ARTICLE

Intermediate results of sutureless intrascleral posterior chamber intraocular lens fixation

Gabor B. Scharioth, MD, Som Prasad, FRCOphth, Ilias Georgalas, MD, Calin Tataru, MD, Mitrofanis Pavlidis, MD

PURPOSE: To report the intermediate multicenter results of a technique of sutureless intrascleral fixation of a standard 3-piece posterior chamber intraocular lens (PC IOL) in the ciliary sulcus. SETTING: Four European ophthalmology centers. METHODS: A technique for sutureless intrascleral fixation of the haptics of a standard 3-piece PC IOL was retrospectively evaluated. The technique uses standardized maneuvers to fixate the PC IOL without need for special haptic architecture or preparation or haptic suturing. All patients having IOL implantation by the technique were evaluated for preoperative status (visual acuity, refractive error, preexisting ocular conditions, optical biometry), postoperative status, complications, and need for further surgery. RESULTS: The study evaluated 63 consecutive patients from 4 institutions (4 surgeons). The median follow-up was 7 months. Two dislocated PC IOLs (3.6%) were decentered; the other 61 IOLs (96.8%) were stable and well centered. There were no cases of recurrent dislocation, endophthalmitis, retinal detachment, or glaucoma. CONCLUSION: Fixation of PC IOL haptics in a limbus-parallel scleral tunnel provided exact centration and axial stability of the IOL and prevented distortion and subluxation in most cases. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2010; 36:254259 Q 2010 ASCRS and ESCRS

In eyes with a subluxated or dislocated lens and significant zonulopathy, cataract surgery can be performed by phacoemulsification, extracapsular cataract extraction, or intracapsular cataract extraction as well as by a pars plana lensectomy approach. After successful lens removal, optical rehabilitation by intraocular lens (IOL) implantation is important. In the absence
Submitted: July 5, 2009. Final revision submitted: September 13, 2009. Accepted: September 18, 2009. From the Augenzentrum Recklinghausen (Scharioth, Pavlidis), Recklinghausen Germany; University of Szeged (Scharioth), Szeged, Hungary; Arrowe Park Hospital (Prasad), Wirral, United Kingdom; Department of Ophthalmology (Georgalas), G. Gennimatas Hospital of Athens, National Health System, Athens, Greece; Eyeclinic Arcor (Tataru), Bucharest, Romania. Corresponding author; Pavlidis M. Mitrofanis, MD, Augenzentrum Recklinghausen, Erlbruch 34-36, 45657 Recklinghausen, Germany. E-mail: mitrofanis.pavlidis@augenzentrum.org.

of sufficient capsule support, IOLs can be implanted in the anterior chamber, fixated in the iris, or in the case of posterior chamber IOLs (PC IOLs), fixated in the ciliary sulcus using a transscleral suture.121 In eyes with remaining capsular bag, the PC IOL can stabilized with a capsular tension ring (CTR)2225 or refixated with a modified CTR26 or capsule tension segments,27 after which the IOL can be implanted in the bag. In cases of pseudophakia, the incidence of displaced PC IOLs after cataract surgery is reported to range from 0.2% to 2.8%.2830 Treatment options include observation, medical therapy (pharmacologic miosis),31 placement of a second IOL in the eye,32 and repositioning, removing, or exchanging the IOL.6,8,3338 We developed a sutureless technique for PC IOL sulcus fixation in which the haptics are permanently incarcerated in a scleral tunnel parallel to the limbus. The technique combines the high degree of control in a closed-eye system and good postoperative axial stability of the IOL. Although the technique is for
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Q 2010 ASCRS and ESCRS Published by Elsevier Inc.

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secondary PC IOL sulcus fixation, it can be modified and used for a subluxated IOLcapsular bag complex or any IOL or intraocular device that requires transscleral fixation.39 We evaluated the outcomes in a large series of patients having PC IOL fixation using the technique at 4 institutions. PATIENTS AND METHODS
This retrospective study evaluated consecutive patients who had PC IOL implantation using the sutureless sulcus fixation technique at 4 institutions in Europe. All patients had surgical stabilization of the IOL by 1 of 4 surgeons using a previously described technique.39 All patients provided informed consent before surgery. No institutional review board approval was required. All patients were evaluated for preoperative status (visual acuity, refractive error, preexisting ocular conditions, optical biometry), postoperative status (slitlamp mydriatic examination for inflammation signs and PC IOL centration), complications, and the need for further surgery.

Figure 1. Three-month postoperative slitlamp image of the limbal position above the scleral tunnel. The PC IOL haptic (arrow) is completely incarcerated in the scleral tunnel.

Surgical Technique
After a standard 3-port pars plana vitrectomy was performed and a corneal incision created for IOL implantation, 2 straight ab externo sclerotomies were prepared with a sharp 24-gauge cannula (Luer #17, Neopoint) 1.5 mm to 2.0 mm from the limbus exactly 180 degrees to each other. This cannula was used to create a limbus-parallel tunnel of approximately 50% scleral thickness starting from the ciliary sulcus sclerotomies and ending with externalization of the cannula after 2.0 to 3.0 mm. A standard 3-piece PC IOL with a haptic designed for the full diameter of the ciliary sulcus was implanted with an injector. The trailing haptic was fixated in the corneal incision. The leading haptic was then grasped at its tip with an endgripping 25-gauge forceps (J383825, Janach), pulled through the sclerostomy, and left externalized. Next, the same forceps was used to grasp the externalized tip and by a pulling-orpushing technique, to implant the haptic in the limbusparallel scleral tunnel. The trailing haptic was then placed in the eye; again, the tip was grasped with the 25-gauge end-gripping forceps, passed through the second sclerotomy, and pulled out through the sclerotomy. The trailing haptic was then introduced into the limbus-parallel tunnel to center the IOL. The distal ends of the loops were inside the tunnel to prevent foreign-body sensation or conjunctival erosion and reduce inflammation-causing stimuli (Figure 1). Instead of a pars plana approach, the technique can also be performed via corneal side port incisions and with the help of an anterior chamber maintainer.39

RESULTS The study population consisted of 63 patients (33 men, 30 women) with a mean age of 64 years (range 15 to 87 years). Table 1 shows the preexisting ocular conditions, the most common of which were aphakia and defects during phacoemulsification. The mean follow-up was 6.8 months G 6 (SD) (median 7.0 months; range 1 to 22 months). Table 2 shows the characteristics of the IOL models implanted. There was no statistically significant correlation between PC IOL type and final visual acuity or postoperative complications. Table 3 shows the postoperative complications, all of which occurred within the first 4 weeks after surgery. The cases of smooth vitreous hemorrhage resolved within 1 week without surgical intervention. In cases of spontaneous IOL dislocation and traumatic

Table 1. Preexisting conditions. Condition Aphakia Capsular defect during phaco Dislocated PC IOL Lens luxation by Marfan syndrome Luxated cataract by PXF Traumatic lens subluxation Zonulysis Previous pars plana vitrectomy Retinal detachment* Glaucoma Patients, n (%) 13 (20.63) 16 (25.40) 10 (15.87) 8 (12.70) 6 (9.52) 6 (9.52) 1 (1.59) 1 (1.59) 1 (1.59) 1 (1.59)

Statistical Analysis
The mean visual acuity was obtained by calculating the logMAR value. The Wilcoxon rank sum test was used to determine whether visual acuity was associated with sex, eye, preoperative conditions, intraoperative complications, or postoperative complications. The relationship between age and visual acuity was examined using the Spearman rank correlation. The change in visual acuity was compared using the Wilcoxon signed rank test.

PC IOL Z posterior chamber intraocular lens; PXF Z pseudoexfoliaton *Repaired concurrently with fixation of IOL

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Table 2. Intraocular lenses used. Optic Material Number Haptic (%) Material

Table 3. Postoperative complications. Complication Temporary corneal edema Persistent IOP elevation Spontaneous IOL dislocation Smooth vitreous hemorrhage Cystoid macular edema Persistent hypotony Iris capture of IOL Traumatic IOL subluxation
IOL Z intraocular lens; IOP Z intraocular pressure

Patients, n (%) 5 (7.94) 2 (3.17) 2 (3.17) 2 (3.17) 1 (1.59) 1 (1.59) 1 (1.59) 1 (1.59)

IOL Model

Sensar AR40e Acrylic/UV 38 (60.32) PMMA (Abbott Medical Optics) AcrySof MA60 (Alcon, Inc.) Acrylic 18 (28.57) PMMA ReZoom NXG1 Acrylic/UV 3 (4.76) PMMA (Abbott Medical Optics) Tecnis ZA9003 Acrylic 1 (1.59) PMMA (Abbott Medical Optics) Oculaid PMMA (Argon PMMA 1 (1.59) PMMA Optics) SofPort AO (Bausch & Lomb) Silicone 2 (3.17) PMMA
IOL Z intraocular lens; PMMA Z poly(methyl methacrylate); UV Z ultraviolet

subluxation, the IOL was recentered in a subsequent surgery in which the haptics were adjusted in the existing scleral tunnel. There were no cases of anterior or posterior chamber inflammation, acute postoperative endophthalmitis, or late endophthalmitis. No postoperative complication had a strong association with a visual acuity of 1.0 or worse. Table 4 shows refraction and corrected distance visual acuity (CDVA). The improvement in CDVA from preoperatively to postoperatively was statistically significant (P Z .005).

DISCUSSION There are several options for managing a dislocated IOL. They include repositioning the IOL in the sulcus or anterior chamber using a pars plana approach,8,30,40,41 replacing the IOL,3,30,35,37,42,43 and securing the IOL to the ciliary sulcus4447,48 or the iris.38,49,50 The placement of sutures around the haptics of a dislocated IOL via an internal approach often requires complex intraocular maneuvers. In addition, many techniques involve placing a loop rather than a knotted suture around the haptic, which may increase the likelihood of the haptic slipping free of the suture during or after surgery.43,44,51 Two-point suture fixation carries a higher risk for axial IOL tilt, and 3- or 4-point fixation heightens the risk for complications resulting from increased intraocular manipulations. Our technique differs from other sutureless methods52,53 in the use of a small-diameter scleral tunnel, which reduces surgical scleral manipulation and trauma. A small-diameter scleral tunnel can provide leak-free closure. This was seen in postoperative anterior segment ultrasound biomicroscopy images (80 MHz iUltrasound, iScience Interventional) in our study (Figure 2). The images show complete scleral tunnel

adhesion and a well-sealed incision at 6 weeks. No signs of leakage or inflammation were observed. In our technique, management of secondary implantation or refixation of dislocated PC IOLs using scleral tunnel fixation of the haptic is less technically demanding because it stabilizes the IOL in the posterior chamber without the need for difficult suturing procedures. Posterior chamber IOL torsion and decentration can be minimized by accurate placement of the haptics in the scleral tunnel above the ciliary sulcus. To avoid tilt, the implanted 3-piece PC IOL should have a haptic designed for the full diameter of the ciliary sulcus. Incarceration of a longer part of the haptic stabilizes the axial position of the PC IOL, which should decrease the incidence of IOL tilt.54 Intraoperative centration of the IOL is possible due to adjustments of the final intrascleral position of the haptics (Figure 3). After a long-term evaluation of the results, we suggest that almost all initial expectations for this technique were fulfilled. Potential complications of transscleral fixation of PC IOLs include suture erosion, suture-knot exposure, and recurrent dislocation caused by a broken suture,55,56 all of which can be

Table 4. Refraction and CDVA results. Parameter Median SE refraction (D) CDVA (logMAR) Mean 0.3 or better, n (%) 0.4 to 1.0, n (%) 1.0 or worse, n (%) Change in CDVA, n (%) Gained 2 or more lines Within G1 line of preop value Lost 2 or more lines Preop 1.46 1.25 16 (25.3) 18 (28.6) 29 (46.0) d d d Postop 0.98 0.40* 39 (61.9) 8 (12.7) 8 (12.7) 46 (73.0) 15 (23.8) 2 (3.2)

CDVA Z corrected distance visual acuity; SE Z spherical equivalent *Statistically significant (P Z .005)

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Figure 2. Anterior segment UBM image shows the scleral tunnel with the incarcerated haptic of the PC IOL at 6 weeks. There are no sign of leakage or inflammation.

Figure 3. Photograph of a well-centered PC IOL 26 months postoperatively.

avoided by the sutureless technique. None of the conditions that existed before surgery resulted in a significantly worse final visual acuity. Two patients (3.2%) had recurrent dislocation of the IOL after surgery, and 1 patient (1.6%) had iris capture. Those patients required additional surgery in which the haptics were repositioned in the scleral tunnel. Other studies30,42,43,47,57 report a 0% to 17% rate of IOL tilt or decentration after IOL suturing to the ciliary sulcus. None of the postoperative complications resulted in a significantly worse mean final visual acuity. The incidence of the other complications is consistent with that expected after vitrectomy, complicated cataract surgery, and sutured PC IOL implantation.30,42,43,47,57 Some techniques for scleral fixation of secondary IOLs in a scleral pocket require at least 2 suture passes through the sclera for each haptic. This creates twice as many potential adverse bleeding events than our sutureless technique as well as possible entry sites for endophthalmitis-causing bacteria. Intrascleral IOL fixation is an established technique in retinal surgery (silicone in buckling procedures) as well as in refractive surgery. Several studies show that sulcus scleral fixation using common ab interno or ab externo techniques results in a different haptic position anterior or posterior to the sulcus. Long-term contact between the haptics and uveal tissue can increase the risk for uveitisglaucomahemorrhage (UGH) syndrome.58 Our technique minimizes the hapticuvea contact surface and thus may reduce the risk for UGH syndrome. Because of the overall diameter of these IOLs, we did not observe increased forces to the sclera. Scleral tunnels are well known from cataract surgery, and we would not expect scleromalacia to occur except,

possibly, in cases of preexisting inflammation (eg, scleritis, episcleritis, rheumatoid arthritis, herpes zoster ophthalmicus).5964 The tips of the haptics are buried, and to date we have not observed conjunctival erosion in any eye. The risk for chronic inflammation or recurrent bleeding is potentially lower than with other sulcus-fixated IOL techniques because of the minimum contact with uveal tissue. Very rigid haptics might cause slow dislocation of the IOL as a result of eye rubbing, contusion, or other events. We therefore recommend avoiding the use of 1-piece poly(methyl methacrylate) IOLs for this technique. In case of a sensible optichaptic junction, such as that of the AcrySof MA60 IOL, this could lead to late separation of the optichaptic junction65; longer follow-up of this issue is needed. Furthermore, our technique was designed for a standard 3-piece PC IOL and is not appropriate for newer 1-piece acrylic or silicone IOLs. Although the eyes in our study were complex with numerous preexisting ocular conditions and some postoperative complications occurred, the mean CDVA after surgery was statistically significantly better than before surgery (P Z .005). After a median of 7 months of follow-up, there were no cases of significant IOL decentration or severe complications. Based on these findings, we believe our technique simplifies scleral fixation of dislocated PC IOLs and allows successful repositioning of dislocated and subluxated PC IOLs. However, longer follow-up is needed to determine the potential for late IOL dislocation and other late complications, such as scleral degeneration and haptic position in the sclera. Our technique also minimizes intraoperative maneuvers, which could reduce the risk for intraoperative trauma. Using a foldable IOL and (preferably) implanting it using an injector keep the incision small and prevent higher surgically

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