SURGICAL OUTCOME OF LATE IN-THE-BAG INTRAOCULAR LENS DISLOCATION TREATED WITH PARS PLANA VITRECTOMY

Comparison of the biometric parameters in patients with high myopia and anisometropia

BACKGROUND

To compare biometric parameters, especially lens parameters, in patients with high myopia and anisometropia.

METHODS

Patients with spherical equivalent greater than -6D and at least one eye with an axial length greater than 26 mm and a difference in binocular axial length greater than 2 mm were included in this study. In each patient, the eye with a relatively shorter axial length was assigned to Group S, and the other eye was assigned to Group L. In patients whose binocular axial length difference was greater than 4 mm, the eye with the shorter axial length was assigned to Group S1 and the other eye was assigned to Group L1. In patients whose shorter eye axial was less than 26 mm, the eye with the shorter axial was assigned to Group S2 and the other eye was assigned to Group L2. Central corneal thickness, corneal curvature radius, axial length, anterior chamber depth, lens thickness, white-to-white corneal diameter and the radius of the anterior and posterior lens capsules were compared between Group S and Group L, Groups S1 and L1, and Groups S2 and L2.

RESULTS

Sixty-four people were enrolled in the study. There were 26 people with an axial length difference more than 4 mm (Group S1 and Group L1) and 34 patients with an axial length less than 26 mm (Group S2 and Group L2). No significant differences were found in any parameters except axial length between Group S and Group L, Groups S1 and L1, or Groups S2 and L2 (p > 0.05).

CONCLUSIONS

The anterior parameters of patients with high myopia did not change with the axial length.

Sutured Scleral-Fixated Versus Anterior Chamber Intraocular Lens Implantation: A Meta-Analysis

BACKGROUND AND OBJECTIVE

No consensus exists on the comparative efficacy and safety of sutured scleral-fixated (SSF) and anterior chamber (AC) intraocular lens (IOL) implantation. We aim to compare outcomes of these two techniques.

PATIENTS AND METHODS

A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was conducted (2005 to 2020). Studies comparing SSFIOLs with ACIOLs were included. Outcomes included corrected distance visual acuity and complications. A meta-analysis was conducted with a random effects model. Weighted mean differences and risk ratios with 95% CIs were computed.

RESULTS

Seven hundred eighty-three eyes from nine studies were included. SSFIOLs had a significantly higher absolute postoperative spherical equivalent (weighted mean difference, 0.32; 95% CI, 0.03 to 0.60; P = .03; low certainty) and incidence of IOL decentration/subluxation (risk ratio, 2.69; 95% CI, 1.03 to 7.01; P = .04; moderate certainty) than ACIOLs. There was no difference in final corrected distance visual acuity (P = .26).

CONCLUSIONS

SSFIOLs have a higher absolute postoperative spherical equivalent and incidence of IOL decentration/subluxation than ACIOLs. Future prospective studies are needed to confirm these findings. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:12-21.].

Trocar blade-assisted scleral fixation for an incomplete dislocated intraocular lens

An incomplete dislocated intraocular lens (IOL) is often treated with IOL exchange because the IOL subluxates posteriorly during surgery and makes it difficult to fixate the IOL in situ. A trocar blade used for 23-gauge vitrectomy was used to lift and stabilize the IOL-capsular complex. The IOL can then be fixated using a suture loop fixation technique, which was originally limited to patients with decentered IOL. The advantage of this technique is that it allows the remaining zonular fibers and IOL to be preserved. The modified technique using a trocar blade to assist scleral fixation allows the incomplete dislocated IOL to be retrieved and fixated with a simplified surgical procedure.

Late in-the-bag intraocular lens dislocation

This review aimed to evaluate the cumulative incidence, patient characteristics, predisposing conditions, and treatment outcomes for late in-the-bag intraocular lens (IOL) dislocation. Literature searches in PubMed (MEDLINE), Embase, and Cochrane Library Central database identified 1 randomized clinical trial, 1 prospective case series, 2 prospective cohort studies, and 36 retrospective studies of this condition, which showed that the cumulative incidence was 0.5% to 3%, it occurred on average 6 to 12 years after cataract surgery, and mean patient age was 65 to 85 years. Pseudoexfoliation syndrome, myopia, and previous vitreoretinal surgery were the most common predisposing conditions. Studies indicated that IOL repositioning and IOL exchange provided similar visual outcomes and were equally safe. The long-term visual outcome seemed satisfactory. However, the quality of evidence regarding treatment was in general quite low. More studies of late in-the-bag IOL dislocation are needed, and in particular, different surgical techniques should be included in high-quality clinical trials.

FIL-SSF Carlevale intraocular lens for sutureless scleral fixation: 7 recommendations from a serie of 72 cases. MICA study (Multicentric Study of the Carlevale IOL)

PURPOSE

Lacking a standard technique, the surgical management of aphakia without capsular support remains to be optimized. The goal of this study is to analyze results for the Carlevale FIL-SSF intraocular lens and propose surgical recommendations.

PATIENTS AND METHODS

The P1.5 Collective performed a retrospective analysis, with a minimum follow-up of 6 months, of the records of 72 implantations of the Carlevale FIL-SSF intraocular lens, specifically designed for sutureless scleral fixation in the ciliary sulcus.

RESULTS

The most common indication was exchange of a posterior chamber intraocular lens (70.8%). The surgery lasted a mean of 53.4minutes due to the creation of scleral flaps. The implant was damaged in 12.5% of cases. Visual acuity was improved in 83.3% of cases. The postoperative spherical equivalent was -0.3 diopters, with no change in corneal astigmatism. The implant was centered and stable in all cases. Two cases (2.8%) of cystoid macular edema were observed and resolved over six months.

DISCUSSION

A number of advantages of the Carlevale FIL-SSF intraocular lens make it a safe and effective solution for correction of aphakia in the absence of capsular support. It requires a longer than usual surgical procedure, and the implant must be handled with care. From their experience, the authors propose 7 recommendations to accelerate the learning curve.

CONCLUSION

In light of the results of this study, we propose the Carlevale FIL-SSF intraocular lens as the new standard for the correction of aphakia without capsular support, but other studies are necessary to determine its exact place within the heirarchy of other available techniques.

Ab externo approach to treat bilateral haptic extrusion secondary to scleral erosion of an intrascleral suture-less fixated Carlevale intraocular lens: Repositioning of intrascleral suture-less fixated IOL

Surgical management of haptic extrusion of an intrascleral suture-less fixated Carlevale intraocular lens (IOL) (FIL-SSF Carlevale lens, Soleko, Italy) by repositioning the IOL without lens extraction was reported.The patient presented an early extrusion of both IOL harpoons just 4 weeks after the initial surgery. New scleral flaps were created 30° superior to the nasal harpoon and 30° inferior to the temporal harpoon, so the IOL was rotated clockwise. Each haptic was grasped with a 25G forceps and introduced into the vitreous cavity and regrasped with another forceps through a new port, 1.5 mm posterior to the limbus, and underneath a new scleral flap.The Carlevale lens is a specially designed IOL for suture-less intrascleral fixation with excellent anatomic and visual results but may also show specific complications. To our knowledge, this is the first report how to efficiently manage harpoon erosion using this simple technique.

Pars plana vitrectomy for posteriorly dislocated intraocular lenses: risk factors and surgical approach

PURPOSE

To present updated risk factors, anatomical and visual outcomes and a surgical approach to posteriorly dislocated intraocular lenses (IOL).

METHODS

A retrospective case series review of patients presenting with posteriorly dislocated IOL to the vitreous was performed. All cases were managed surgically with pars plana vitrectomy (PPV) followed by IOL repositioning and refixation or IOL exchange. Clinical characteristics, risk factors for IOL dislocation, visual outcomes and intraoperative and postoperative complications were investigated.

RESULTS

Forty patients with posteriorly dislocated IOL underwent 3-port PPV and lens retrieval at an average of 6.5 years after cataract surgery. The main causes of IOL dislocation were previous PPV, myopia, pseudoexfoliation syndrome, ocular trauma and recurrent intravitreal injections. The existing IOL was repositioned and secured in 90% of the cases. Visual acuity improved in 34 patients, maintained in 5 and deteriorated in 1. All IOLs were central and stable at final follow-up.

CONCLUSION

Posterior intraocular lens dislocation is becoming more prevalent. The main underlying causes found in this series were previous vitrectomy, myopia and recurrent intra-vitreal substance injections. Visual acuity improved in most cases after lens repositioning; however visual outcome is often limited due to associated ocular co-morbidities despite adequate lens position. Despite complete lack of zonular support, a posteriorly dislocated IOL can often be preserved by repositioning and fixation of the lens in the posterior chamber. Pathologies primarily associated with this type of lens malposition include history of vitrectomy, high myopia and multiple intravitreal substance injections.

Posterior segment Intra-Ocular Implant (IOL) dislocation: Predisposing factors, surgical management, outcome analysis

PURPOSE

To evaluate the predisposing factors, management and visual prognosis of intraocular Lens (IOL) dislocation into the posterior segment.

METHODS

The cases of posterior IOL dislocation from January 2012 to May 2017 at 2 centers were reviewed. Only eyes with dislocations requiring IOL explantation or repositioning were included. Predisposing factors, interval between cataract surgery and IOL dislocation, circumstances of onset, management, and postoperative complications are reported.

RESULTS

72 eyes of 72 patients were included. The mean age was 67.6 years. 47 patients (68%) were men. The mean time interval from cataract surgery to IOL dislocation was significantly shorter in the out-of-the bag group than the in-the-bag IOL dislocation group (3.8 months vs 132 months, P=0.002). Predisposing factors for out-of-the-bag IOL dislocation were mainly capsular rupture and/or zonular dehiscence (83%) after complicated cataract surgery. The predisposing factors for in-the-bag IOL dislocation were high myopia (40%), pseudoexfoliation syndrome (40%), previous vitrectomy (38%), or Marfan syndrome (3%) with uneventful cataract surgery. The type of luxated implant was mainly a 3-piece foldable IOL (50%), followed by foldable one-piece IOL (28%) and a rigid one-piece IOL (17%). Most cases of posterior chamber IOL dislocation occurred spontaneously (80%) without a trigger event. Management consisted of a posterior approach in 24 cases (33%) or an anterior approach in 48 cases (67%), associated with IOL repositioning in 20 eyes (28%), and IOL replacement in 34 eyes (47%). Finally, 18 eyes (25%) were left aphakic. Postoperative complications occurred in 7 cases (9.7%).

CONCLUSIONS

Predisposing factors and time from cataract surgery to IOL dislocation were different for out-of-the bag versus in-the-bag IOL dislocation. Management of IOL dislocation varied considerably, depending on surgeon preference and experience. Surgery for IOL dislocation significantly improved best corrected visual acuity and was associated with a low complication rate.

Management of subluxed and dislocated intraocular lenses in patients with uveitis: a practical approach

PURPOSE

To describe practical approaches to the management of subluxed or dislocated intraocular lenses (IOL) in patients with uveitis.

PATIENTS AND METHODS

Retrospective case series from a specialist uveitis clinic.

RESULTS

Fifteen IOLs in 13 patients were subluxed inferiorly (12) or dislocated into anterior chamber (2) or vitreous (1) at a mean delay of 12 years after cataract surgery. Six eyes required vitrectomy and seven IOL explantation. A dislocated IOL was repositioned by scleral fixation in one, and a new IOL was implanted in three (two scleral-sutured, one iris-claw). Eight were observed without surgery and 7 were left functionally aphakic (4 corrected with contact lens). The mean final best-corrected visual acuity was 0.6 LogMAR.

CONCLUSIONS

There are several management choices for IOL dislocation which should take into account the degree of uveitis, patient age and expectations. We present a pragmatic approach: surgery can often be avoided in this high-risk group.

Cost-effectiveness analysis in a randomized trial of late in-the-bag intraocular lens dislocation surgery: repositioning versus exchange

PURPOSE

To compare the cost-effectiveness of two operation methods for late in-the-bag intraocular lens (IOL) dislocation.

METHODS

In this randomized clinical trial, 104 patients were randomly assigned to IOL repositioning by scleral suturing (n = 54) or IOL exchange with a retropupillary iris-claw lens (n = 50). A cost-effectiveness analysis (CEA) was performed in conjunction with previously published 6-month efficacy and safety results. An incremental cost-effectiveness ratio was calculated as the cost difference between the operation groups relative to their difference in postoperative corrected distance visual acuity (CDVA) (mean and 95% confidence interval: minimum and maximum), reported as the cost difference in United States Dollars ($) per logMAR difference.

RESULTS

Exchange surgery was $281.20 ± 17.66 more expensive than repositioning, mainly explained by the new IOL and the frequent use of anterior vitrectomy. A previous trial publication revealed no significant difference in the 6-month postoperative CDVA between the groups. In the CEA, the mean group difference yielded an incremental cost-effectiveness ratio of -$281.20 per -0.11 logMAR (-$1108/QALY) in favour of repositioning, ranging from -$281.20 per -0.29 logMAR (-$406/QALY) in favour of repositioning to +$281.20 per -0.08 logMAR (+$1522/QALY) in favour of exchange. The CEA did not include the mean 9.5 min shorter operation time for exchange.

CONCLUSION

Repositioning tended to be more cost-effective than exchange; however, this is modified if also considering the operation time. Overall, it seems the cost-effectiveness is not alone sufficiently different to recommend one of the operation methods over the other for late in-the-bag IOL dislocation.

Long-Term Outcomes after Surgery for Late In-The-Bag Intraocular Lens Dislocation: A Randomized Clinical Trial

PURPOSE

To compare the long-term efficacy and safety of 2 operation methods for late in-the-bag intraocular lens (IOL) dislocation.

DESIGN

Prospective, randomized, parallel group surgical clinical trial.

METHODS

During a 3-year period, 104 patients (104 eyes) were assigned one group for IOL repositioning by scleral suturing (n = 54) or one group for IOL exchange by retropupillary fixation of an iris claw IOL (n = 50). A single surgeon performed all operations using an anterior approach. Patients were examined before surgery and at 6 months and 1 and 2 years after surgery. The present study included the 66 patients (63%) who completed the 2-year follow-up, and the main outcaome measurement was corrected distance visual acuity (CDVA) 2 years after surgery.

RESULTS

After 2 years, the mean CDVA was 0.20 ± 0.29 logarithm of the minimum angle of resolution (logMAR) units (range, -0.18 to 1.10) in the repositioning group and 0.22 ± 0.30 logMAR (range, -0.10 to 1.22) in the exchange group (P = .69). A CDVA of 20/40 or better was achieved by 76% of all patients. Four eyes (12%) had cystoid macular edema in the repositioning group compared with 5 eyes (15%) in the exchange group. Two eyes underwent redislocation (1 in each group). There were no cases of endophthalmitis or retinal detachment.

CONCLUSIONS

There were no significant differences between the visual acuity using IOL repositioning and that using IOL exchange 2 years after surgery. The two methods were equally efficient and safe from a long-term perspective and are both considered acceptable treatments.

Secondary intraocular lens implantation: a large retrospective analysis

PURPOSE

To investigate preoperative ocular risk factors and indications for secondary intraocular lens (IOL) implantation and compare postoperative complications, visual and refractive outcomes in a tertiary referral center.

METHODS

Patients older than 14 years that underwent secondary IOL implantation and had a minimum follow-up of 3 months were enrolled in this retrospective case series. Preoperative ocular risk factors, indications for surgery, postoperative complications, and visual and refractive outcomes including prediction error (PE) and absolute error (AE) were evaluated. IOLs were fixated in following positions: anterior chamber (AC), retropupillary iris-claw (IC), sulcus, and capsular bag or sclera.

RESULTS

One-hundred eighty-two eyes of 174 patients with mean follow-up of 17 ± 13.6 months were evaluated. Leading cause for surgery was IOL dislocation (75%), followed by secondary aphakia (19%) and IOL opacifications (6%). Previous vitrectomy was the major preoperative ocular risk factor (43%). Mean corrected distance visual acuity improved from preoperative 0.68 ± 0.55 to 0.42 ± 0.31LogMAR by the last follow-up (p = 0.001). PE and AE differed highly depending on the indication for surgery (p = 0.041 and p = 0.008, respectively) and the IOL fixation (p = 0.011 and p = 0.028, respectively), with IC-IOLs showing the lowest PE and AE. Postoperative AC-hemorrhage occurred mainly after IC-IOLs (p = 0.003), and postoperative hypotony was significantly higher in eyes with previous uveitis (p = 0.026).

CONCLUSIONS

Previous vitrectomy seems to be a major underreported risk factor in eyes that undergo secondary IOL implantation. Refractive outcomes depend on indication for surgery and fixation type, with retropupillary IC-IOLs providing the best refractive results, though not statistically significant compared to other IOL positions.

Analysis of retinal and optic nerve electrogenesis dynamics after vitrectomy for complicated catarct surgery

Background. The article presents impact results of vitrectomy for complicated cataract surgery on retinal and optic nerve electrogenesis. Materials and methods. 30 patients (30 eyes) with history of dropped nucleus (1st group) or intraocular lens dislocated into the vitreous cavity after phacoemulsification (2nd group) underwent electrophysiological examination before vitrectomy, and on Day 1, Day 3, Day 7, Day 14, Day 30, Day 60, and Day 180 after surgery. Results. In the 1st and 2nd groups, on the 1st day after vitrectomy, we observed a significant decrease in retinal and optic nerve electrogenesis in comparison to normal indices (p > 0.01); to Day 180, electrophysiologic indices returned to normal values. In the 1st group, baseline retinal and optic nerve electrogenesis was decreased in comparison to normal parameters. In the 1st and 2nd groups, the electrogenesis of photoreceptors recovered twice as rapidly, as that of bipolar cells; papillomacular bundle neurons were more resistant to vitrectomy. Conclusion. Thus, the presence of lens nucleus fragments in the vitreous cavity results in a reliable inhibition of the retinal and optic nerve electrogenesis due to phacotoxic effect. Vitrectomy causes a short-term depression of the retinal and optic nerve electrogenesis, followed by normalization of indices to Day 180. Photoreceptors have greater rehabilitation activity than bipolar cells. The neurons of axial topographic orientation have the highest resistance to vitrectomy impact.

The Effect of Anterior Capsule Polishing on Capsular Contraction and Lens Stability in Cataract Patients with High Myopia

Purpose

To evaluate the effect of anterior capsule polishing in patients with high myopia after cataract surgery.

Setting

The Eye Hospital of Wenzhou Medical University, Zhejiang, China.

Design

Prospective study.

Methods

High myopic patients with a bilateral cataract who underwent phacoemulsification with 360° anterior capsular polishing in one eye and without polishing in the contralateral eye were recruited. The following parameters were recorded at 1, 3, and 6 months postoperatively, including the area and diameter of the anterior capsule opening (area and D), IOL tilt and decentration, refraction, and postoperative aqueous depth (PAD).

Results

Paired samples of 38 eyes of 19 patients were enrolled. The area decreased significantly in both the polished group and unpolished group, whereas the diameter reduced more in the unpolished group. The IOL tilt and decentration at 3-month and 6-month follow-up showed significant differences between two groups. In the unpolished group, the IOL decentration firstly appeared between one-month to three-month visit, while the refraction error, PAD, and IOL tilt were significantly different between the three-month and six-month visits.

Conclusion

360° anterior capsule polishing can effectively reduce the extent of the anterior capsule contraction and increase the stability of IOL. The study was registered at http://www.clinicaltrials.gov, and the clinical trial accession number is NCT 03142269.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Net technique for intraocular lens support in aphakia without capsular support

Background

This paper describes a modified surgical technique for intraocular lens implantation in aphakic eyes with no capsular support.

Methods

Retrospective case series. Seventeen eyes of 17 aphakic patients with no capsule support underwent intraocular lens (IOL) implantation using a standardized technique in which a net was created at the ciliary sulcus plane with two threads forming a net pattern. The net was used as support for the IOL. Follow-up ranged from 6 to 38 months, with an average of 23 months.

Results

In all cases, the IOL was safely implanted and remained stable during the follow-up. In 16 eyes, the IOL remained well centered; in one eye, slight decentration was observed. Distance-corrected visual acuity improved by a mean of 4 lines, from 1.13 (LogMAR) to 0.52 (P = 0.01).

Conclusion

This technique might be especially useful in cases of insufficient capsular support associated with tissue loss or iris atrophy. In these cases, iris fixation is not feasible; thus, the only surgical alternative is IOL scleral fixation.

Electronic supplementary material

The online version of this article (doi:10.1186/s40942-017-0085-8) contains supplementary material, which is available to authorized users.

Characteristics of patients with spontaneous dislocation of in-the-bag intraocular lens after pars plana vitrectomy

PURPOSE

To determine the characteristics of eyes with late in-the-bag dislocation of an intraocular lens (IOL) after pars plana vitrectomy (PPV).

METHODS

Fourteen eyes of 14 patients with a dislocated IOL after PPV were studied retrospectively. The data collected from the medical charts included the age, sex, history of eye diseases, axial length, and interval from PPV to time of IOL dislocation. The surgical procedures used during the PPV were also recorded.

RESULTS

Seven eyes had undergone PPV for rhegmatogenous retinal detachment; 6 eyes, for proliferative diabetic retinopathy; and 1 eye, for retinal vein occlusion. The average interval between the PPV and the diagnosis of the dislocated IOL was 6.2 years (range 2.3-10.1 years). In all eyes, the peripheral vitreous was thoroughly removed with scleral depression during the PPV.

CONCLUSIONS

The IOL dislocation was most likely caused by damage to the zonular fibers by the peripheral vitrectomy with scleral depression.