Prevention of suture exposure in transscleral intraocular lens fixation: an original technique

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.

Surgical correction of corneal opacity and aniridia with penetrating keratoplasty and a new iris prosthesis implant

PURPOSE

This study is to describe the clinical outcome of penetrating keratoplasty combined with implantation of a novel intraocular lens with an artificial iris, aided by continuous vitreous chamber infusion, in patients with severe aniridia and corneal alterations.

METHODS

This was a prospective single-center case series study involving five patients with corneal alterations and aniridia. All subjects underwent simultaneous penetrating keratoplasty and implantation of a new intraocular lens with an artificial iris with the assistance of infusion into the vitreous chamber to regulate intraocular pressure during the surgical procedure. Visual acuity, corneal endothelial cell density, and intraocular pressure assessments were performed in the postoperative period. The final cosmetic outcome of the iris prosthesis placement was also evaluated.

RESULTS

In all cases, increased visual acuity and a good aesthetic result were observed in all affected eyes except one in which, despite the excellent aesthetic outcome, the eye was very hypotonic as it had high myopia and had undergone several previous surgeries.

CONCLUSION

The single surgical procedure combining implantation of an intraocular lens-iris prosthesis with penetrating keratoplasty is an effective technique for the simultaneous treatment of aphakia and aniridia. However, larger series with longer-term follow-up are needed to definitively establish the benefits of this technique.

Modified Technique for Scleral-Sutured Fixation with the Double Knots Technique for Posterior Chamber Intraocular Lens: Short-Term Observation

Purpose

To evaluate the short-term safety and efficacy of a novel approach of utilizing the 9-0 looped polypropylene suture with double knots buried into the scleral groove and the scleral tunnel to minimize the risk of the suture erosion and suture knot exposure.

Design

Clinical-based retrospective study.

Methods

Records of consecutive patients who had anterior vitrectomy and scleral-fixated posterior chamber intraocular lens (IOL) implantation between July 2018 and April 2020 with a minimum follow-up of 3 months were reviewed.

Results

This study enrolled a total of 21 eyes from 20 patients (15 male). These patients had a mean age of 58.52 ± 8.55 years and were followed for an average of 1.08 ± 0.58 years postoperatively. Best-corrected visual acuity (BCVA) improved from a preoperative mean of 0.43 ± 0.41 logMAR to a significantly higher mean 3-month postoperative value of 0.09 ± 0.21 logMAR (Z = -3.35, p < 0.01). There were no statistical differences between the preoperative and postoperative corneal endothelial cell density (p=0.71). The postoperative complications included transient increased intraocular pressure in 5 eyes (24%). No other complications were detected during the follow-up.

Conclusions

The modified technique proposed is a safe, effective, and reliable approach resulting in good visual outcomes. Our procedure might have the potential benefit to avoid suture-related complications in scleral-fixated IOL implantation. Trial registration. Retrospective case series study, not applicable.

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

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

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.

Short-term Clinical Outcomes after Transscleral Fixation Using the Intrascleral Pocket Technique: A Retrospective Cohort Study Analysis

Purpose

To compare the two transscleral fixation (TSF) techniques of intrascleral pocket and conventional scleral flap with conjunctival division techniques in terms of short-term clinical effects.

Methods

This retrospective cohort study included all consecutive patients with aphakia in Gyeongsang National University Hospital in Jinju, Korea, who underwent TSF between January 2012 and December 2014. The medical records of all patients were retrospectively reviewed, and the endothelial cell count (ECC), refraction, best-corrected visual acuity (BCVA), intraocular pressure, slit lamp, and fundus examination results before and 1 day and 6 months after surgery were recorded. The postoperative complications and visual outcomes were also recorded.

Results

The intrascleral pocket and conventional-flap groups did not differ significantly in terms of demographics, presurgical BCVA, or ECC. However, the intrascleral pocket group had a significantly lower BCVA at 1 day and 6 months after surgery compared to the conventional-flap group. The two groups did not differ in terms of ECC 6 months after surgery. The intrascleral pocket group had no postoperative complications, but five patients in the conventional-flap group complained of irritation. In both groups, the intraocular lens was well positioned without tilting or subluxation, and astigmatism was significantly reduced at 1 day and 6 months after surgery.

Conclusions

The intrascleral pocket technique of TSF does not involve conjunctival dissection and is a successful method of sulcus fixation. It stably corrects the intraocular lens and is easy to perform, which helps to reduce operation time. It also reliably yields rapid visual acuity recovery without complications.

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.

Sutureless intrascleral pocket technique of transscleral fixation of intraocular lens in previous vitrectomized eyes

In this case series, we assessed a new technique, the intrascleral pocket procedure of transscleral fixation (TF) of the intraocular lens (IOL) in post-vitrectomized eyes. We performed the transscleral fixation of IOL in four aphakic patients who underwent pars plana vitrectomy. Two points 180° apart were marked at the limbus. A 2-mm-sized intrascleral pocket was created by lamellar dissection using a crescent blade without conjunctival dissection. A 2.8-mm clear corneal incision (CCI) was made using a keratome. Prolene sutures were exteriorized through the CCI pocket and a three-piece foldable acrylic IOL was injected via CCI and the ends of the haptics were exteriorized through the CCI. The prolene sutures for each haptic in the intrascleral pocket bed were then tied and knots were buried under scleral flaps. No patient had complaints such as conjunctival irritation, and visual acuity was almost identical to preoperative best-corrected visual acuity at day 1 postoperatively. IOLs were well placed without tilting or subluxation. They had no wound dehiscence or endophthalmitis postoperatively. The intrascleral pocket procedure of TF without the need for conjunctival dissection is a successful method for sulcus fixation in post-vitrectomized eyes predisposed to developing glaucoma.

Scleral fixation underneath an intact conjunctiva

PURPOSE

To describe a technique for the fixation of intraocular lenses or capsular tension rings through the ciliary sulcus or pars plana.

METHODS

This alternative technique allows burial of the knot and the free suture ends within the sclera, without using a scleral flap or pocket or even a conjunctival opening.

RESULTS

No suture exposure has occurred with the use of the suture burial technique in approximately 25 eyes in 4 years. Additional benefits include less patient discomfort and an improved anatomic and cosmetic outcome starting from the first postoperative day.

CONCLUSIONS

This technique causes minimal tissue damage and scarring with almost no postoperative discomfort.

Scleral fixation of intraocular lens in eyes with history of open globe injury

PURPOSE

To report the results and complications of scleral fixation of intraocular lens (SF-IOL) in traumatized eyes of children with iris defects and inadequate capsular support with technique customized to the condition of the eye.

METHODS

Retrospective review of pediatric eyes with a history of open globe injury and SF-IOLs. All eyes had undergone pars plana vitrectomy and lensectomy after primary repair of the laceration. Site of scleral fixation and limbal incision were selected according to the site of traumatic scar, remaining capsular support, and keratometry.

RESULTS

Ten patients with a mean age of 6.1 years were included. Mean duration of aphakia was 18.7 months. Five eyes had adequate capsular support for one haptic of the IOL. The only intraoperative complication was mild ciliary body hemorrhage. Mean follow-up was 11.8 months. Uncorrected visual acuity did not improve postoperatively in only one eye due to severe corneal astigmatism. Best-corrected visual acuity improved in 6 eyes. Mean postoperative sphere and cylinder were 1.8 and -3.05 diopters, respectively. The only postoperative complication was decentration of a sulcus-fixed haptic needing reoperation in one eye.

CONCLUSION

SF-IOL is a viable option for correcting traumatic aphakia and can have good results if customized to the condition of the eye.