Original Article
Safety
and Visual Outcome of Scleral Sutured Posterior Chamber Intraocular Lenses
(SS-PCIOL)
Mushtaq
Ahmad, Sofia Iqbal, Nazullah, Naz Jehangir
Pak J Ophthalmol 2011, Vol. 27 No. 3
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See end of article for authors affiliations …..……………………….. Correspondence to: Mushtaq
Ahmad Department
of Ophthalmology HMC, Submission of paper June 2011 Acceptance for publication September’ 2011 …..……………………….. |
Purpose: The aim of this study was to determine the
safety and visual outcome of scleral sutured fixation of posterior chamber intraocular lenses. Material and Methods: This
prospective and interventional study was conducted from April 2010 to April
2011 in the department of Ophthalmology Hayatabad Medical Complex Peshawar.
Thirteen eyes of 13 subjects were enrolled for scleral sutured posterior
chamber intraocular lens. There were three follow up visits at 1st
post op day, at two months and at six months. Results: A total of 13 eyes
underwent scleral sutured posterior chamber intraocular lens. There were 10
male and 3 female patients. All patients had completed their six months
follow-up. After six months nine patients (69.23%) out of 13 achieved 6/12
vision or better. Three patients did not come for their follow-up visits and were
excluded from the study. Two patients had bleeding intra operatively from the
scleral suture site. Two patients had suture erosion, one patient had lens
tilt due to vitreous tag postoperatively and one patient had cystoid macular
edema. Conclusion: The technique of scleral sutured
posterior chamber intraocular lens insertion via the ab externo method with a
thick scleral flap offers a low complication profile and should be considered
as a viable option for secondary intraocular lens. |
Intraocular lenses were introduced in
cataract surgery by Sir Harold Ridley in 19491 and they became
standard of care in the late 1980s. However, various models, fixation sites and
techniques are recommended for difficult situations. Fixation of intraocular
lenses in cases of insufficient or no capsular support is challenging and
requires good surgical techniques to resolve different situations2.
In such a situation, the surgeon has four options, to leave the eye aphakic, to
implant an anterior chamber intraocular lens (AC IOL), to fixate a posterior
chamber intraocular lens (PC IOL) in the iris or to fixate a PC IOL in the
sclera. The potential issues of anisometropia, optical aberrations, and contact
lens intolerance make aphakia a less than optimal solution in all but a few
patients3.
Following the implantation of the first anterior
chamber lens in 1952 by Baron, multiple lens type were developed. However, even
with a perfectly implanted AC IOL, it is postulated that sub clinical uveitis
secondary to lens-tissue contact creates inflammatory products that could be
directly toxic to the endothelium and angle and could also result in cystoid
macular oedema4.
The rates of adverse outcomes associated
with AC IOL implantation are cystoid macular oedema (CME) (1% to 10%), corneal
decompensation (1% to 7.8%) glaucoma (0 to 15%) and retinal detachment (0 to
4%). The frequency of endophthalmitis was reported to be 0.2%5.
Some surgeons prefer iris-sutured
intraocular lenses. These techniques need sufficient iris stroma for fixation.
Furthermore, there could be a need for special intraocular lenses, which may
not be available everywhere. In addition, urgency, extra cost, logistics, and
adapted biometry are all possible complicating factors. These can cause
cat-like pupil and iris chafing, with uveitis and/or pigment dispersion and
secondary complications such as chronic inflammation and secondary glaucoma.
Recognition of the high rate of adverse events associated with closed-loop AC
IOLs in the 1980s prompted the development of novel techniques for fixating an
IOL in the aphakic eye.
In 1986, Malbran and colleagues were the
first to describe scleral sulcus fixation of PC IOLs6. In 2003, an
Two major
concerns with scleral fixation IOLs are posterior placement of the haptics in
sulcus and longevity of the sutures. Haptics correctly placed in the sulcus
will most likely achieve stable fixation after fibrosis to the surrounding
structures8.
MATERIAL AND
METHODS
This prospective and Interventional study was conducted from April
2010 to April 2011 in the department of Ophthalmology, Hayatabad Medical
Complex Peshawar. Thirteen eyes of 13 subjects were enrolled from April 2010 to
October 2010 for scleral sutured PCIOL. All of them had completed their six
months follow-up. Three follow-up visits were given at 1st post
operative day, after two months and after six months. All patients were
determined to have aphakia of insufficient or no capsular support. Patients
were asked to be a part of the study if they met the inclusion criteria, which
primarily included the presence of aphakia with no capsular support, informed
consent to participate in the study, and the follow-up visits.
Exclusion criteria were as follows: Extremes of ages, only eye,
pre-existing macular disease and amblyopia. Patients were also excluded if they
had a vitreo-retinal pathology. Preoperative evaluation of the patients was
done thorough history and examination. The aetiology, best corrected visual
acuity (BCVA) and intra and postoperative compli-cations were recorded on
proforma. BCVA and complications were noted at each follow-up visit.
Surgery was carried out by a single surgeon under local
anaesthesia in adults and under General anaesthesia in children. Local
anaesthesia consisted of peribulbar injection of 1:1 mixture of 0.5%
bupivacaine and 2% lignocaine with adrenaline (1:1000).
Limited conjunctival peritomy was carried out and 2 triangular
scleral flaps 2/3rd of the scleral thickness and 180° apart were
made at 3 and 9 o’clock with the base at the limbus and size 3mm from base to
apex.
A corneal incision with 3.2mm knife at 12 o’clock was given.
Anterior vitrectomy were carried out in all cases. 10/0 prolene suture was used
in all cases for lens fixation. 10/0 nylon suture was used for scleral flap and
corneal repair. Conjunctiva sutured with 7/0 vicryl. A 27 gauge needle was
passed through a sclera at 0.7mm scleral bed from the limbus on one side and a
10/0 prolene suture on a straight needle through opposite scleral bed. The
prolene suture needle was engaged into the 27 gauge needle in the peripupillary
plan. The 27 gauge needle was withdrawn along with the prolene needle. The
corneal incision enlarged with scissor to accommodate the IOL optic to 6.50mm.
The suture was drawn out through the corneal incision. The suture was cut and
each end tied to the haptics eyelets of the IOL. Sutures were pulled through
the scleral bed and tied. Scleral flaps were sutured with 10/0 nylon and
conjunctiva with 7/0 vicryl.
The corneal wound stitched with 10/0 nylon interrupted sutures.
RESULTS
A total of 16 eyes of 16 patients underwent scleral sutured PC
IOL. Thirteen patients had completed their six months follow-up. Three patients
who did not complete their follow-up visits were excluded from the study. There
were 10 male and three female patients. All of them had unilateral surgery. Age
ranged from 10 years to 65 years. Out of 13 cases 9 (69.23 %) cases had left
eye while 4 cases (30.76%) had right eye. Indications for scleral sutured PC
IOL were complicated eye surgery with posterior capsule rupture in 8 cases
(61.53%), traumatic lens subluxation in 3 cases (23.07%) and lens dislocation
in one case (7.69%).
Nine patients (69.23%) achieved 6/12 or better visual acuity on 3rd
post operative follow up visits. On 1st postoperative day the BCVA
was decreased due to corneal oedema. Two patients (15.38%) had bleeding
intraoperatively from fixation suture site. Bleeding stopped spontaneously and
cleared up as much as possible with anterior vitrectomy. In one patient 1st
postop visual acuity was decreased but improved at 2nd follow-up
visit. Two patients (15.38%) had suture erosion, one patient (7.69) had lens
tilt due to vitreous tag postoperatively and one patient (7.69%) had cystoid
macular oedema.
Demographic profile, aetiology, pre and post operative best
corrected visual acuity are shown in (Table I).
DISCUSSION
Currently no consensus exists on the question of optimal method
for intraocular (IOL) implantation without capsular support. Scleral sutured
IOLs require a precise surgical technique and prolonged surgical time. In the
absence of adequate capsular support or in the presence of zonular dialysis
various techniques of IOL implantation are available. AC IOLs, iris-sutured PC
IOLs, and scleral sutured PC IOLs are common methods of lens implantation for
patients with little or no capsular support. Studies have reported various benefits
and complications for each procedure. However, the decision of which IOL to be
placed for each patient may introduce selection bias that could have affected
study outcomes. For example, angle abnormalities and peripheral synechea may
have precluded AC IOL placement in some patients, and patients with limited
iris tissue may not get an iris-sutured lens. Schein and colleagues compared
all 3 intraocular lenses and found similar visual acuity outcome with all 3
types and a slight increase of CME with SS PC IOLs9. In our study
out of 13 patients one patient got cystoid macular oedema and one patient had
intraocular lens tilt, all the other patients achieved good visual acuity. All
patients were followed up for six months and had stable visual acuity. The percentage
of patients with stable or improved postoperative visual acuity is (69.23%)
which is comparable to both iris-sutured lenses (72%) and ACIOL (71.4%–76%)10.
In our study, we had one case of lens till, but there was no case
of IOL dislocation. Previously published data report a lens tilt rate of 11%
and dislocation rate between 0 and 10%11. The incidence of lens
dislocation is 9.9% after an iris-sutured lens and 3% after AC IOL implantation12.
Studies of the scleral sutured PC IOL, in particular, have shown
that it is a safe procedure that can improve visual acuity, but it can present
various complications. The published complications include glaucoma, CME,
retinal detachment, endophthal-mitis, lens tilt or dislocation, and suture
exposure or breakage. All of these complications have been reported at variable
frequencies following placement of iris-sutured IOLs, and all except suture
exposure or breakage have been documented with AC IOLs.
In uncontrolled and controlled studies, the risk of choroidal hemorrhage
ranged from 0 to 22%13. In our study, only two eyes developed
hemorrhage, which started in the scleral suture site.
A new concern has been raised about the long-term safety of using
10-0 polypropylene as the suture material to fixate the IOL haptic to the
scleral wall. Recent reports have indicated that prolene suture can undergo
hydrolysis and degrade, leading to spontaneous subluxation of the
scleral-sutured IOL in 10–27% of cases14.
It is known, however, that a haptic sewn to the sclera, outside of
the ciliary sulcus, will not form a fibrous membrane and that as many as 50% of
scleral-sutured haptics are unintentionally sewn outside the ciliary sulcus.
This case series provides evidence that SS PCIOL insertion can be
performed with minimal postoperative complications. This technique appears to
be a satisfactory method of visual rehabilitation.
CONCLUSION
The technique of scleral sutured PC IOL insertion via the ab
externo method with a thick scleral flap offers a low complication profile and
should be considered as a viable option for secondary IOL implantation.
Ultimately, individual patient factors and surgeon preference and expertise
should be a guide to decide as to which secondary IOL is most appropriate for
each patient.
Author’s affiliation
Dr. Mushtaq Ahmad
Registrar Ophthalmology
Department HMC,
Dr. Sofia Iqbal
Associat Prof. Ophthalmology
HMC,
Dr. Nazullah
Assistant Prof. Ophthalmology
Dr. Naz Jehangir
Medical Officer Ophthalmology
HMC, Peshawar
Table
1:
|
Laterality
of the eye |
Age |
Sex |
Aetiology |
Preoperative
BCVA |
Postoperative
BCVA after one day |
Postoperative
BCVA after two months |
Postoperative
BCVA after six months |
Complications |
|
Lt eye |
35 yrs |
Male |
Trauma (Traumatic lens
Subluxation) |
6/60 |
6/24 |
6/12 |
6/9 |
None |
|
Lt eye |
60yrs |
Male |
Complicated surgery (posterior
capsular rupture with vitreous loss) |
6/36 |
6/36 |
6/24 |
6/9 |
None |
|
Rt eye |
13yrs |
Male |
Trauma (Traumatic lens
subluxation) |
6/24 |
6/18 |
6/18 |
6/6 |
Intraoperative Vitreous
bleed |
|
Lt eye |
35 yrs |
Male |
Marfan Syndrome Lens dislocation
to AC |
6/12 |
6/9 |
6/9 |
6/9 |
None |
|
Rt eye |
56yrs |
Female |
Complicated surgery (posterior
capsular rupture with vitreous loss) |
6/24 |
6/18 |
6/12 |
6/12 |
None |
|
Lt eye |
65yrs |
Male |
Psuedoexfoliation complicated
cataract surgery (posterior capsular rupture vitreous loss) |
6/18 |
6/36 |
6/18 |
6/18 |
Suture erosion |
|
Lt eye |
60yrs |
Female |
Complicated surgery (posterior
capsular rupture with vitreous loss) |
6/12 |
6/24 |
6/12 |
6/12 |
Suture erosion |
|
Rt Eye |
60yrs |
Female |
Complicated surgery (posterior
capsular rupture with vitreous loss) |
6/24 |
6/36 |
6/18 |
6/18 |
Intraoperative Vitreous
bleed |
|
Rt Eye |
34 yrs |
Male |
Traumatic (Traumatic posterior
capsular rupture vitreous loss) |
6/24 |
6/36 |
6/24 |
6/24 |
Lens tilt due to vitreous tag |
|
Lt Eye |
57yrs |
Male |
Complicated surgery(posterior
capsular rupture with vitreous loss) |
6/18 |
6/18 |
6/24 |
6/36 |
CME |
|
Lt Eye |
11yrs |
Male |
Congenital lens aspiration ( No
Posterior capsular Support Aphakia) |
6/18 |
6/12 |
6/12 |
6/12 |
None |
|
Lt
Eye |
14yrs |
Male
|
Microspherophakia/
Ectopia lentis |
6/24 |
6/18 |
6/9 |
6/9 |
None |
|
Lt Eye |
45yrs |
Male |
Multiple Intraocular surgery
(Aphakic) |
6/24 |
6/36 |
6/24 |
6/12 |
None |
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