ± 649 cells/mm2) visits (p = 0.35). The mean IOL tilt was 8.1 ± 3.2°. There were no vision-threatening complications, such as retinal detachment, endophthalmitis, or IOL dislocation, during or after surgery.

CONCLUSIONS

The endoscope-assisted single-needle technique is a safe and effective method of intrascleral IOL fixation surgery.

Early Experience with Two Techniques of Intrascleral Intraocular Lens Fixation

BACKGROUND

We compared our early experience of visual outcomes, operation time, and complications for two techniques of intrascleral intraocular lens (IOL) fixation: T-fixation and flanged IOL fixation.

METHODS

Data from patients who underwent scleral fixation of an IOL between October 2017 and December 2018 were analyzed retrospectively. Intraoperative time for fixation steps, corneal endothelial cell density (ECD) rate reduction, and intraoperative/postoperative complications were compared between T-fixation (Group T, n = 4) and flanged IOL fixation (Group F, n = 6).

RESULTS

Mean patient age was 73.7 ± 13.0 years. Intraoperative time was significantly longer for Group T (27.5 ± 9.7 min) than for Group F (13.0 ± 3.8 min; P=0.03, Mann-Whitney U-test). Intraoperative complications included iris damage from the 30-G needle in 2 eyes in Group F. Postoperative complications included iris capture by the IOL in 1 eye in Group F. No incidents of postoperative retinal detachment or IOL dislocation were identified. The ECD reduction rate did not significantly differ between groups.

CONCLUSIONS

Both techniques yielded favorable surgical outcomes. Flanged IOL fixation might be superior because of its shorter intraoperative time but could initially be technically difficult because of the need to perform angled sclerotomy with a 30-G needle to avoid iris injury.

A different surgical approach to cases with zonular weakness or dialysis: sutureless transscleral fixated intraocular lens implantation and stabilization of lens capsule

PURPOSE

To evaluate the effect of sutureless transscleral fixated intraocular lens (IOL) implantation and capsule stabilization of IOL optics on postoperative visual outcomes in cases with zonular dialysis in excess of 70°.

METHODS

Fifteen eyes of thirteen patients with > 70° zonular dialysis and endothelial cell counts higher than 1500 cells/mm² who had been followed for at least 6 months were included. A modified surgical approach was applied to these eyes with sutureless transscleral fixated IOL implantation and the IOL was secured to the capsulorhexis to stabilize the lens capsule (optic capture).

RESULTS

The mean best-corrected visual acuity (BCVA) was 0.21 ± 0.2 on the first day, 0.45 ± 0.33 on the first week, 0.60 ± 0.32 on the first month, 0.80 ± 0.26 on the third month, and 0.82 ± 0.27 on the sixth month. When preoperative BCVA and postoperative BCVA were compared, a statistically significant increase was observed in postoperative BCVA beginning from the seventh postoperative day. There was a statistically significant (p = 0.038) decrease in endothelial cell count at postoperative third and sixth months (1895 ± 65, 1872 ± 376, respectively) compared to preoperative values.

CONCLUSIONS

The use of this new surgical modification that utilizes capsular tension rings combined with a procedure that secures the sutureless scleral IOL fixation to the capsulorhexis for the treatment of eyes with zonular dialysis in excess of 70° was found to be very successful in the 6 months of follow-up. More cases and longer follow-up periods are required to provide an idea as to whether different complications will develop in such patients.

27-gauge trocar-assisted transconjunctival sutureless intraocular lens scleral fixation

OBJECTIVE

To present the surgical outcome of posterior chamber intraocular lens scleral fixation using a 27-gauge trocar-assisted transconjunctival sutureless technique in aphakic patients due to cataract surgery complications with inadequate capsular support.

METHODS

Six consecutive patients with aphakia due to cataract surgery complications with inadequate capsular bag support were operated by two surgeons. Intraocular lens scleral fixation was performed with a 27-gauge trocar-assisted transconjunctival sutureless technique. Patients were followed-up for 12 months. Preoperative and postoperative best-corrected visual acuities were assessed with Early Treatment Diabetic Retinopathy Study charts and expressed in decimals.

RESULTS

All patients showed statistically significant best-corrected visual acuity improvement and excellent anatomic results. Mean preoperative best-corrected visual acuity was 0.17 (range of 0.1-0.2). Mean postoperative best-corrected visual acuity was 0.84 (range of 0.63-1.00). Mean initial spherical equivalent refractive error was +11.85 (range of +9.00 to +15.00). Mean final spherical equivalent refractive error was -0.25 (range of -1.25 to +2.25). There were no postoperative complications during the whole follow-up.

CONCLUSION

Fixation of a posterior chamber intraocular lens using a 27-gauge trocar-assisted transconjunctival sutureless intrascleral technique is an excellent option for aphakic patients secondary to cataract surgery complications with inadequate capsular support.

Modified Intraocular Lens Intrascleral Fixation Technique Using Two Vitrectomy Ports as Lens Haptic Fixation Sites

Introduction

We developed a new technique that uses two of the vitrectomy ports as intraocular lens (IOL) haptic fixation sites and compared that with a conventional T-fixation method.

Methods

A total of 33 eyes were retrospectively divided into the port-fixation (n=21) and conventional (n=12) groups. For the port-fixation group, supranasal and inferotemporal trocars (25-gauge) were placed in the center of a T-shaped lamellar scleral incision 2 mm from the corneal limbus and a supratemporal trocar at 3.5 mm. Following a vitrectomy, along with lens or IOL extraction as needed, the infusion cannula was changed from an inferotemporal to supratemporal trocar. The first IOL haptic and trocar were then simultaneously withdrawn from the eye by grasping with vitreoretinal forceps, with the same performed for the second IOL haptic and trocar, after which the infusion cannula was removed. In the conventional group, 2 T-shaped scleral incisions and three trocars were separately placed.

Results

Postoperatively, transient ocular hypotension and hypertension were observed in a few eyes in both groups. At 6 months after surgery, astigmatism was 1.71±1.13 D in the port-fixation group and 2.21±1.78 D in the conventional group (p=0.40, t-test).

Conclusion

This new technique may be effective because of the lower number of scleral wounds.

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.

A 1-Year Prospective Comparative Study of Sutureless Flanged Intraocular Lens Fixation and Conventional Sutured Scleral Fixation in Intraocular Lens Dislocation

PURPOSE

To compare surgical outcomes of sutureless flanged intraocular lens (IOL) fixation and conventional sutured scleral fixation (SF) for secondary IOL implantation in patients with IOL dislocation.

METHODS

This is a prospective, comparative cohort study on 103 consecutive patients (103 eyes) with IOL dislocation who underwent vitrectomy with IOL removal and sutured SF (53 eyes) or flanged IOL fixation (50 eyes). Operating time, best-corrected visual acuity (BCVA), refractive difference, IOL tilt and decentration using swept-source anterior segment OCT, and postoperative complications were measured for 12 months.

RESULTS

Operating time was significantly shorter for the flanged IOL fixation than for sutured SF (19.4 ± 4.6 vs. 48.9 ± 5.2 min, p < 0.001). BCVA in both groups improved at 1, 3, 6, and 12 months postoperatively (p < 0.05). BCVA in the 2 groups was similar during the 12 months of observation. The refractive difference, IOL tilt, IOL decentration, and incidence of postoperative complications were also not different in the 2 groups.

CONCLUSION

Sutured SF and flanged IOL fixation had similar visual outcomes and IOL stability in patients with IOL dislocation. However, the operating time for flanged IOL fixation was less than half that of the sutured SF. This technique is an efficient alternative for treating IOL dislocation.

Trocar-assisted, flanged sutureless scleral-fixated intraocular lens implantation combined with silicone oil injection after penetrating keratoplasty surgery

We describe a combined technique of trocar-assisted sutureless scleral-fixated intraocular lens implantation and silicone oil injection at the same session. Two 3 mm scleral tunnels were created 2 mm away from and parallel to the limbus with the 23-gauge vitrectomy trocars entering the sclera transconjunctivally at an angle of approximately 10° at the 3 o'clock and 9 o'clock meridians. After the 3-piece foldable IOL was delivered to the anterior chamber through the corneal incision, the tip of one of the IOL haptics was grasped with a 23-gauge serrated retinal forceps entered through the trocar located at the 3 o'clock meridian. Then the haptic was removed from the scleral tunnel together with the trocar out of the globe. The same procedure was applied to the other haptic. A transconjunctival secure 10-0 nylon suture was placed at the scleral tunnel entry site around the haptic. The ends of the haptics were cauterized to make a flange. The resultant flanges of the haptics were pushed back and fixed into the scleral tunnels. Perfluorooctane was taken out of the eye with vitreoretinal surgery and the silicone was injected into the eye to prevent hypotonia. No complications were seen intraoperatively or postoperatively. After 1-month follow-up period, IOL was seen stabilized.

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.

Double-Needle Yamane Repositioning of a Previous Yamane Fixation

We describe a case of anteriorly dislocated, Yamane-fixated secondary intraocular lens (IOLs) with pigmentary dispersion syndrome. The patient presented with significant visual impairment and elevated intraocular pressure despite being maximally treated with all topical antihypertensive medications. The iris-IOL touch was confirmed by ultrasound biomicroscopy, and fundus examination revealed evidence of pigment granules on the optic disc. The previous Yamane-fixated secondary IOL was repositioned using a double-needle adaptation of Yamane technique and Kim's modification of scleral-fixated IOLs. To our knowledge, this is the first ever documented case of double-needle Yamane technique of a previous Yamane-fixated eye. In cases of inadequate capsular support, the development of new surgical techniques for the fixation of IOL continues to improve the safety and efficacy of these complicated surgeries.

Evaluation of suturless scleral fixation with posterior chamber foldable intraocular lens implantation

AIM

To assess the sutureless scleral fixation technique for posterior chamber foldable intraocular lens (PCIOL) implantation in aphakic eyes with insufficient or no capsular support.

METHODS

A technique for sutureless intrascleral fixation of the haptics of a standard 3-piece PCIOL was used which ensures sutureless fixation by permanent incarceration of the haptics in a scleral tunnel parallel to the limbus. All patients were evaluated for preoperative status [visual acuity, refractive error, K readings, intraocular pressure (IOP) measurement, slit lamp examination, fundus examination and optical biometry], postoperative status and complications. Ultrasound biomicroscopy (UBM) was done for 10 cases to evaluate optic tilt.

RESULTS

The study evaluated 42 eyes of 42 patients. The follow-up period was 6mo. Improvement of best corrected visual acuity (BCVA) one line occurred in 10 cases (23.8%) and loss of one line in 3 cases (7.1%). Intraoperative complications included: haptic kink in 4 cases (9.5%), haptic breakage in 1 case (2.4%), haptic dislocation in 1 case (2.4%), haptic slippage in 3 cases (7.1%), IOL dislocation in 1 case (2.4%) and sclerotomy related bleeding in 1 case (2.4%). Postoperative complications included: transient mild vitreous hemorrhage in 3 cases (7.1%), choroidal detachment in 1 case (2.4%), cystoid macular edema (CME) in 1 case (2.4%), optic capture in 1 case (2.4%), subconjunctival haptic in 2 cases (4.8%), ocular hypotony in 4 cases (9.5%) and ocular hypertension in 1 case (2.4%). There were no cases of retinal detachment or endophthalmitis. UBM showed optic tilt in 3 cases (30%).

CONCLUSION

Fixation of three-piece foldable IOL haptics in scleral tunnel parallel to the limbus-provided axial stability and proper centration of the IOL with minimal or no tilt in most cases and a low complication rate during the follow up period which lasted 6mo.

Scleral pockets for an innovative technique of intrascleral fixation of intraocular lens

The aim of this article is to report the results of an innovative technique for a scleral fixation of a posterior chamber intraocular lens using our new modified technique. We retrospectively reviewed the medical records of 15 eyes of 15 patients who underwent sutureless intrascleral intraocular lens fixation using our modified technique. We used a 23-gauge knife to perform sclerotomy and create two parallel scleral pockets for the haptics. The mean follow-up period was 3 years (3 ± 1). No complications were detected during the follow-up period. The creation of two parallel scleral pockets, parallel to the limbus, greatly simplifies the introduction of intraocular lens haptics.

Comparison of Two Modified Sutureless Techniques of Scleral Fixation of Intraocular Lens

BACKGROUND AND OBJECTIVE

To compare the visual outcome and complications of two different sutureless scleral-fixated intraocular lens (IOL) implantation techniques, that is, intrascleral IOL fixation technique and modified Yamane's technique of scleral fixation of IOL.

PATIENTS AND METHODS

Patients who underwent scleral fixation of IOL (SFIOL) from June 2015 to February 2017 with more than 6 months of follow-up were examined retrospectively. Improvement in visual acuity (VA), intraocular pressure (IOP) measurements, endothelial cell count, central macular thickness (CMT), and intraoperative/postoperative complications were compared at 6 months follow-up.

RESULTS

Seventy eyes were analyzed. The mean follow-up was 10.5 months ± 1.5 months. The final visual outcomes in both groups, modified intrascleral IOL fixation technique (Group A, n = 30) and modified Yamane's technique (Group B, n = 40), were comparable. The indications for surgery were aphakia (n = 15), subluxated/dislocated cataract (n = 31), and dislocated/subluxated IOL (n = 24). The majority of the eyes (92%) improved to VA 0.3 logMAR units or better. The uncorrected distance visual acuity (UDVA), endothelial cell density, and CMT at the 6-month follow-up were comparable in both groups. Postoperatively, transient IOP rise occurred in 18 eyes, retinal detachment in one eye, vitreous hemorrhage in one eye, cystoid macular edema in two eyes, and mild IOL decentration in two eyes.

CONCLUSION

Both techniques have favorable visual outcomes; however, modified 27-gauge needle-assisted Yamane's technique is technically superior because of its transconjunctival approach and less surgical time, and its needle-assisted approach for haptic externalization prevents haptic damage during externalization. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e129-e134.].

Sutureless Intrascleral Haptic-Hook Lens Implantation Using 25-Gauge Trocars

Purpose

To report a new technique for sutureless intrascleral fixation of three-piece foldable intraocular lenses (IOLs) using 25-gauge trocars.

Methods

We performed this technique on patients with insufficient posterior capsule support. Seventeen eyes from 15 patients with aphakia, dislocated IOL, or subluxated crystalline lens undergoing posterior chamber sutureless implantation of an IOL were studied. The haptics of the IOL were externalized using two 25-gauge forceps. The haptics were bended back (hook-like) into the vitreous cavity through a scleral incision made by using a 25-gauge trocar. And, IOL tilt was determined by using a slit lamp and UBM, and complications were recorded.

Results

The IOLs were fixed with exact centration and axial stability. No wound leakage was reported even without the use of sutures. The mean best-corrected visual acuity (BCVA) was 0.82 logarithm of the minimum angle of resolution (logMAR) units preoperatively, and the mean BCVA was 0.44 logMAR units at the 6-month follow-up visit. No postoperative retinal detachment, endophthalmitis, IOL tilt or dislocation, or vitreous hemorrhage was noted.

Conclusion

Sutureless intrascleral haptic-hook posterior chamber IOL implantation using 25-gauge trocars provides good IOL fixation with reliable wound closure without the use of sutures. This trial is registered with ChiCTR1800017436.

SILICONE MICROTUBE-ASSISTED SCLERAL FIXATION OF A POSTERIOR CHAMBER INTRAOCULAR LENS

PURPOSE

To report a novel technique for intrascleral fixation of a posterior chamber intraocular lens using a silicone microtube to manipulate the haptics into position.

METHODS

Intrascleral fixation was performed in six eyes and the results evaluated in this retrospective case series. A silicone microtube with a 0.2-mm external diameter was passed from a sclerocorneal incision through the chamber and a sclerotomy made using a 30-gauge needle. The tips of the intraocular lens haptics were connected to the silicone microtube outside the eye. After the intraocular lens was injected into the posterior chamber, the haptics were drawn through the scleral incision through their attachment to the silicone microtube.

RESULTS

The mean postoperative corrected visual acuity was 0.62 logarithm of the minimum angle of resolution (20/43) with a mean refraction error of -0.06 ± 0.4 diopter, which did not differ significantly (P = 0.53) from the expected value. The postoperative complications included transient ocular hypotension, vitreous hemorrhage, and choroidal detachment.

CONCLUSION

Our technique using a silicone microtube reduces the number of intraocular procedures compared with previous methods using forceps or needles for moving the intraocular lens haptics from the posterior chamber to the outside through sclerotomies.

27-gauge needle-assisted externalization and haptic securing technique for sutureless scleral fixation of the intraocular lens - moving toward simplicity

Purpose

To report a modified technique of sutureless intrascleral fixation of a posterior chamber intraocular lens with use of instruments of anterior segment surgery and its outcomes.

Design

Prospective, noncomparative, interventional case series.

Participants

Ninety-two eyes of 92 patients with aphakia and subluxated lens who underwent surgery were evaluated.

Materials and methods

27-gauge needles were introduced transclerally and guided by the viscocanula to externalize via the main wound. The haptics were loaded into the lumen and externalized from entry points. The haptics were then fixed in a scleral tunnel made by a 27-gauge needle. The best-corrected visual acuity (BCVA) and complications were determined.

Results

Ninety two eyes which were operated and completed follow-up of 6 weeks were included in the study. The most common indications for scleral-fixated intraocular lens (SFIOL) were subluxated lens – 55 eyes (59%), and surgical aphakia – 31 eyes (34%). Sixty-nine eyes (75.7%) had a postoperative vision of uncorrected visual acuity of 6/18 on day 1. There was an improvement in mean logMAR BCVA (0.086±0.18) at 6 weeks as compared to preoperative visual acuity (p<0.05). BCVA of 6/12 or better was attained in 94% of the cases at 6 weeks. Special mentions need to be made for 6 (7%) of our cases. Three of the patients were cases of fully treated postoperative endophthalmitis who lacked capsular support. Two of the other cases had undergone pars plana vitrectomy for retinal detachment. Both had silicon oil removal done 1 month before the SFIOL procedure. One of the patients had Marfan’s syndrome.

Conclusion

Our procedure is safe, easy, less traumatic, and less resource-demanding with good visual outcomes and can be performed even in low-resource settings of developing countries. It may also be considered in patients who have had posterior segment surgeries previously.

Adjustments of haptics length for tilted intraocular lens after intrascleral fixation

Purpose

To report the findings and surgical techniques on two cases of severe tilting of an intraocular lens (IOL) that had been implanted with intrascleral fixation and the tilting was detected by anterior segment optical coherence tomography (AS-OCT).

Observations

Two patients underwent flanged intrascleral fixation of an IOL with the double needle technique. AS-OCT showed that the tilt of IOL was 25.3° in Case 1 and was 38.1° in Case 2, and a second surgery was planned to reduce the IOL tilt. Both edges of the flanged haptics were externalized and shortened by 2–3 mm. Then, the haptics edges were inserted intrasclerally. The tilt of the IOLs was reduced to 7.7° and 5.7°, and the myopia-shifted refraction was reduced from −2.75 diopters (D) and −4.50 D to −0.13 D and −0.50 D of the approximate planned refraction in the two cases.

Conclusions and importance

An excessive tilt of an intrasclerally fixed IOL can be corrected by shortening the length of the haptics. AS-OCT was useful in not only detecting the tilted IOL but also in monitoring the degree of tilt after adjustment surgery.

[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.

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.].

Effects of optical diameter of intraocular lenses with intrascleral fixation on higher-order aberrations

Background

Intrascleral fixation of an intraocular lens (IOL) is used in eyes that lack capsular support. The aim of the study is to determine whether a larger optical diameter IOL will decrease the higher-order aberrations (HOAs) when the haptics are extended for intrascleral fixation than a smaller diameter IOL.

Methods

Three-piece acrylic IOLs with 6.0 mm optics (X-60, VA-60BBR) and 7.0 mm optics (X-70, VA-70 AD) were fixed at lengths of 13, 14, 15, 16, or 17 mm. A wavefront analyzer was used to measure the HOAs within the central 3.0 and 5.2 mm optic diameter.

Results

The astigmatic aberration within the central 5.2 mm was greater than that within the central 3.0 mm for all IOLs. The HOAs increased significantly with an extension of the IOLs with both optical diameters (P < 0.001). The coma aberration within the central 5.2 mm was greater than that within the central 3.0 mm but it did not increase with an extension of the haptics. The astigmatic aberration of the X-60 IOL was significantly greater than that of the X-70 only at an extension of 17 mm. The astigmatic aberration of the VA-70 AD was not significantly different from that of the VA-60BBR. The cylindrical power changed from 0.047 D in the X-60 to 0.118 D in the VA-70 AD when the IOLs were extended from 13 to 17 mm.

Conclusion

When three-piece IOLs are highly extended for intrascleral fixation, the astigmatic aberration increases significantly. However, IOLs with 7 mm optics do not have less astigmatic and coma aberrations than IOLs with 6 mm optics.

Flanged Intrascleral Intraocular Lens Fixation with Double-Needle Technique

PURPOSE

To report the clinical outcomes of a new technique for transconjunctival intrascleral fixation of an intraocular lens (IOL).

DESIGN

Prospective, noncomparative, interventional case series.

PARTICIPANTS

One hundred eyes of 97 consecutive patients with aphakia, dislocated IOL, or subluxated crystalline lens who underwent posterior chamber sutureless implantation of an IOL were studied.

METHODS

Two angled incisions parallel to the limbus were made by 30-gauge thin-wall needles. Haptics of an IOL were externalized with the needles and cauterized to make a flange of the haptics. The flange of the haptics were pushed back and fixed into the scleral tunnels.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (VA), corneal endothelial cell density, IOL tilt, and complications were determined.

RESULTS

The IOLs were fixed with exact centration and axial stability. The mean preoperative best-corrected VA was 0.25 logarithm of the minimum angle of resolution (logMAR) units; after surgery, it improved significantly to 0.11 logMAR, 0.09 logMAR, 0.12 logMAR, and 0.04 logMAR at 6, 12, 24, and 36 months, respectively (P < 0.01, P < 0.01, P = 0.03, and P = 0.10, respectively). The mean corneal endothelial cell density decreased from 2341 cells/mm² before surgery to 2313 cells/mm², 2240 cells/mm², 2189 cells/mm², and 2244 cells/mm² at 6, 12, 24, and 36 months, respectively (P < 0.01, P < 0.01, P < 0.01, and P = 0.17, respectively). The mean IOL tilt was 3.4°±2.5°. The postoperative complications included iris capture by the IOL in 8 eyes (8%), vitreous hemorrhage in 5 eyes (5%), and cystoid macular edema in 1 eye (1%). There were no incidents of postoperative retinal detachment, endophthalmitis, or IOL dislocation.

CONCLUSIONS

We have developed a new technique for intrascleral IOL fixation. The flanged IOL fixation technique is a simple and minimally invasive method for achieving good IOL fixation with firm haptic fixation.

Motorized injector-assisted intrascleral intraocular lens fixation

For eyes with deficient capsular support, intraocular lens (IOL) implantation has long been a technical challenge. Recently, intrascleral fixation of the haptics of a three-piece posterior chamber IOL has become a popular option. In this procedure, externalization of the leading haptic during IOL injection is a stressful step. We present a modified technique to improve the ease and safety of this step. Our modified technique involves IOL injection with a motorized injector with several important modifications described here. With these modifications, a surgeon can easily maintain the correct orientation of the IOL in a well-controlled manner during IOL injection. The records of 13 patients who underwent this technique were retrospectively evaluated. Corrected-distance visual acuity improved significantly after surgery (p<0.05). No postoperative retinal detachment, endophthalmitis, IOL decentration, or vitreous hemorrhage was noted during the follow-up period. In conclusion, the motorized injector-assisted intrascleral IOL fixation technique is a safe and effective alternative to the conventional procedure. This technique makes the process of leading haptic externalization easier and more controllable.