One-year outcomes of eyes treated with a sutureless scleral fixation technique for intraocular lens placement or rescue

Scleral-fixated intraocular lens implantation with "irregular, knotless, zigzag-shaped scleral tunnel suture technique" combined with pars plana vitrectomy or anterior vitrectomy

PURPOSE

This study aims to introduce a new suture method and report surgical outcomes of patients who underwent scleral-fixated intraocular lens (SF-IOL) implantation combined with either pars plana vitrectomy (PPV) or anterior vitrectomy (AV).

METHODS

Twenty-three eyes performed SF-IOL implantation combined with PPV (Group 1), and 34 eyes performed SF-IOL implantation combined with AV (Group 2) were included in the study prospectively. The SF-IOL, either polymethyl methacrylate or foldable IOL, was sutured into the sclera using PC-9 sutures in an irregular, knotless, and zigzag-shaped manner. The scleral tunnel was approximately 12-15 mm long, with at least four sharp edges. Suture tips were trimmed within the scleral tunnel. Postoperative outcomes and complications were evaluated.

RESULTS

Both groups showed no complications such as suture tip expulsion, suture reaction, IOL dislocation, or increased intraocular pressure during postoperative visits. Group 1 exhibited a statistically significant improvement in visual acuity compared to preoperative values (P = 0.036 for the 1st month, <0.001 for the 3rd month). Similarly, Group 2 demonstrated a statistically significant improvement in visual acuity compared to the preoperative period (P = 0.001 for the 1st month, <0.001 for the 3rd month).

CONCLUSION

The "irregular, knotless, and zigzag-shaped scleral tunnel suture technique" yielded favorable results in terms of IOL stability and visual acuity. This technique can be safely employed in patients undergoing SF-IOL implantation combined with PPV or AV.

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.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

A novel Yamane technique modification: Reverse intraocular lens implantation for simplifying trailing haptic insertion

We described a modified Yamane technique for simplifying trailing haptic insertion in aphakia correction. In Yamane intrascleral intraocular lens (IOL) implantation technique, trailing haptic implantation is challenging for many surgeons. This modification provides an easier and safer way of trailing haptic insertion into the needle tip and decreases the possibility of bending or breaking the trailing haptic.

Real world outcomes of sutureless and glueless sclerally fixated intraocular lens implantation

PURPOSE

To report the outcomes of sutureless intrascleral fixation of a 3-piece intraocular lens in the ciliary sulcus, in a large cohort of patients with aphakia of various aetiology METHODS: Retrospective, non-comparative, single centre interventional study of 250 aphakic eyes of various causes, which underwent sutureless and glueless intrascleral fixation of 3-piece intraocular lens (IOL). All patients were required to have at least 3 months of follow up post procedure to be included in the study. Anatomical and functional outcomes obtained were statistically analysed for significance.

RESULTS

A total of 250 eyes of 246 patients were included in the study population. The average age was 56.5 years ± 16.4 (range 6-86 years). The mean best-corrected visual acuity (BCVA) significantly improved from 0.74 ± 0.6 logMAR (approx. Snellen equivalent 20/110) to 0.48 ± 0.36 logMAR (approx. Snellen equivalent 20/60), (p < 0.001) following surgery. Early postoperative complication (<2 weeks) included hypotony (n = 10, 4%), ocular hypertension (n = 38,15.2%) and vitreous haemorrhage (n = 50, 20%). Late complications included retinal detachment (n = 14, 5.6%%), cystoid macular oedema (n = 24, 9.6%), scleral erosion (n = 1, 0.4%), haptic extrusion to subconjunctival space (n = 3, 1.2%) and IOL subluxation or dislocation (n = 5, 2%) CONCLUSION: This cost-effective and easier technique of sutureless scleral fixated 3-piece IOL implantation provided good visual acuity outcomes in a large cohort of patients and was well tolerated.

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.

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

Background

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

Purpose

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

Methods

Retrospective cohort study of consecutive cases.

Results

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

Conclusion

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

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.

Scleral Fixation of Intraocular Lens in Aphakic Eyes without Capsular Support: Description of a New Technique

Purpose

To study the efficacy and safety of a modified trans-scleral intraocular lens (IOL) fixation technique in aphakic eyes when performed by ophthalmologists in training.

Methods

The study was conducted in an institutional setting that included 43 surgeries performed by surgeons training in small incision cataract surgeries. The data were analyzed for stability and position of IOL, refractive changes, best-corrected vision, and associated complications.

Results

Mean age of the subjects was 53.8 ± 18.5yrs (range 6–81yrs). Surgical aphakia (58.14%) was the most common cause. The corrected distance visual acuity improved significantly at six weeks (p = 0.0003). The mean residual spectacle correction was +0.74 ± 1.2D spherical equivalent (cylinder −1.6±1.5D at 84 ± 50°) at the 6th-month follow-up (24.35 ± 6.71wks). Lens tilt on ultrasound biomicroscopy (kappa 0.762; p < 0.001) and the IOL centration (kappa 0.411; p = 0.001), assessed by two independent masked observers, were satisfactory at the 6th-month visit. Transient postoperative vitreous hemorrhage was the most common complication (46.5%). Cellular deposits on the IOL surface (18.6%), cystoid macular edema (11.6%), subconjunctival haptic exposure (4.66%), and haptic slippage (2.33%) were the other complications.

Conclusion

This method of trans-scleral IOL fixation is an effective rescue procedure for eyes with deficient capsular support when ophthalmologists perform in training.

TWENTY-FIVE AND TWENTY-SEVEN-GAUGE SUTURELESS INTRASCLERAL FIXATION OF INTRAOCULAR LENSES: Clinical Outcomes and Comparative Effectiveness of Haptic Flanging in a Large Single-Surgeon Series of 488 Eyes

PURPOSE

To describe the clinical outcomes and surgical technique in transconjunctival sutureless intrascleral fixation of intraocular lenses, including the effectiveness of haptic flanging and peripheral iridotomy.

METHOD

Retrospective series of patients who underwent sutureless intrascleral fixation of three-piece intraocular lenses by a single surgeon.

RESULTS

A total of 488 eyes were included in this study. Mean follow-up was 444 days. Mean preoperative best-corrected visual acuity was 20/355, and mean postoperative best-corrected visual acuity was 20/39 (P < 0.001). Intraocular lens dislocation occurred during the postoperative period in 67 (13.7%), with the majority (65.7%) occurring within 3 months after surgery. Dislocation occurred in 13 of 196 (6.6%) flanged haptics versus 54 of 292 (18.5%) unflanged haptics (P < 0.001). Reverse pupillary block occurred in 7 of 231 eyes (3.0%) without intraoperative peripheral iridotomy but only in 1 of 257 eyes (0.4%) with iridotomy (P = 0.0297). Other complications included haptic exposure (1.2%), retinal detachment (1.0%), and endophthalmitis (0.4%).

CONCLUSION

This is the largest reported series of sutureless intrascleral fixation of intraocular lenses using trocar cannulas. This technique is an effective surgical option with low complication rates. The authors recommend that haptic flanging and peripheral iridotomy be performed in all cases.

Clinical outcomes of combined pars plana vitrectomy and scleral fixation of the intraocular lens with a suspension bridge method in eyes with aphakia or insufficient capsular support

Purpose

To describe a modified technique of scleral fixation for intraocular lens (IOL) implantation and report the clinical outcomes of combined pars plana vitrectomy and scleral IOL fixation using the suspension bridge method.

Methods

This retrospective case series included 57 eyes (56 patients) of aphakia or phakic and pseudophakic eyes with insufficient capsular support that underwent IOL implantation or dislocated IOL repositioning with scleral fixation using the ‘suspension bridge’ method by a single surgeon between 1 July 2010 and 1 March 2019. Preoperative status, changes in visual acuity, refractive outcomes as spherical equivalent and related complications were assessed with a minimum follow‐up of 3 months.

Results

The mean follow‐up period was 25.5 ± 25.4 months. Preoperative visual acuity (logarithm of the minimum angle of resolution) was 1.32 ± 0.68 (20/400 Snellen), and it significantly improved to 0.80 ± 0.53 (20/125), 0.59 ± 0.56 (20/80) and 0.24 ± 0.37 (20/35) at 1 week, 1 month and 3 months, respectively (p < 0.001). Postoperative complications included corneal wound dehiscence (n = 1), vitreous incarceration (n = 1), optic‐iris capture (n = 6) and cystoid macular oedema (n = 1). The above‐mentioned complications were successfully corrected with simple procedures. However, one case of IOL dislocation required reoperation.

Conclusion

The modified technique of the suspension bridge method precludes the need for a scleral flap, with the advantage of easy adjustment of the IOL position. It is a simple and feasible technique with good surgical results and low complication rates.

Scleral-fixated intraocular lens implants-evolution of surgical techniques and future developments

Varied options are available for the implantation of secondary intraocular lens implants in the absence of zonular or capsular support. Loss of the capsule can occur in the context of complicated cataract surgery, trauma or inherited conditions such as Marfan syndrome or pseudoexfoliation. Approaches to overcome this include optical measures such as the use of spectacles or contact lenses, and surgical therapy incorporating the use of anterior chamber, iris-fixated or scleral-fixated lenses. Surgical techniques to implant scleral-fixated lenses have undergone various modifications, since the first publication of sutured intrascleral fixation described in the 1980s. However, despite the advances in surgical techniques, studies are limited either by their retrospective nature, small sample size and most importantly small duration of follow-up. This comprehensive review aims to amalgamate the evolution of various surgical techniques with regards to intrascleral lens fixation and suggests areas for future development.

Scleral fixation using a hydrophilic four-haptic lens and polytetrafluoroethylene suture

To assess the safety of scleral fixation using the Akreos AO60 intraocular lens (IOL) and Gore-Tex suture. Prospective evaluation of 20 patients who underwent scleral fixation of an Akreos AO60 with Gore-Tex. Patients presenting with aphakia or dislocated IOL without capsular support were enrolled in the study. Main outcome measures included visual acuity, endothelial cell density, and postoperative complications over 6 months of follow-up. Mean ± standard deviation (SD) uncorrected logMAR visual acuity improved from 1.92 ± 0.23 (20/1600 Snellen equivalent) preoperatively to 0.80 ± 0.56 (20/125) at 6 months postoperatively (p < 0.001). Mean ± SD best-corrected visual acuity (BCVA) logMAR was 0.43 ± 0.23 preoperatively and 0.37 ± 0.24 (20/50) at 3-6 months postoperatively (p = 0.312). The mean ± SD endothelial cell density was 1740.50 ± 522.92 cells/mm² and 1187.19 ± 493.00 cells/mm² (p < 0.001) pre and postoperatively, respectively. Mean ± SD postoperative spherical equivalent was - 1.12 ± 1.50D. Postoperative complications included exposure of suture in 40% of the patients, hypotony in 15%, ocular hypertension in 10%, transient vitreous hemorrhage in 10%, retinal detachment in 5%, and transient lens opacification in 5%. Scleral fixation with an Akreos AO60 and Gore-Tex appears generally safe. However, given the high incidence of suture erosion observed, the use of scleral flaps or rotating and burying the knots is recommended in order to reduce the risk of this complication.

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.

REFRACTIVE OUTCOMES AFTER SUTURELESS INTRASCLERAL FIXATION OF INTRAOCULAR LENS WITH PARS PLANA VITRECTOMY

PURPOSE

To evaluate the refractive outcomes of sutureless intrascleral fixation of intraocular lens with pars plana vitrectomy.

METHOD

A retrospective, consecutive cohort from multiple surgeons of a single center. Primary outcomes included spherical equivalent (SEQ) and change in SEQ (ΔSEQ) from preoperative intraocular lens power calculations. Secondary outcomes included refractive outcomes of fixation at 1.5 mm, 2 mm, and 2.5 mm posterior to the limbus.

RESULTS

In total, 84 eyes of 80 patients were included. Preoperative logarithm of the minimum angle of resolution visual acuity was 1.21 ± 0.68 (20/320). The mean follow-up time was 2.33 ± 1.36 years. At 3 months, SEQ was -0.50 ± 1.59 D and ΔSEQ was 0.58 ± 1.49 D. At 1 year, SEQ was -0.55 ± 1.32 D and ΔSEQ was 0.39 ± 1.42 D. At the last follow-up, logarithm of the minimum angle of resolution visual acuity was 0.34 ± 0.34 (20/40), SEQ was -0.51 ± 1.44 D, and ΔSEQ was 0.57 ± 1.27 D. There was no difference between SEQ or ΔSEQ throughout follow-up (P = 0.97 and P = 0.96, respectively). At fixation distances more posterior to the limbus, mean ΔSEQ was more hyperopic at 3 months, 1-year, and the last follow-up (P = 0.02, P = 0.01, and P = 0.006, respectively).

CONCLUSION

Refractive outcomes for sutureless intrascleral fixation of intraocular lens with pars plana vitrectomy were favorable and showed stability postoperatively. These results may aid surgeons achieve better desired refractive outcomes for this technique.

27-GAUGE SUTURELESS INTRASCLERAL FIXATION OF INTRAOCULAR LENSES WITH HAPTIC FLANGING: Short-Term Clinical Outcomes and a Disinsertion Force Study

PURPOSE

To determine whether haptic flanging during 27-gauge sutureless intrascleral fixation of intraocular lenses (IOLs) increases IOL stability and to report the short-term clinical outcomes of sutureless intrascleral surgery using 27-gauge trocar cannulas with haptic flanging.

METHODS

Retrospective surgical case series using live and cadaveric human eyes.

RESULTS

In the cadaveric experiment using five eyes, flanged haptics required more force to dislocate the IOL compared with unflanged haptics (14 ± 4 vs. 3 ± 1 g, P = 0.03). The clinical series included 52 eyes from 52 patients. The average age at the time of surgery was 73 ± 14 years, with a mean follow-up of 27 ± 19 weeks. The most common indication for surgery was IOL dislocation/subluxation (n = 43, 83%). Mean visual acuity improved from 20/140 preoperatively to 20/50 at postoperative Month 1 (P < 0.001). The most common postoperative issue was intraocular pressure elevation (n = 12, 23%). Two patients (4%) needed a reoperation for IOL dislocation.

CONCLUSION

Haptic flanging during 27-gauge sutureless intrascleral surgery creates a more stable scleral-fixated IOL compared with the traditional unflanged technique based on a cadaveric human eye study. In addition, this variation of sutureless intrascleral surgery seems safe and effective for patients who require secondary IOLs.

A Simple Modified Way of Glueless, Sutureless Scleral Fixation of an IOL: A Retrospective Case Series

PURPOSE

To evaluate the outcome and viability of a modified self-sealing scleral pocket technique for scleral fixation of an intraocular lens (IOL).

DESIGN

Retrospective interventional case series.

METHODS

A retrospective, interventional case series in which 81 eyes underwent this modified technique, performed in the previous 4 years. Cases included a dislocated IOL and an absent posterior capsule or subluxated cataract. Two diagonally opposed paralimbal, curved self-sealing scleral pockets were made 3 mm away from the limbus along with a vitrectomy. A multipiece IOL was used, and the haptics were fixed under the scleral pockets inside a linear scleral tunnel underneath the superficial scleral flap. The conjunctiva was opposed by using cautery. Postoperatively, anterior segment optical coherence tomography (AS-OCT) was performed in order to detect intrascleral hyper-reflective cross-section of the haptics and optic tilt. The optic position was re-evaluated using ultrasound biomicroscopy (UBM). Main outcomes were mean pre- and postoperative best corrected visual acuity (BCVA), postoperative astigmatism. Postoperative AS-OCT was performed to detect the position of the haptics and optics. UBM was done to recheck any optic tilt.

RESULTS

Mean pre- and postoperative BCVA were LogMAR 1.2 ± 0.59 and LogMAR 0.47 ± 0.3 (P < 0.001). Mean postoperative astigmatism was 1.27 ± 1.02 Dcyl. In AS-OCT, an intrascleral hyper-reflective shadow signified stable haptics without any optic tilt. UBM also showed a stable position of the IOL optic without any tilt.

CONCLUSIONS

This modified, simple way of scleral fixation of an IOL decreases the duration of surgery with minimal complication.

PARS PLANA VITRECTOMY WITH ANTERIOR CHAMBER VERSUS GORE-TEX SUTURED POSTERIOR CHAMBER INTRAOCULAR LENS PLACEMENT: Long-Term Outcomes

PURPOSE

To compare clinical outcomes of combined pars plana vitrectomy (PPV) with anterior chamber intraocular lens (ACIOL) placement versus scleral fixation of a posterior chamber intraocular lens (PCIOL) using Gore-Tex suture.

METHODS

Retrospective, interventional case series of eyes undergoing combined PPV and IOL placement for retained lens material, aphakia, or dislocated IOL. Eyes with history of amblyopia, corneal opacity, retinal, or optic nerve disease were excluded. Outcome measures were change in visual acuity and occurrence of postoperative complications with minimum follow-up of 1 year.

RESULTS

Sixty-three eyes of 60 patients were identified. Thirty-three eyes underwent combined PPV and ACIOL placement and 30 eyes underwent combined PPV and scleral fixation of a PCIOL using Gore-Tex suture. Mean follow-up was 502 ± 165 days (median 450, range 365-1,095 days). In the ACIOL group, mean visual acuity improved from 20/914 preoperatively to 20/50 postoperatively (P < 0.001). In the scleral-fixated PCIOL group, mean visual acuity improved from 20/677 preoperatively to 20/46 postoperatively (P < 0.001). No difference in visual acuity was noted between groups at 1-year (P = 0.91) or final follow-up (P = 0.62). Regarding postoperative complications, eyes undergoing ACIOL placement had a significantly higher rate of transient corneal edema (30.3 vs. 6.7%, P = 0.02) compared with eyes undergoing scleral fixation of a PCIOL.

CONCLUSION

Combined PPV with ACIOL placement or scleral fixation of a PCIOL with Gore-Tex suture were well tolerated. The techniques resulted in similar visual outcomes at minimum follow-up of 1 year.

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.

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Flapless and sutureless intrascleral fixation of posterior chamber intraocular lens for correction of aphakia

A new intrascleral fixation technique for a standard 3-piece posterior chamber intraocular lens (PC IOL) using a simple guide is described. To secure the haptics, 27-gauge scleral tunnels are created. Both haptics are secured extraocularly. The leading haptic of the PC IOL placed in the cartridge is released partly and introduced into the lumen of the guide. The PC IOL is inserted into the eye, and the leading haptic is externalized by pulling the guide gently through the 27-gauge sclerotomy site. The trailing haptic is externalized using the same procedure. This technique facilitates achieving minimally invasive sutureless intrascleral PC IOL fixation.

Scleral Fixation of Intraocular Lenses with Gore-Tex Suture: Refractive Outcomes and Comparison of Lens Power Formulas

PURPOSE

To report refractive outcomes of scleral-fixated intraocular lens (IOL) implantation with Gore-Tex (W.L. Gore & Associates, Newark, DE) suture and combined pars plana vitrectomy and compare predicted refractive outcomes among 5 IOL power calculation formulas.

DESIGN

Retrospective case series.

PARTICIPANTS

Patients undergoing scleral-fixated IOL implantation with Gore-Tex suture at our institution between January 2015 and June 2018.

METHODS

Comparison of preoperative biometrics with postoperative refraction and calculation of predicted refractive outcome with 5 different IOL formulas.

MAIN OUTCOME MEASURES

Prediction error and absolute error to compare postoperative refraction with refraction predicted by lens power calculation formulas.

RESULTS

Thirty-one eyes of 31 patients were included. All power calculations assumed in-the-bag position of the IOL. The Akreos A060 (Bausch & Lomb, Rochester, NY) was implanted in 23 eyes and the CZ70BD (Alcon, Fort Worth, TX) in 8 eyes, and all lenses were sutured 3 mm behind the limbus. Average postoperative spherical equivalent (SE) was -0.79±0.95 diopters (D). Average prediction error (postoperative SE refraction minus target refraction) was -0.19±0.72 D. Postoperative SE was within 1.0 D of target in 25 of 31 patients (81%) and 2.0 D of target in 31 of 31 patients (100%). The repeated-measures analysis of variance of absolute error by lens power formula was significant (P = 0.012), with Haigis demonstrating greater error. There was no significant difference among Barrett II, Sanders-Retzlaff-Kraff theoretical (SRK/T), Holladay 2, or Hoffer Q.

CONCLUSIONS

For eyes undergoing pars plana vitrectomy with scleral-sutured IOL implantation, assumption of in-the-bag IOL position when calculating lens power leads to acceptable refractive outcomes. Barrett II, SRK/T, Holladay 2, and Hoffer Q formulas were noninferior to each other.

Novel technique of sutureless glueless scleral fixated intraocular lens (SFIOL)

Purpose:

To report results of a novel technique for sutureless, glueless intrascleral fixation of three-piece posterior chamber intraocular lens (IOL) using 26-G needle for management of aphakia.

Methods:

In this prospective series, 30 eyes of 20 patients with aphakia, subluxated IOL, or crystalline lens were included. 26-G-needle-guided intrascleral fixation of three-piece posterior chamber IOL was performed according to the described technique. The patients were evaluated on day 2, 1 week, 6 weeks, and 3 months postoperatively for change in best-corrected visual acuity (BCVA), intraocular pressure (IOP), IOL centration, and any other complications. The postoperative tilt of the IOL was indirectly measured by determining the lenticular astigmatism which in turn was calculated by the difference between net corneal astigmatism and refractive astigmatism. Paired t-test was used to determine the significance of any association between the preoperative and postoperative BCVA and IOP. P < 0.05 was considered significant.

Results:

Of 30 eyes (n = 30 patients), 18 were surgical aphakia, 6 traumatic aphakia, 5 subluxated IOL, and 1 ectopia lentis (Marfan syndrome). The mean preoperative BCVA was 1.37 ± 0.37 (logMAR) and postoperative BCVA at 3 months was 0.37 ± 0.29 (logMAR). A significant improvement in the mean BCVA (P < 0.05) was observed after the procedure. The mean IOP preoperatively was 13.33 ± 4.18 and postoperatively at 3 months was 12.82 ± 3.97 (P > 0.05), which was not significant. None of the eyes developed any intraoperative and postoperative complications. The IOLs had appropriate centration and stability.

Conclusion:

We have developed this new technique for intrascleral IOL fixation which is quite simple, cost-effective, minimally invasive, neither requires glue nor suture and gives consistent outcome.

COMBINED PARS PLANA VITRECTOMY AND SCLERAL FIXATION OF AN INTRAOCULAR LENS USING GORE-TEX SUTURE: One-Year Outcomes

PURPOSE

To report the 1-year clinical outcomes of combined pars plana vitrectomy and ab externo scleral fixation of an intraocular lens using Gore-Tex suture.

METHODS

Retrospective, interventional case series. Outcome measures were change in visual acuity and occurrence of intraoperative and postoperative complications with minimum follow-up of 1 year.

RESULTS

Eighty-four eyes of 83 patients were identified. The mean best available visual acuity improved from 20/782 preoperatively to 20/65 postoperatively (P < 0.001). The mean follow-up was 598 ± 183 days (median 533 days, range 365-1,323 days). There were no intraoperative complications noted. A Bausch & Lomb Akreos AO60 intraocular lens was implanted in 77 eyes and an Alcon CZ70BD in 7 eyes. Postoperative complications included transient vitreous hemorrhage in six eyes (7.1%), cystoid macular edema in four eyes (4.8%), ocular hypertension in three eyes (3.6%), hyphema in two eyes (2.4%), and transient corneal edema in two eyes (2.4%). There were no cases of postoperative endophthalmitis, suture erosion/breakage, hypotony, retinal detachment, suprachoroidal hemorrhage, choroidal detachment, uveitis-glaucoma-hyphema syndrome, or persistent postoperative inflammation during the follow-up period.

CONCLUSION

Combined pars plana vitrectomy and ab externo scleral fixation of an intraocular lens with Gore-Tex suture was well tolerated at a minimum of 1-year follow-up. No suture-related complications were encountered.

Combined 23-gauge transconjunctival vitrectomy and scleral fixation of intraocular lens without conjunctival dissection in managing lens complications

Background

To evaluate the safety and efficacy of combined 23-gauge transconjunctival pars plana vitrectomy and scleral fixation of intraocular lens (IOL) without conjunctival dissection.

Methods

A retrospective study in Chang Gung Memorial Hospital, Keelung and Taoyuan, Taiwan. Patients receiving combined 23-gauge transconjunctival pars plana vitrectomy and scleral fixation of IOL without conjunctival dissection were enrolled. The ocular findings, causes of lens complication, surgical procedures, type of IOL used, and complications were documented.

Results

We included 40 eyes from 39 patients (27 male, 12 female) with a mean age of 59.5 [standard deviation (±) 14.8] years old. The mean follow-up duration was 6.8 ± 5.4 months. The cause of lens complications was ocular trauma in 24 (60%) eyes, cataract surgery complications in 11 (28%) eyes, and spontaneous subluxation of crystalline lens in 5 (13%) eyes. The overall best corrected visual acuity (BCVA) (logMAR) improved from 1.359 ± 0.735 to 0.514 ± 0.582 (p < 0.001). The BCVA also improved significantly in each group with different causes of lens complications. Preoperative BCVA was the only factor associated with the postoperative visual outcome (p = 0.008). Most surgery-related complications were self-limited, including mild vitreous hemorrhage (5%), microhyphema (5%), transient elevated intraocular pressure (3%), and transient hypotony (3%). Cystoid macular edema and IOL decentration was found in 3 (8%) eyes and 1 (3%) eye respectively.

Conclusions

Combined 23-gauge transconjunctival vitrectomy and scleral fixation of IOL without conjunctival dissection is effective and safe in managing a wide variety of lens complications, with good postoperative comfort and visual recovery.

Trial registration

Retrospective study, not applicable.

Electronic supplementary material

The online version of this article (10.1186/s12886-018-0776-4) contains supplementary material, which is available to authorized users.

[Outcomes of intraocular lens implantation in the absence of capsular support: a review of current literature]

Тhe prevalence of complications associated with the deficiency or absence of capsular support in cataract patients is 5-15%. Moreover, approximately 20% of patients have an inconspicuous zonular weakness, which is often left undetected preoperatively.

AIM

to classify and comparatively analyze the latest published data on the outcomes of various kinds of complicated cataract surgery.

MATERIAL AND METHODS

Analysis of available literature on the subject of research published in 2003-2016.

RESULTS

The method of sutured scleral fixation of the intraocular lens (IOL) is the most fully covered in the current literature. It has been used long enough and is, therefore, well tested. Its typical complications include sutures degradation, hemorrhage, and inflammation. Sutureless fixation of the IOL, which has become more common in recent years, is free of complications associated with degradation of the sutures. However, studies on the long-term results of this technique are few and most of them were conducted in a small clinical material.

CONCLUSION

Basing on the present analysis, one may conclude that at the current level of surgery, sutureless scleral and iridal fixation of the IOL is more preferable in terms of possible postoperative complications.

Surgical refixation of posteriorly dislocated intraocular lens with scleral-tuck technique

Purpose:

To report the outcomes of surgical refixation of posteriorly dislocated intraocular lens (IOL) using scleral-tuck method, and to compare the “scleral groove” and the “scleral flap” techniques used.

Study Design:

Single-center, retrospective, interventional, comparative study.

Methods:

Medical records of patients undergoing closed globe scleral refixation of posteriorly dislocated posterior chamber IOL (PCIOLs) by scleral-tuck method using two different techniques (”scleral groove” vs. “scleral flap” technique) were reviewed. This approach involved retrieving the dislocated PCIOL, externalizing the haptics through 2 sclerotomies created in paralimbal lamellar scleral grooves, or under lamellar scleral flaps and tucking the haptics into limbus-parallel scleral tunnels. No specific haptic architecture, haptic suturing, or large incisions were needed. Main outcome measures included best-corrected visual acuity (BCVA), final mean refractive error, and intra- and post-operative complications.

Results:

Thirteen eyes of 13 patients (scleral groove, n = 6; scleral flap, n = 7 eyes) with a mean follow-up of 20.6 months were included. BCVA in all eyes was maintained or improved postoperatively, with three eyes (23%) showing ≥2 line improvement. Median astigmatic error at 6-week follow-up was −1.25 D cylinder (range: −0.5 D–−2.0 D) which remained stable till final follow-up. All IOLs remained stable and well centered. None of the eyes had a recurrent dislocation, retinal detachment, endophthalmitis, or glaucoma. Both techniques were comparable in terms of postoperative BCVA, and refraction.

Conclusion:

Intrascleral haptic fixation by scleral-tuck method is reliable and effective for secure IOL refixation of posteriorly dislocated IOLs, providing good IOL centration and stability with minimal surgically-induced astigmatism. Both techniques (scleral groove and scleral flap) appear to have similar outcomes in the short term.

Scleral-Fixated Intraocular Lenses: Past and Present

Intraocular lenses (IOLs) can have inadequate support for placement in the capsular bag as a result of ocular trauma, metabolic or inherited conditions such as Marfan's syndrome or pseudoexfoliation, or complicated cataract surgery. Surgical options for patients with inadequate capsular support include alternative placement in the anterior chamber (ACIOLs), fixation to the iris, or fixation to the sclera. The surgical techniques for each of these approaches have improved considerably over the last several decades resulting in improved visual and ocular outcomes. If no capsular or iris support exists, the surgeon can fixate an IOL to the sclera or the patient can remain aphakic. IOLs can be fixated to the sclera using sutures or by tunneling the IOL haptics into the sclera without sutures. This review summarizes the pre-operative considerations, surgical techniques, outcomes, and unique complications associated with implantation of scleral-fixated IOLs.

Modified technique for transscleral fixation of posterior chamber intraocular lenses

Background

Suture exposure remains to be a potential problem of transscleral fixated posterior chamber intraocular lens (PCIOL). We report a modified technique to minimize the risk of suture exposure for the transscleral fixation of PCIOL.

Methods

The modified surgical technique is as following: at first, two 3 mm × 4 mm square scleral pockets were created from groove incisions at opposite positions. A straight needle attached to a 10–0 polypropylene suture was passed through one incision groove. Then, a 27-Gauge hollow needle passed through the opposite sclera incision bed was used to retrieve the straight fine needle via its barrel. The sutures were tied to themselves after one more bite on the scleral bed. At last, the suture ends were left long (about 4 mm) and laid flat into corresponding laminar scleral pockets. This modified technique of PCIOL was performed in 48 post-traumatic aphakic vitrectomized eyes from 48 patients (47 male, one female) with mean age of 34.8 ± 14.8 years. Main outcome measures included best corrective visual acuity (BCVA), IOL decentration, IOL tilt, and postoperative complications.

Results

The mean follow-up was 32.3 ± 10.8 months (3–67 months). The LogMAR BCVA remained stable, from a preoperative value of 0.46 ± 0.34 to postoperative 0.44 ± 0.34 (p = 0.69). Mild IOL tilt (5–10°) was observed in five eyes, and slight IOL decentration (0.5–1.0 mm) was seen in three cases. No case of suture exposure, suture breakage, IOL dislocation, or endophthalmitis was observed during the follow up period.

Conclusion

The modified technique allowed stable placement of PCIOLs in post-traumatic aphakic eyes with a wide range of follow-up. Our procedure might have the potential benefit to avoid suture exposure in scleral-fixated IOL implantation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12886-015-0118-8) contains supplementary material, which is available to authorized users.

Scleral fixation of intraocular lenses using Gore-Tex suture: clinical outcomes and safety profile

BACKGROUND/AIMS

To report the short-term safety profile and clinical outcomes of scleral fixation of intraocular lenses (IOLs) using Gore-Tex suture.

METHODS

Retrospective, interventional case series. 85 eyes of 84 patients undergoing ab externo scleral fixation of a Bausch and Lomb Akreos AO60 or Alcon CZ70BD IOL using Gore-Tex suture. Primary outcome measures were change in visual acuity and occurrence of intraoperative and postoperative complications with minimum follow-up of 90 days.

RESULTS

85 eyes of 84 patients were identified. Mean logarithm of the minimum angle of resolution visual acuity improved from 1.43±0.72 (20/538 Snellen equivalent) preoperatively to 0.64±0.61 (20/87 Snellen equivalent) postoperatively (p<0.001). Mean follow-up was 325 days (median 264 days, range 90-996 days). There were no intraoperative complications noted. Postoperative complications included hypotony in eight patients (9.4%), ocular hypertension in six eyes (7%), vitreous haemorrhage in six eyes (7%), hyphema in two eyes (2%), serous choroidal detachment in two eyes (2%), cystoid macular oedema in two eyes (2%) and corneal oedema in one eye (1%). There were no cases of postoperative endophthalmitis, suture erosion/breakage, retinal detachment, suprachoroidal haemorrhage, uveitis-glaucoma-hyphema syndrome or persistent postoperative inflammation in the follow-up period.

CONCLUSIONS

Ab externo scleral fixation of IOLs with Gore-Tex suture was well tolerated in all cases. No suture-related complications were encountered. This procedure led to improvement in visual acuity and was not associated with significant intraoperative or postoperative complications.

Scleral Fixation of Posteriorly Dislocated Intraocular Lenses by 23-Gauge Vitrectomy without Anterior Segment Approach

Background. To evaluate visual outcomes, corneal changes, intraocular lens (IOL) stability, and complications after repositioning posteriorly dislocated IOLs and sulcus fixation with polyester sutures. Design. Prospective consecutive case series. Setting. Institut Universitari Barraquer. Participants. 25 eyes of 25 patients with posteriorly dislocated IOL. Methods. The patients underwent 23-gauge vitrectomy via the sulcus to rescue dislocated IOLs and fix them to the scleral wall with a previously looped nonabsorbable polyester suture. Main Outcome Measures. Best corrected visual acuity (BCVA) LogMAR, corneal astigmatism, endothelial cell count, IOL stability, and postoperative complications. Results. Mean follow-up time was 18.8 ± 10.9 months. Mean surgery time was 33 ± 2 minutes. Mean BCVA improved from 0.30 ± 0.48 before surgery to 0.18 ± 0.60 (p = 0.015) at 1 month, which persisted to 12 months (0.18 ± 0.60). Neither corneal astigmatism nor endothelial cell count showed alterations 1 year after surgery. Complications included IOL subluxation in 1 eye (4%), vitreous hemorrhage in 2 eyes (8%), transient hypotony in 2 eyes (8%), and cystic macular edema in 1 eye (4%). No patients presented retinal detachment. Conclusion. This surgical technique proved successful in the management of dislocated IOL. Functional results were good and the complications were easily resolved.