Multipiece posterior chamber intraocular lens as sutureless, glueless scleral fixated intraocular lens.

PURPOSE: The purpose of the study is to report the outcomes of sutureless, glueless multipiece posterior chamber intraocular lens (PCIOL) as scleral fixated intraocular lens (SFIOL) implantation in patients with poor or no posterior capsular support.
METHODS: Medical records of 45 eyes of 42 patients who underwent SFIOL implantation where no suture or glue was used to fixate intraocular lens (IOL) to the sclera from November 2016 to October 2017, with minimum 18 months of follow-up were retrospectively analyzed. The best-corrected visual acuity, indication of surgery, other significant eye examination findings, and complications were analyzed.
RESULTS: Out of 42 patients, 62% were males and 38% were females. Mean age of subjects was 48.5 ± 16.5 years (range 13-79 years). Mean preoperative and postoperative visual acuity was 1.48 ± 0.6 Logarithm of the Minimum Angle of Resolution (logMAR) units and 0.6 ± 0.3 logMAR units, respectively. Most common complication was vitreous hemorrhage six eyes (13.3%) followed by postoperative hypotony in five eyes (11.11%). Other complications such as transient postoperative intraocular pressure rise, hyphema, tilted IOL, cystoid macular edema, retinal detachment were also noted.
CONCLUSION: Multipiece PCIOL used as SFIOL without any sutures and glue is a viable, cost-effective method of IOL implantation in eyes with aphakia following surgical complication or trauma, with comparable outcome to other techniques of SFIOL implantation. Copyright:

Introduction

Cataract surgery is one of the most commonly performed intraocular surgeries. The presence of weak zonules, inadequate capsular support, and optical aphakia (secondary to surgery or posterior lens dislocation) makes the conventional placement of posterior chamber intraocular lens (PCIOL) in the capsular bag or the ciliary sulcus difficult or impossible. Such cases can be surgically managed by an anterior chamber intraocular lens (ACIOL), iris fixated lens, iris claw lens, or sclera fixated intraocular lens (SFIOL). Both ACIOL and iris fixated/iris-claw lens are associated with pigment dispersion and intraocular inflammation. Furthermore, ACIOL and iris-claw intraocular lens (IOLs) demand an intact iris diaphragm which may not be so in all cases of traumatic aphakia.

SFIOL behaves as a PCIOL implanted in sulcus, the position being near the nodal point of eye; hence advantageous.[1] SFIOL though a safer option for optical rehabilitation in cases with inadequate capsular/zonular support is associated with suture-related complications.[1] This had led to several modifications in techniques for SFIOL implantation that includes glued IOL, sutureless, flapless SFIOL. Here, we describe a technique of sutureless, glueless SFIOL using a three-piece PCIOL and analyze the complications associated with this procedure.

Methods

The records of 45 eyes of 42 patients who had undergone sutureless, glueless SFIOL between November 2016 and October 2017 were studied retrospectively. All surgeries were performed by a single surgeon. The study protocol was approved by the institutional ethics committee. Written informed consent of all participants was taken.

The following details were recorded: age, gender, pre-and postoperative best-corrected visual acuity (BCVA), indication for surgery, detailed slit-lamp and fundus examination, pre/postoperative intraocular pressure (IOP), and complications (if any). The patients were followed up postoperatively at 1 week, 1 month, 3 months, 6 months, 12 months, and 18 months. The main outcome measures were postoperative BCVA, IOP, and intraoperative/postoperative complications.

Operative procedure

The surgery was performed under peribulbar anesthesia. A 270°C peritomy was done from four to eight O’ clock. 23G 3-port positive predictive values (PPV) were done in all cases (including those who had undergone primary vitreoretinal surgery). Two partial thickness sclera flaps (4 mm × 2 mm) were fashioned 180°C apart at three O’ clock and nine O’ clock. A 6 mm sclero-corneal tunnel centered at 12 O’ clock meridian was made which was used for IOL explantation/lens extraction (in cases of IOL drop/posterior dislocation of lens/subluxated lens) and IOL insertion. Sclerotomy ports parallel to the iris were made beneath the sclera flaps about 1.5 mm behind the limbus with a 22 gauge (22G) microvitreoretinal blade. A three-piece IOL (polymethyl methacrylate optic and prolene haptics, aurolens [Aurolab, model number B3602 India] of 6 mm optic diameter, overall size 13.5 mm, A constant 118.5, modified C loops haptics) was preferred (no financial interest) as it is very economic and affordable to the patients. The three-piece IOL was inserted with McPherson's forceps through the sclera-corneal tunnel. A 23G end gripping forceps were introduced through the sclerotomy beneath the scleral flap to grasp the tip of the leading haptic and externalize it. The same technique was again repeated 180° opposite to externalize the trailing haptic. The grasping of the trailing haptic with the 23G forceps to externalize it was aided by the endoilluminator and binocular indirect ophthalmomicroscope system. 26G needle (bent to 60° about one mm from the hub) fixed to a two milliliter (2 ml) syringe containing trypan blue dye was used to create a stained intrascleral tract on either side below the flaps to tuck the haptics [Figure 1]. The trocars were removed at the end and integrity of the incisions ensured. Conjunctiva was apposed with 8-0 vicryl sutures. Subconjunctival injection of dexamethasone and gentamicin was given. The eye was padded following antibiotic ointment application. Postoperative medications included antibiotic-steroid eye drops in tapering schedule and atropine 1% eye drops. Some patients with postoperative hypotony needed a short course of oral steroids.

Figure 1

(a) Scleral flaps fashioned 180° apart. (b) Sclerotomy made below flaps 1.5 mm behind limbus. (c) Intraocular lens inserted, haptics externalized. (d) Grasping of trailing haptic aided by the endoilluminator and binocular indirect ophthalmomicroscope. (e) Twenty-six gauge needle used to create intrascleral tract. (f) Haptics tucked

Results

The study comprised of 45 eyes of 42 patients who underwent PPV with sutureless, glueless SFIOL. The mean age of subjects was 48.5 ± 16.5 years (range 13–79 years). Out of 42 patients, 26 were males (62%) and 16 were females (38%).

SFIOL was performed for aphakia following complicated cataract surgery in 20 eyes (44.4%). Of these 12 cases (60%) had large posterior capsular rent, four cases (20%) had nucleus drop, and four cases (20%) had IOL drop. SFIOL was performed for traumatic aphakia in 11 cases (24.4%) – four cases (36.36%) had posterior IOL dislocation and seven cases (63.63%) had anterior/posterior lens subluxation/dislocation [Figure 2]. Of the total, seven eyes (15.5%) were operated for aphakia following surgery done elsewhere and five eyes (11.11%) underwent SFIOL as a secondary procedure following primary vitreoretinal surgery. One patient (two eyes) with Marfan's syndrome underwent SFIOL implantation for bilateral subluxated lens.

Figure 2

Scleral fixated intraocular lens in a patient with anterior subluxated lens

The mean preoperative visual acuity was 1.48 ± 0.6 Logarithm of the Minimum Angle of Resolution (logMAR) units. The mean postoperative BCVA was 0.8 ± 0.2 logMAR units at 1 week, 0.6 ± 0.3 logMAR units at 1 month, 0.48 ± 0.2 logMAR units at 3 months, 0.41 ± 0.4 logMAR units at 6 months which was maintained till 18 months of follow-up [Graph 1].

Graph 1

Visual acuity improvement postoperatively

Mean preoperative IOP was 17.3 ± 6.2 mmHg. Postoperative IOP rise (mean 20.2 + 8.3 mmHg) was noted in two eyes (4.4%) at 1 week which returned to normal levels (13.7 + 4.2 mmHg) at 1-month follow-up without any antiglaucoma medications suggesting inflammation as the cause. Postoperative hypotony (mean IOP 3.2 ± 0.9 mmHg) was noted in five eyes (11.11%) but it returned to normal following a short course of oral steroids. Most common complication was mild vitreous hemorrhage in six eyes (13.3%) which resolved on its own in 1 week. Other complications included cystoid macular edema in two eyes (4.4%), IOL tilt in three eyes (6.6%), SFIOL haptic disinsertion in one eye (2.2%), and retinal detachment (RD) in one eye (2.2%). The RD was noted at 3 months postoperative when the patient reported sudden diminution of vision. It was a case operated for traumatic posterior lens dislocation, and RD was caused by an anterior break near the ora that was missed.

Discussion

The placement of IOL in the capsular bag is anatomically the most preferable following cataract extraction as it provides stable fixation and is closest to the nodal point of eye. In eyes with inadequate or no capsular support, there are various IOL implantation or fixation techniques, SFIOL being the most popular and safe. To avoid the suture-related complications, Gabor and Pavlidis developed a sutureless SFIOL technique where the exteriorized haptics of a PCIOL were fixated into sclera tunnel parallel to the limbus.[2] A standard three-piece PCIOL with an overall length of 12.5–14 mm ensures a stable fixation in the posterior chamber behind the iris.[3] The large optic diameter of 6 mm reduces the risk of significant postoperative decentration.[4] In addition, the longer haptics when exteriorized along its curvature stabilize the axial positioning of the IOL and thus reduce IOL tilt.[5]

Minor issues such as haptic kinking (occurs if the haptic is not grasped at its tip with the forceps while exteriorizing it) and mild hyphema (due to injury to the iris root/ciliary body) are common with beginners. Other complications were comparable to previously described techniques of SFIOL fixation [Tables 1 and 2].[678910] There was excellent visual recovery at the end of 1 month, which was maintained throughout the 18 months of follow-up.

Table 1

Comparison of complication rates with other techniques of sutureless scleral fixated intraocular lens

Complication	Scharioth et al.[7] [sutureless SFIOL, n=63]	Kumar et al.[8] [glued SFIOL, n=53]	Yamane et al.[9] [flanged SFIOL, n=100]	Our study (sutureless, flapless SFIOL, n=45]
IOP rise	2 (3.2%)	0	2 (2%)	2 (4.4%)
Hypotony	1 (1.6%)		2 (2%)	5 (11.11%)
CME	1 (1.6%)	4 (7.5%)	1 (1%)	2 (4.4%)
VH	2 (3.17%)	0	5 (8%)	6 (13.3%) - mild VH
IOL tilt/decentration		3 (5.6%) [decentration]		3 (6.6%) [tilt]
Others	Spontaneous IOL dislocation-2 (3.17%)	Hyphema - 2 (3.7%)		SFIOL Haptic disinsertion-1 (2.2%), RD - 1 (2.2%)

Table 2

Comparison of complication rates with glued intraocular lens

Variables	Kumar et al.[10]	Kumar et al.[8]	Our study
Type of IOL	Glued foldable IOL	Glued single piece PMMA IOL	Sutureless, glueless 3-piece PMMA IOL
Sample size (number of eyes)	208	53	45
Follow up	16.7 months±10.2 (SD)	12 months	18 months
Transient hyphema/VH (%)	0.4	3.7	13.3
Early IOP rise/corneal edema (%)	5.7	-	4.4
Optic capture (%)	4.3	-	-
IOL decentration (%)	3.3	5.6	IOL tilt 6.6
Haptic extrusion (%)	1.9	-	-
Subconjunctival haptic (%)	1.4	-	-
CME (%)	1.9	7.5	4.4
Pigment dispersion (%)	1.9	3.7	-
Other complications (%)	Reoperation 7.7	Percentage loss of endothelial cells 5.23±3.4	Hypotony 11.11
		Iridodonesis 18.8	Haptic disinsertion/reoperation 2.2

IOL: Intraocular lens, PMMA: Polymethylmethacrylate, SD: Standard deviation, IOP: Intraocular pressure, VH: Vitreous hemorrhage, CME: Cystoid macular edema

Conclusion

This method of IOL implantation is appropriate for eyes with deficient or absent posterior capsule [Figure 2] that can be easily performed with available IOL designs, instruments, and less surgical time. This technique is also safer than other IOL implantation methods in cases with inadequate capsular support. Furthermore, in cases with deficient iris tissue, this method of fixation ensures IOL stability in the absence of iris diaphragm [Figure 3]. Our experience with this technique of sutureless, glueless SFIOL with adequate sample and longer duration of follow-up suggests the stability of this surgical technique and its potential in surgical correction of aphakia. However, a still longer duration of follow-up is recommended to study the long-term complications of this technique.

Figure 3

(a) Preoperative and (b) postoperative photographs of a patient with deficient iris tissue who underwent scleral fixated intraocular lens implantation

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.