Scleral fixation of intraocular lenses

Fusion-Flanged Intrascleral Intraocular Lens Fixation Technique: Simple, Safe, Efficient

PURPOSE

To develop a new, sutureless intrascleral intraocular lens (IOL) fixation technique based on the Yamane double-needle and Canabrava 4-flanged techniques.

METHODS

The Fusion-Flanged technique involves using a 7-0 polypropylene suture loop threaded through the eyelets of the IOL. Afterward, both ends of the suture are passed outside the eye through a 27-gauge needle. This technique creates a single flange by joining the 2 suture ends through handheld cautery, and this flange is then embedded into the scleral tunnel to securely fix the IOL in place.

RESULTS

This technique was performed on a total of 7 aphakic patients. Four of them had encountered complications following manual small incision cataract surgery, while the remaining 3 experienced complications after phacoemulsification. The results indicated a significant improvement in visual acuity, with mean preoperative and postoperative corrected distance visual acuities of 0.77 ± 0.11 and 0.27 ± 0.08 (logarithm of the minimum angle of resolution [logMAR] units), respectively.

CONCLUSIONS

The Fusion-Flanged intrascleral IOL fixation technique offers improvements in simplicity, safety, and the overall efficiency when compared to existing sutureless intrascleral fixation techniques. Notably, this technique is versatile and can be applied to both non-foldable and foldable IOLs.

Pars plana vitrectomy and scleral-fixated intraocular lenses: comparison of Gore-Tex suture and flanged intrascleral haptic fixation techniques

OBJECTIVE

To compare clinical outcomes of combined pars plana vitrectomy (PPV) and secondary scleral fixation of an intraocular lens (IOL) using Gore-Tex suture versus flanged intrascleral haptic fixation (FIHF) using double needles.

DESIGN

Single-centre retrospective cohort series.

PARTICIPANTS

Eyes undergoing PPV with simultaneous scleral fixation of an IOL.

METHOD

Eyes that underwent fixation of a Bausch & Lomb Akreos AO60 or enVista MX60E IOL using Gore-Tex suture or a Tecnis ZA9003 or Zeiss CT LUCIA 602 IOL using FIHF were included. The primary outcome was change from baseline visual acuity to postoperative month 3. Secondary outcomes included deviation from refractive target aim and rates of postoperative complications.

RESULTS

Seventy-nine eyes of 72 patients were included. Mean (±SD) follow-up was 16 ± 10.5 months (range, 4.5-45.2 months). Fifty-three eyes (67.1%) underwent Gore-Tex suture fixation, and 26 eyes (32.9%) underwent FIHF. Across all eyes, mean visual acuity improved from 1.30 ± 0.74 logMAR (20/399 Snellen equivalent) preoperatively to 0.36 ± 0.36 logMAR (20/45 Snellen equivalent) at 3 months (p < 0.001). No difference in visual acuity at month 3 was noted between the 2 techniques (p = 0.34). Mean deviation from refractive target aim was not significantly different between the Gore-Tex and FIHF groups (+0.14 ± 1.33 D vs -0.16 ± 0.88 D; p = 0.45). Reoperation rates were similar between groups (2 of 53 eyes in the Gore-Tex group vs 3 of 26 eyes in the FIHF group; p = 0.32).

CONCLUSION

Combined PPV and scleral fixation of IOLs with Gore-Tex suture and FIHF resulted in similar improvements in visual acuity. No significant differences in refractive outcome and postoperative complication profiles were noted.

Indications and Outcomes of Intraocular Lens Explantation in a Tertiary Eyecare Center in Hungary between 2006 and 2020

Purpose

Our study aimed to evaluate the indications and outcomes of intraocular lens (IOL) explantation surgeries in a tertiary eyecare center in Hungary.

Materials and Methods

This retrospective study included all IOL explantation surgeries performed between 2006 and 2020 at the Department of Ophthalmology of Semmelweis University, Budapest, Hungary. There were no exclusion criteria for this study. For each patient, the demographics, clinical history, preoperative status, indications for IOL explantation, and operative and postoperative details were reviewed. Primary outcomes included explantation indications and the type of secondary implanted IOL.

Results

A total of 161 eyes from 153 patients were included (96 males; 62.7%); age at the time of the IOL explantation was 65.0 ± 17.4 years. The mean time between primary cataract surgery and IOL explantation was 8.5 ± 7.7 years. In total, 139 (86.3%) PCIOLs and 22 (13.7%) ACIOLs were explanted. The main indications for IOL explantation were dislocation (n = 133; 95.7%) and refractive cause (n = 2; 1.4%) in the PCIOL group. Among ACIOL explantations, the main reasons were pseudophakic bullous keratopathy (n = 14; 63.6%), dislocation (n = 4; 18.2%), and refractive cause (n = 2; 9.1%). In the PCIOL group, 115 (82.7%) primary IOLs were implanted in the capsular bag, 16 (11.5%) were sulcus fixated, and 8 (5.8%) were scleral fixated. The most frequent ocular comorbidities were previous vitrectomy (n = 50, 31.1%), previous ocular trauma (n = 45, 28.0%), glaucoma (n = 16, 9.9%), pseudoexfoliation syndrome (n = 15, 9.3%), and high axial myopia (n = 14, 8.7%). The most commonly used secondary IOL implant was the prepupillary iris-claw IOL (n = 115, 73.7%), followed by the retropupillary iris-claw IOL (n = 32, 20.5%). Uncorrected visual acuity (UCVA) was significantly better following IOL exchange in the entire sample (1.57 ± 0.61 (range: 2.40-0.05) vs. 0.77 ± 0.56 (range: 2.40-0.00); p < 0.001). Best-corrected visual acuity (BCVA) was maintained or improved in 80.7% of cases after IOL explantation.

Conclusions

The most common indication for IOL explantation at a tertiary eyecare center in Hungary is IOL dislocation, followed by pseudophakic bullous keratopathy. Prepupillary and retropupillary iris-claw IOL are the most frequently used secondary implants and their use resulted in a significant UCVA improvement following IOL exchange.

Anterior scleral thickness in Marfan syndrome: A quantitative analysis

PURPOSE

To investigate the anterior scleral thickness (AST) in patients with Marfan syndrome (MFS).

METHODS

A prospective, cross-sectional study was conducted at the Department of Ophthalmology, Ghent University Hospital, Ghent, including patients with a genetically confirmed clinical diagnosis of MFS and age-, gender- and axial length-matched controls. Subjects with known corneal, conjunctival or scleral pathology and a history of ocular surgery, including pars plana vitrectomy, recent contact lens use or high-grade astigmatism were excluded. Subjects underwent non-cycloplegic autorefraction, Scheimpflug-based corneal tomography, axial length measurement and spectral-domain optical coherence tomography (OCT). AST was manually measured at 1 mm (AST1), 2 mm (AST2) and 3 mm (AST3) from the scleral spur, temporally and nasally.

RESULTS

A total of 56 subjects (28 subjects in the MFS group and 28 matched subjects in the control group) were included in this study. In patients with MFS, AST was significantly reduced compared to matched controls, both overall and at every analysed measuring point in the nasal and temporal areas (p < 0.001). Central corneal thickness (CCT) and mean keratometry (Kmean) values were significantly lower in patients with MFS (p < 0.05). A positive correlation was found between nasal AST and CCT in patients with MFS. No correlation was found between AST and Kmean or between AST and axial length. In patients with MFS with ectopia lentis, compared to those without, temporal AST3 was significantly lower (p < 0.05). AST was significantly lower in patients with MFS harbouring a variant predicted to cause haploinsufficiency compared to those with a variant expected to lead to a dominant negative effect for both nasal and temporal measurements.

CONCLUSION

Based on anterior segment OCT measurements, AST of patients with MFS is significantly lower compared to matched controls.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sutureless intrascleral intraocular lens fixation and modified iris cerclage pupilloplasty for aphakia and traumatic mydriasis

PURPOSE

To evaluate the safety and efficacy of sutureless intrascleral intraocular lens (IOL) fixation combined with modified iris cerclage pupilloplasty for treating aphakia and traumatic mydriasis.

METHODS

Five patients with aphakia and traumatic mydriasis were operated on by the same surgeon. All patients underwent sutureless intrascleral IOL fixation combined with modified iris cerclage pupilloplasty and were followed up for ≥6 months. Best-corrected visual acuity (BCVA) was measured using the logarithm of the minimum angle of resolution (logMAR). BCVA, intraocular pressure (IOP), pupil diameter, and corneal endothelial cell count (CECC) preoperatively and postoperatively were statistically analyzed. The pupil shape, photophobia, IOL position, and surgical complications were evaluated.

RESULTS

The mean BCVA was significantly improved 6 months postoperatively (0.26 ± 0.17 logMAR, P = 0.042) than preoperatively (0.50 ± 0.30 logMAR). No significant difference was observed between the preoperative and postoperative IOP (P = 0.138). The mean pupil diameter significantly reduced postoperatively than preoperatively (3.44 ± 0.35 mm vs. 7.28 ± 0.35 mm, P = 0.043). There was no significant decrease in CECC postoperatively (P = 0.225). The pupil shape was round-like, and photophobia disappeared in all patients. No intraoperative or postoperative complications occurred.

CONCLUSION

Sutureless intrascleral IOL fixation combined with modified iris cerclage pupilloplasty is a safe and efficient procedure for treating aphakia traumatic mydriasis patients without sufficient capsular support.

Management of complications of sutureless intrascleral intraocular lens fixation

PURPOSE

The purpose of the study was to report the complications of sutureless intrascleral (SIS) intraocular lens (IOL) fixation and its management.

MATERIALS AND METHODS

A multicenter, retrospective, consecutive interventional case series of patients with intra or postoperative complications after SIS IOL fixation during the technical learning curve of vitreoretinal surgeons from three Taiwanese referral hospitals. The used surgical techniques were the Scharioth technique for intrascleral tunnel fixation, Yamane technique (double-needle scleral fixation), and modified Yamane technique (double-needle flanged haptic scleral fixation). The IOL models and surgical instruments used as well as each patient's ocular characteristics and complication management were recorded.

RESULTS

Of the eight included patients, the complications of 3 (37.5%) and 5 (62.5%) were noted intraoperatively and postoperatively, respectively. Haptic-related complications, including haptic breakage, slippage, and haptic disinsertion, occurred in six eyes. Other complications included uveitis-glaucoma-hyphema syndrome, retinal detachment, and IOL tilt. For the two patients with haptic slippage, repositioning was achieved using a modified cow-hitch technique that resulted in favorable IOL centration and restored visual acuity.

CONCLUSION

Most complications surgeons encountered during their early exposure to SIS IOL fixation were haptic related. Surgeons should be aware of such complications to prevent and manage them during surgery. Our modified cow-hitch technique could be used to reposition IOLs with unilateral haptic slippage.

Modified Four-Point Scleral Fixated Sutured Posterior Chamber Intraocular Lens Implantation Using 2 Eyelets Polymethyl Methacrylate Lens and 8-0 Polypropylene Suture

Purpose

To present a modified technique of 4-point scleral fixation using polymethyl methacrylate (PMMA) 2 eyelets intraocular lens (IOL) with 8-0 polypropylene sutures.

Methods

A 270-degree conjunctival peritomy is done, and 4 sclerotomies (2 nasal and 2 temporal) are created. Lamellar scleral or clear corneal incision is made at superior site (6 mm wide for sclera or 5.5-6 mm for corneal). A short segment of 8-0 polypropylene is inserted into each eyelet, each thread of the suture is externalized through the sclerotomy site, and the lens is inserted. The suture is tightened evenly, and the knot is rotated and internalized. Scleral incision and conjunctival peritomy are sutured with 8-0 vicryl.

Results

We have performed this technique in 6 patients with excellent visual outcomes and no reported complications over 1 year of follow-up. This technique has practical advantages including rigid and stable PMMA IOL, high tensile, and slim 8-0 polypropylene suture which is easily internalized and less irritated, and affordable and widely available overall consumables.

Conclusion

We present a modified 4-point scleral fixation technique for posterior chamber IOL placement using PMMA IOL with 2 eyelets and 8-0 polypropylene as compared to previous studies that used foldable IOL with 4 eyelets and 10-0 polypropylene or Gore-Tex sutures. This procedure has moderate technical complexity, comparable to previously reported techniques with good overall clinical outcomes and several practical advantages, particularly related to the affordability and availability of the consumables.

Visual Outcomes of Traumatic Lens Dislocations and Subluxations Managed by Pars Plana Vitrectomy and Lensectomy

AIM

The aim of this study was to evaluate the visual outcome of lens dislocation and subluxation managed by pars plana vitrectomy (PPV) and lensectomy in patients with open (OGIs) or closed globe injuries (CGIs).

METHODS

Medical records of 70 consecutive patients treated by PPV and lensectomy over a period of 11 years (1 January 2010-31 December 2020) were retrospectively reviewed. We collected demographic data, best corrected visual acuity (BCVA) using a Snellen Chart pre- and postoperatively, associated ocular injuries and treatment strategy. Visual outcome was evaluated according to the final BCVA which was defined as poor <0.1 or good ≥0.1.

RESULTS

The mean age was 57.9 ± 17.6 years. CGIs were present in 49 (70.0%) cases and open OGIs in 21 (30.0%) cases. The dislocation mechanism was zonular lysis in 59 cases (84.3%) and capsular rupture in 11 cases (15.7%). The intraocular lens implant (IOL) was sutured to the sclera in 51 (72.9%) cases or positioned in the capsular bag or in the sulcus in 3 (4.3%) cases and 1 (1.4%) case, respectively, whereas 15 (21.4%) patients remained aphakic. A good BCVA ≥ 0.1 was achieved in 45.71% of the eyes. The presence of retinal detachment (RD) (p = 0.014), iridodonesis (p = 0.011) and initial BCVA (p = 0.000) achieved statistical significance in predicting visual outcome. After treatment, 45.71% of patients achieved a final BCVA ≥ 0.1.

CONCLUSION

RD, iridodonesis and initial BCVA were risk factors for poor visual outcome in our series.

Four-Point Flange Intrascleral Fixation With Double Suture Through the Dislocated Plate-Haptic Trifocal Intraocular Lens

PURPOSE

To describe a technique for the replacement of dislocation of plate-haptic trifocal intraocular lens (IOL) through double-suture 4-point flange intrascleral fixation.

DESIGN

Retrospective, interventional, noncomparative, case series.

METHODS

A total of 7 eyes of 7 patients with a dislocated plate-haptic trifocal IOL were enrolled for 4-point flange intrascleral fixation with double 7-0 polypropylene suture. Preoperative and postoperative visual acuity, operating time, refractive results, postoperative IOL tilt and decentration, and intraoperative and postoperative complications were recorded.

RESULTS

The mean postoperative uncorrected distance visual acuity (UDVA) was 0.05 ± 0.06 logarithm of the minimum angle of resolution (logMAR). The mean postoperative uncorrected intermediate visual acuity (UIVA) at 80 cm was 0.09 ± 0.06 logMAR and the mean postoperative uncorrected near visual acuity (UNVA) at 40 cm was 0.06 ± 0.07 logMAR. The mean postoperative residual spherical equivalent values were -0.27 ± 0.39 diopters. The visual function index-14 questionnaire showed that no difficulty was found in >80% of subjects for all tasks. The mean surgical time was 16.23 ± 5.64 min. The mean tilt of IOL was 3.74° ± 1.31° and the mean decentration of the IOL was 0.18 ± 0.09 mm. No important complications appeared.

CONCLUSION

We have described the technique of 4-point flange intrascleral fixation for plate-haptic trifocal IOL.

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.

Changes in Corneal High Order Aberrations and Anterior Chamber Parameters Following Scleral Fixated Intraocular Lens Implantation

BACKGROUND

To evaluate the change in corneal high order aberrations (HOAs) and anterior chamber parameters following scleral fixation in aphakic patients using the Scheimpflug camera system.

METHODS

This retrospective study included patients who were aphakic after phacoemulsification surgery and underwent scleral-fixed intraocular lens (SF-IOL) implantation with Z suture technique between 2010 and 2022. Preoperative and postoperative best corrected visual acuity (BCVA), anterior segment parameters and corneal aberrations were evaluated with a combined Scheimpflug-Placido disc corneal topography device (Sirius Costruzione Strumenti Oftalmici, Florence, Italy). The following values were recorded: Simulated keratometry (SimK), flat meridian (K1), steep meridian (K2), iridocorneal angle (ICA), temporal anterior chamber angle (T-ACA), nasal anterior chamber angle (N-ACA), horizontal anterior chamber diameter (HACD), anterior chamber volume (ACV), corneal volume (CV), total Root Mean Square (RMS), high order aberrations (HOAs), spherical aberration, coma, trefoil, quadrifoil, and secondary astigmatism.

RESULTS

The study included 31 eyes of 31 patients (mean age: 63.00±19.41 years, 17 males/14 females). Postoperative BCVA was better than preoperative BCVA (p=0.012). Postoperatively, there was a statistically significant increase in ACV and CV values and a statistically significant decrease in K2 (p=0.009, p=0.032, p=0.015). Preoperative T-ACA and preoperative and postoperative ACV were negatively correlated with postoperative intraocular pressure (r=-0.427 p=0.033, r=-0.406 p=0.032 and r=-0.561 p=0.001). There were statistically significant postoperative increases in corneal RMS, trefoil and HOAs for 3 mm pupil diameter (p=0.0177, p=0.001, p=0.031) and in corneal RMS, trefoil and quadrifoil aberrations for 6 mm pupil diameter (p=0.033, p=0.001, p=0.001).

CONCLUSIONS

In conclusion, SF-IOL implantation with Z-suture technique used for visual rehabilitation of aphakic patients may affect visual quality by increasing corneal HOAs while improving visual acuity.

Scheimpflug imaging for evaluation of intraocular lens position in modified flanged scleral fixated intraocular lens

Background

Scleral fixation of intraocular lens (IOLs) is the most preferred technique for the management of aphakia and the techniques have evolved over the years. These methods have their advantages and disadvantages, however, the major concern being the position of the intraocular lens, its stability and complications. The final IOL position is the major determinant of the final visual acuity, and various imaging modalities have been used to quantify the IOL tilt.

Objectives

Use of Scheimpflug imaging to evaluate the IOL tilt in modified flanged scleral-fixated intraocular lens (MFSIOL).

Design

Retrospective chart review of 41 consecutive patients who underwent MFIOL.

Methods

We conducted a retrospective chart review of 41 consecutive patients who underwent MFIOL. The baseline and final best-corrected visual acuity (BCVA), refractive error, and clinical examination findings were recorded. The vertical and horizontal tilts of the IOLs were calculated using the Scheimpflug image. The IOL tilt (in degrees) in the vertical and horizontal axes was the primary outcome and the BCVA, residual refractive error, intraocular pressure, and surgical complications were secondary outcome measures.

Results

The mean baseline BCVA was logMAR 0.49, which improved to logMAR 0.356 (p < .005) after the surgery. The mean IOL tilt in the vertical axis was 3.40° (range of 0.0°-8.5°, interquartile range: 1.21-5.66) and in the horizontal axis was 1.35° (range of 0.60°-4.620°, interquartile range: 0.44-1.86), respectively. There was no correlation between angle of IOL tilt and UCVA (r = 0.089, p = 0.580), BCVA (r = 0.109, p = 0.498), final spherical error (r = 0.081, p = 0.615), cylindrical error (r = 0.207, p = 0.195), axial length (r = 0.105, p = 0.514), and IOL power (r = -0.139, p = 0.388).

Conclusion

Modified flanged IOL (MFIOL) is an alternative technique for intrascleral fixation of IOL resulting in good lens stability. The IOL tilt achieved by this technique is minimal and did not influence the final visual outcome or spectacle correction. Scheimpflug imaging is simple and non-invasive method to measure the IOL tilt.

Plain Language Summary Scheimpflug imaging for modified flanged scleral fixated lens position

This study on 41 eyes was aimed to analyze the lens tilt using Scheimpflug imaging in cases of modified flanged scleral fixation of intraocular lens (MFSFIOL), which is a novel technique to minimize the complications and simplify the procedure. The intraocular lens (IOL) remained stable with an acceptable range of vertical and horizontal tilt. There was no significant effect of IOL tilt on the final best-corrected visual acuity (BCVA) or spectacle correction. Scheimpflug imaging is an accurate and non-invasive technique for assessment of lens position in the patients with intrascleral fixation of IOL.

Flapless and Conjunctiva-Sparing Technique for Transscleral Fixation of Intraocular Lens to Correct Refractive Errors in Eyes without Adequate Capsular Support

Purpose

To evaluate refractive outcomes, intraocular lens (IOL) power calculation, and IOL position following a novel conjunctiva-sparing transscleral fixation technique.

Methods

Forty-one eyes of 40 patients managed with a flapless transscleral-sutured technique were included. Preoperative and postoperative refractive errors (spherical equivalents, SE) were compared. IOL position was assessed on the Scheimpflug images. IOL power was calculated by SRK/T, Holladay 1, and Hoffer Q formulas.

Results

The mean age was 57.39 ± 14.83 years (range: 26 to 79 years), and the mean follow-up was 7.46 ± 6.42 months (range: 1 to 24 months). Surgical indications were aphakia (n = 14), subluxated lenses (n = 3), and IOL dislocation (n = 24). The SE was 4.50 ± 6.38 diopter (D) (range: -3.75 to 13.75 D) preoperatively and -1.68 ± 1.57 D (range: -5.50 to 1.13 D) postoperatively (P < 0.001). The mean tilt angle and decentration were 2.90° ± 1.93° (range: 0.39° to 9.10°) and 0.23 ± 0.19 mm (range: 0.02 to 0.94 mm) vertically, and 1.75° ± 1.41° (range: 0.24° to 7.65°) and 0.18 ± 0.19 mm (range: 0.02 to 1.06 mm) horizontally, which were clinically insignificant. All three IOL formulas produced myopic errors (range: -0.29 to -0.50 D). The SRK/T had the lowest median absolute error (0.55 D), followed by the Holladay 1 (0.70 D) and the Hoffer Q (0.74 D). The three formulas had the same percentage of prediction errors (PEs) within ±0.5 D (43.48%), while the Hoffer Q had the highest percentage of PEs within ±1.0 D (82.61%).

Conclusion

The present technique can serve as an alternative approach for transscleral IOL fixation and refractive correction in eyes with compromised capsular support, ensuring the stability of IOLs and reasonable IOL power calculation accuracy.

Comparison of Visual and Aberrometric Outcomes in Suture-Free Scleral Fixation: Three-Piece Lenses versus Carlevale Lenses

Purpose: To compare the refractive results between sutureless scleral fixation intraocular lens (IOLs) (Carlevale, Soleko) and suture-free scleral fixation three-piece IOLs (Sensar AR40, Johnson & Johnson) for secondary implantation in patients with IOL dislocation or aphakia. Methods: This is a monocentric retrospective study on 28 patients (28 eyes) with sutureless scleral fixation Carlevale IOL and 25 patients (25 eyes) with suture-free scleral fixation three-piece IOL. Best-corrected visual acuity (BCVA) evaluation, refractive measures and IOL tilt evaluation with anterior segment optical coherence tomography were conducted at one, three, six and twelve months after surgery. Point Spread Function (PSF) was measured using a total ocular aberrometer. Results: BCVA in both groups improved since the postoperative visit at 1 month and reached a stable value at 3 months At month 12, mean BCVA was 0.23 logMAR in group one and 0.32 logMAR in group two. Mean IOL tilt angle at 12 months was 2.76° ± 1.87 in group one and 2.51° ± 1.80 in group two. PSF at 12 months was 0.18 ± 0.09 in group one and 0.15 ± 0.05 in group two. There were no statistically significant differences (p > 0.05) for all comparisons. The post-operative complications were similar within the two groups. Conclusions: Our results show that secondary IOL implantation has similar visual and surgical outcomes when a sutureless Carlevale lens scleral fixation and a suture-free scleral fixation three-piece IOL are used.

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

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.

Corneal endothelial cell damage after scleral fixation of intraocular lens surgery

PURPOSE

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

STUDY DESIGN

Retrospective study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

INFECTIOUS ENDOPHTHALMITIS AFTER SCLERAL FIXATION OF AN INTRAOCULAR LENS

PURPOSE

To determine the mechanism of infection, clinical features, and risk factors of endophthalmitis after scleral fixation of an intraocular lens.

METHODS

We included 15 patients with infectious endophthalmitis after scleral fixation of an intraocular lens between April 2004 and December 2017, as well as four patients found through a literature search. Thus, a total of 19 patients were analyzed.

RESULTS

Among 19 eyes, infectious endophthalmitis developed at a mean of 23 months (range: 1 day-10 years) after scleral fixation surgery. Nine eyes (47.4%) had early-onset endophthalmitis (≤6 weeks), and 10 eyes (52.6%) had delayed-onset endophthalmitis (>6 weeks). Eleven eyes (57.9%) had presumed microbial influx due to suture exposure. Those with delayed-onset endophthalmitis showed a higher rate of suture-related infection (80.0% vs. 33.3%) and culture of gram-negative bacteria (70.0% vs. 12.5%) than did those with early-onset endophthalmitis.

CONCLUSIONS

Infectious endophthalmitis can develop late after scleral fixation of an intraocular lens, usually related to the exposed sutures, and the visual prognosis is poor. Eyes that have sutured scleral fixation should be monitored regularly, and preventive measures should be performed if an exposed suture is found.

Double-Needle Yamane Technique Using Flanged Haptics in Ocular Trauma-A Retrospective Survey of Visual Outcomes and Safety

To evaluate visual outcomes and safety of the double-needle technique using flanged haptics (Yamane technique) in patients with aphakia caused by ocular trauma at a trauma referral center. Retrospective: Consecutive interventional case series of 30 patients who underwent the Yamane technique due to posttraumatic aphakia. The double-needle technique using flanged haptics was combined with anterior vitrectomy (group A) in 14 patients, and with pars plana vitrectomy (PPV) (group B) due to retinal detachment, nucleus dislocation into the vitreous cavity, or intraocular lens (IOL) displacement in 16 patients. No intraoperative complications were noted. There was significant improvement in the visual acuity in both groups at the second postoperative visit. However, the visual acuity was significantly worse in the group treated with the Yamane technique combined with PPV. Silicone oil tamponade in PPV group was associated with worse visual acuity, whereas post lensectomy status was associated with poor visual function result in the anterior vitrectomy group. There was one case of slight IOL decentration and one retinal detachment during the postoperative follow-up period in the group with PPV. In this case series, the Yamane technique applied in traumatized eyes was found to be an efficacious and safe procedure. Combining the Yamane technique with PPV due to posterior segment ocular trauma was associated with worse functional results in the follow-up at three months. Further studies with longer follow-up evaluations are required to verify long-term complications.

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

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

A Modified Flanged Intrascleral Intraocular Lens Fixation Technique Using an Externalized Needle for Haptic Docking

The Yamane intrascleral flanged haptic fixation technique has obviated the need for resources such as suture or glue. However, intraocular maneuvers to properly dock haptics into the needles for externalization can be difficult for even adept eye surgeons and is especially difficult when visualization through the cornea is poor. Additionally, one traditional resource, intraocular forceps, has been critical in both the original technique and proposed modifications since its inception. We describe a modified flanged intrascleral intraocular lens fixation technique by docking the second haptic externally at the main corneal incision. This technique does not require the use of microforceps, which is advantageous to surgeons who lack access to specialized instrumentation. Additionally, this technique may provide added safety, visibility, and ease for surgeons by docking the haptic externally at the corneal incision rather than within the eye.

Trans-scleral plugs scleral fixation IOL and penetrating keratoplasty to restore vision in vitrectomized eyes

PURPOSE

To report the surgical outcomes of penetrating keratoplasty (PKP) and sutureless scleral fixation (SSF) using Carlevale Lens (Soleko) combined procedure to solve corneal failure and aphakia in vitrectomized eyes and discuss eventual advantages of this new approach.

METHODS

Two patients underwent primary wound repair and pars plana vitrectomy after a penetrating ocular trauma and were referred to the author's clinic. The PKP and SSF-Carlevale lens implantation were performed under retrobulbar anesthesia. Intraoperative and postoperative complications were recorded, intraocular lens positioning was evaluated using anterior segment optical coherence tomography (AS-OCT) and endothelial cell density was determined using an endothelial microscope. Both patients completed 12 months follow-up.

RESULTS

The surgery was performed without intraoperative complications. After 1 month, the lens was fixed well, and the graft showed no sign of rejection. At the last visit after 12 months, the corneal graft remained transparent with good endothelial cell density in both cases; conjunctival scarring or inflammation and plugs externalization did not occur during follow-ups. Best-corrected visual acuity was 4/10 Snellen in the first case, while in the second case, we witnessed a limited visual recovery of 1/20 Snellen due to retinal issues.

CONCLUSION

We report the feasibility of secondary IOL implantation using Carlevale with penetrating keratoplasty. The relative of ease of Carlevale lens implantation through the transscleral plugs reduces the open globe length resulting in a safer procedure, especially for vitrectomized eyes.

Four-flanged prolene fixation for a toric trifocal intraocular lens of the double C-Loop design in an eye with severe capsular phimosis

Purpose

To report a rare case of severe capsular phimosis after toric trifocal intraocular lens implantation, in a patient who was already on systemic immunosuppression and to present a modified fixation technique, based on the four-flanged prolene technique, which could be adapted for fixation of intraocular lenses of the double-C-loop design.

Observations

A 33 year old gentleman, who underwent uneventful, sequential, bilateral phacoemulsification with implantation of toric trifocal intraocular lenses, presented 6 weeks post-operatively, with severe capsular phimosis, causing decentration of the IOL and deformation of the haptics in both eyes. The left eye was successfully managed by Nd-YAG laser anterior capsulotomy, while the right eye required surgical intervention.

Conclusion and importance

In the present case report, we describe a novel technique to successfully reposition and realign a decentered toric trifocal intraocular lens of the double C-loop haptic design, after severe capsule phimosis.

•

A novel technique using four-flanged prolene suture to reposition a toric-trifocal IOL without the need for explantation.

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Secondary IOL repositioning and fixation made possible even for toric trifocal IOLs.

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Successful re-centration and re-alignment of a toric-trifocal IOL after aggressive capsular phimosis.

Clinical Outcomes and Lens Constant Optimization of the Zeiss CT Lucia 602 Lens Using a Modified Yamane Technique

Purpose

To report the clinical and refractive outcomes of a modified Yamane technique for scleral fixation of the CT Lucia 602 lens.

Design

Retrospective case series.

Patients

One hundred twenty-one eyes with dislocated posterior chamber lens implants, surgical aphakia, subluxed crystalline lenses, capsular tear, anterior chamber, or iris sutured posterior chamber lens intolerance were included.

Methods

Secondary implantation of the Zeiss CT Lucia 602 lens was performed by a single surgeon using a modified Yamane technique employing a single needle, rather than the double-needle approach. One hundred twelve eyes underwent simultaneous 3 port pars plana vitrectomy and 9 eyes had previously undergone posterior vitrectomy surgery. Exclusion criteria were age <18, simultaneous glaucoma or corneal procedures, staged corneal transplantation, and follow-up <30 days.

Main Outcome Measures

A paired t-test was used to compare pre- and post-operative corrected distance visual acuity (CDVA), the mean predictive error, and the mean absolute predictive error between the manufacturer’s and optimized constants for Hoffer Q, Holladay I, and SRK/T. Complication rates were reported.

Results

One hundred twenty-one consecutive eyes with a mean follow-up of 237 days were included. The pre-operative CDVA was 0.871 ± 0.785 logMAR (mean ± standard deviation, Snellen equivalent 20/149), which improved to 0.401 ± 0.608 (Snellen equivalent 20/50) post-operatively. In 109 eyes with reliable postoperative refractions, the mean predictive refractive error (D) ± std was +0.74 ± 1.37 for Hoffer Q, +0.66 ± 1.41 for Holladay 1, and +0.47 ± 1.49 for SRK/T (p<0.05). Refractive outcome analysis yielded a mean optimized personalized anterior chamber depth (pACD) of 5.69, Surgeon Factor of 1.79, and A constant of 118.56. Vision-limiting complications occurred in 11 eyes (9.1%).

Conclusion

Scleral fixation of the CT Lucia 602 lens using a single-needle modification of the Yamane technique resulted in very good visual acuity, predictable postoperative refractive errors, but some vision-limiting complications in this heterogeneous group of eyes with significant comorbidities.

Intraocular Lenses: Overview of Designs, Materials, and Pathophysiologic Features

This article provides an overview of intraocular lenses (IOLs) currently used in cataract surgery. Aspects presented include design features related to IOL construction and sites of fixation; optic, filter, and haptic materials; as well as pathophysiologic features of uveal biocompatibility, capsular biocompatibility, and postoperative IOL opacification. This overview also includes supplementary (add-on; piggyback) lenses implanted in eyes that are already pseudophakic and considerations on IOLs used in the pediatric population. Different IOLs are made available to surgeons each year, including lenses with increasingly complex design characteristics owing to advancements in manufacturing and surgical techniques.

Scleral fixated secondary intraocular lenses: a review of recent literature

PURPOSE OF REVIEW

A variety of techniques exist for secondary intraocular lens (IOL) implantation. Of note, scleral fixated intraocular lenses have become more popular with a variety of techniques, both with and without use of sutures. Herein, we focus on reviewing recently published studies describing the long-term outcomes of scleral fixation techniques.

RECENT FINDINGS

Although initial papers describing novel techniques often report short-term outcomes, several studies have recently described intermediate and long-term outcomes for scleral fixated IOLs, albeit all being retrospective case series. Suture fixation methods with long-term follow-up, up to a minimum of 50 months, report dislocation rates between 0 and 15%. Sutureless scleral fixation techniques have increased in popularity the past several years. Although they appear to have a lower rate of IOL dislocation: several studies have reported 0% and one study 8%. The follow-up period for sutureless scleral fixation technique studies, however, is shorter with most studies reporting follow-up of less than a year. Rates of retinal detachment vary between individual studies, but are similar for both suture fixation and sutureless with the majority of studies reporting a rate between 0 and 5%. These studies show that long-term outcomes are important considerations in surgical decision-making.

SUMMARY

Scleral fixation techniques have shown long-term durability and safety in recent retrospective studies. Comparison of techniques has been limited, and more robust studies may be required to provide stronger anatomic, functional, and comparative data.