Scleral fixation of dislocated posterior chamber intraocular lenses: Temporary haptic externalization through a clear corneal incision

PURPOSE: To report the results of managing dislocated posterior chamber intraocular lenses (PC IOLs) by externalizing the haptics through a clear corneal incision. SETTING: The Retina Center at Pali Momi, Aiea, Hawaii, USA. METHODS: This retrospective consecutive series comprised cases in which a dislocated PC IOL was managed with pars plana vitrectomy. With this method, the dislocated PC IOL is retrieved and stabilized in the anterior chamber. The haptic is externalized through a clear corneal incision for suture knot placement and then reinserted. A scleral fixation suture is placed 1.25 mm posterior to the limbus under a scleral flap. RESULTS: The study included 14 eyes of 14 patients with a minimum follow-up of 6 months (median 15.4 months). There were 2 subluxated PC IOLs, 11 posteriorly dislocated PC IOLs, and 1 in-the-bag IOL dislocation. Postoperative vision and/or visual symptoms were stable or improved in 86% of eyes. Two eyes had worse vision caused by conditions not related to surgery including chronic cystoid macular edema from latanoprost use and optic atrophy. All IOLs were well fixated and stable, although 1 eye with asymmetric haptics had a slightly tilted IOL. CONCLUSIONS: Dislocated PC IOL management by externalizing the haptic through a clear corneal incision stabilized the IOL in the anterior chamber, minimized intraocular operative manipulations, and allowed easier placement of the opposite haptic over residual capsule, if available. Stable fixation was achieved without dislocation or IOL-related complications recurring.     

Sutureless intrascleral posterior chamber intraocular lens fixation

We report a technique for sutureless fixation of standard 3-piece posterior chamber intraocular lenses (PC IOLs) in the ciliary sulcus in eyes without capsule support, which we have used in cases of subluxated and luxated cataract and for secondary IOL implantation. Fixation of the haptics in a limbus-parallel scleral tunnel allows exact centration and provides axial stability of the PC IOL to prevent distortion. The technique uses uncomplicated maneuvers for standard 3-piece PC IOL fixation without the need for special haptic architecture or preparation.     

Autologous blood-assisted scleral fixation of intraocular lens

In this technique, the lamellar scleral tunnel is fashioned to cover IOL haptics and autologous blood is used to close the conjunctiva, which alleviates the need for fibrin glue. The cornea is marked at four and 10''O clock meridian, and 2 mm incision is made on the conjunctiva. A lamellar scleral tunnel is fashioned 2 mm superior on one side and 2 mm inferior on the other side of this mark. The IOL is inserted into the anterior chamber and the haptics are exteriorized using bent 26-gauge hypodermic needle, flanged, and buried in the tunnel. A visible conjunctival blood vessel is punctured, allowing the blood to pool underneath the conjunctiva. The conjunctiva is approximated with the help of blood coagulum and allowed to remain dry for 3 min. Lamellar scleral tunnels give adequate cover to haptics, and autologous blood can be used to glue the conjunctival flaps instead of fibrin glue.     

Ultrasound biomicroscopy of haptic position after transscleral fixation of posterior chamber intraocular lenses

PURPOSE: To determine the haptic position of ab externo transsclerally fixated posterior chamber intraocular lenses (PC IOLs) by ultrasound biomicroscopy (UBM). SETTING: Mansoura Ophthalmic Center, Mansoura University, Mansoura, Egypt. METHODS: Ultrasound biomicroscopy was used to determine the haptic position in relation to the ciliary sulcus, iris, and ciliary body in 20 patients with transsclerally fixated PC IOLs. The patients ranged in age from 10 to 65 years. RESULTS: All IOL haptics were easily visualized and imaged by UBM. Of the 40 IOL haptics, 22 (55.0%) were located in the sulcus, 11 (27.5%) anterior to the sulcus, and 7 (17.5%) posterior to the sulcus region. CONCLUSIONS: Ab externo scleral fixation of PC IOLs is a blind procedure in most cases. Ultrasound biomicroscopy showed the difficulty in reliably placing the haptics in the ciliary sulcus using this technique. Thus, endoscopic visualization of the iridociliary angle during surgery is recommended.     

无后囊不缝线后房型人工晶状体巩膜层间固定术

目的 研究无后囊支持的后房型人工晶状体不缝线巩膜层间固定的方法及应用价值。方法 ２３例无后囊支持患者,将人工晶状体两袢不缝线而固定于水平位置的巩膜层间,随访１０～３４月,平均１６．６月。结果 视力≥０．５者１９眼（８２．６％）。术后高眼压６眼,前房出血１眼,１周内消退,视网膜脱离１眼,人工晶状体位置均良好,固定切口无渗漏。结论 该术式简便经济,能减少并发症,人工晶状体位置稳定。     

巩膜面直接缝线固定人工晶体术

探讨后房型人工晶体缝线固定植处的简易术式。方法采用不做巩膜瓣,直接在巩膜表面进出针。并将固定线直接缝扎在巩膜表面的方法对２９例行人工晶体缝线固定术,并对其追踪观察。     

巩膜固定后房型人工晶状体植入术的临床观察

目的：观察巩膜固定后房型人工晶状体植入术治疗玻璃体切除后无囊膜支撑的无晶状体眼的效果。

方法：回顾分析采用巩膜固定后房型人工晶状体植入术治疗的14例14眼患者资料。在2：00,8：00位角膜缘后1.5mm处巩膜瓣下穿刺引出三片式折叠人工晶状体的双襻,将襻插入预制巩膜隧道内固定,缝合巩膜瓣覆盖穿刺口及襻。

结果：患者14例均顺利植入人工晶状体,术后随访6～12mo,患者视力提高、人工晶状体位置稳定、眼压正常、无重大并发症。

结论：应用巩膜固定后房型人工晶状体植入术治疗无囊膜支撑的玻璃体切除后无晶状体眼安全性高,操作简便,疗效确切,值得进一步观察与实践。     

Ab externo iris fixation of posterior chamber intraocular lens through small incision

During secondary posterior chamber intraocular lens (PC IOL) implantation with iris fixation in the absence of capsule support, we implanted an acrylic 3-piece PC IOL through a small clear corneal incision with haptics secured in knots; there was no need for IOL capture. Sutures were placed appropriately in the iris tissue before the IOL was inserted, ensuring safety of the procedure and centration of the IOL.     

无巩膜瓣后房型人工晶状体缝线固定术的临床观察

目的评价无巩膜瓣后房型人工晶状体(IOL)双襻固定术的技巧及效果。方法对20例(20眼)因各种原因致晶状体后囊膜破裂较大或囊膜完全缺损而不能行囊袋内或前囊膜睫状沟IOL植入患者,用无巩膜瓣的"W"形巩膜层间缝合技术固定双襻后房型IOL,术后随访3～18个月,观察临床效果及术中、术后并发症。结果术后视力≥0.5者8眼(40%),0.3～0.5者8眼(40%),0.15～0.3者4眼(20%);术中、术后并发症:玻璃体出血1例,低眼压2例,IOL偏移2例。结论无巩膜瓣的"W"形巩膜层间缝合技术固定双襻后房型IOL操作简单,术中、术后并发症少,值得临床推广。     

Recurrent microhyphema despite intracapsular fixation of a posterior chamber intraocular lens

A 61-year-old woman experienced multiple episodes of transient visual blurring in her pseudophakic eye, each of which lasted about 1 hour. Repeat examination during a symptomatic episode revealed anterior chamber red blood cells consistent with a microhyphema in the pseudophakic eye despite intracapsular fixation of a posterior chamber intraocular lens (PC IOL). Ultrasound biomicroscopy confirmed intracapsular fixation of the IOL haptics and revealed proximity of the edge of the IOL optic to the inferior pupillary margin in the region of an iridociliary body cyst. Uveitis-glaucoma-hyphema syndrome may occur despite intracapsular fixation of a PC IOL.     

Secondary posterior chamber intraocular lens implantation without scleral fixation

AIM: Retrospective evaluation of results of secondary PC IOL implantation without scleral fixation. MATERIAL AND METHODS: 29 eyes of 21 patients including 8 children underwent secondary PC IOL implantation into the sulcus. In all these eyes there was partially or completely preserved posterior capsule. RESULTS: Final postoperative visual acuity of 20/40 or better was achieved in 82.7% of the eyes with PC IOL. CONCLUSION: Secondary PC IOL implants give good anatomical and functional results.     

Long-term observation of the refraction with a reversed-optic posterior chamber intraocular lens

A 73-year-old man had phacoemulsification and implantation of a posterior chamber intraocular lens (PC IOL) in both eyes. In the right eye, the optic was unintentionally reversed in the bag. In the left eye, the posterior capsule was ruptured and the IOL haptics were fixated in the ciliary sulcus. The refraction in the sulcus-fixated left eye was stable from 1 month to 4 years. The right eye had a myopic shift at 1 month, with a regression of 1.50 diopters that continued for 2 years. The final IOL position in the right eye was 0.25 mm anterior to the position predicted by the SRK/T formula. It took 2 years for the refraction in the eye with the reversed-optic PC IOL to become stable. A large myopic shift and gradual regression in refraction may stem from a different wound-healing reaction than that of properly fixated IOLs.     

Trocar-assisted sutureless intrascleral posterior chamber foldable intra-ocular lens fixation

Purpose

We report a novel technique characterized by sutureless scleral fixation of three-pieces foldable intraocular lens (IOL) using 25-gauge transconjunctival sutureless vitrectomy (TSV) trocars in patients with insufficient posterior capsule support.

Materials and Methods

We performed this technique on the eight eyes of the seven patients. The scleral tunnels (STs) are prepared by insertion of the 25-gauge TSV microcannulas using the trocars, and anterior vitrectomy is performed through the clear corneal paracentesis with the aid of anterior chamber maintainer (ACM). Finally, the three-piece foldable IOL haptics are incarcerated into the prepared STs.

Results

The patients were followed up 5–8 months. None of the patients had complications such as postoperative endophthalmitis, glaucoma, IOL tilt or decentralization, and retinal detachment. Injection of a foldable IOL through a clear corneal small incision also contributes the less surgical-induced astigmatism.

Conclusion

The presented novel sutureless scleral IOL fixation technique may provide minimal trauma to the surrounding tissues, good IOL stabilization decreasing the incidence of IOL tilt along with shorter operation time, and postoperative quiet eye.     

Original three-point fixation technique for sutured posterior chamber intraocular lens

PURPOSE AND METHODS: In order to avoid the complications associated with posterior chamber intraocular lens (IOL) scleral fixation, the authors have developed an original surgical technique by which the IOL is secured at the ciliary sulcus by suturing the haptics to the sclera in three points (at the 3, 5 and 9 o'clock positions). This technique was utilized for secondary IOL implantation in 21 aphakic eyes. The mean follow-up was 18 months, range 6-28 months. RESULTS: All eyes that underwent secondary implants had equal or better visual acuity postoperatively; none developed serious intra- or postoperative complications. No tilt or decentration of the IOL was observed postoperatively. DISCUSSION: The technique described appeared easy to perform and produced good visual outcomes with stable transscleral fixation of the IOL.     

Implantation of scleral-fixated posterior chamber intraocular lenses

A surgical technique for implanting a posterior chamber intraocular lens (IOL) in eyes without capsular or zonular support is presented. A 10-0 polypropylene suture attached to a standard needle is tied to the apex of each haptic and passed transclerally through the ciliary sulcus to secure the haptics at the 3 o'clock and 9 o'clock meridians. This technique produced good visual results in six aphakic patients who were contact lens intolerant, two patients in whom capsular or zonular rupture at the time of cataract surgery precluded standard nonsuture fixation techniques, one patient who had intracapsular cataract extraction for a subluxated, cataractous lens, and one patient who had secondary IOL implantation in combination with penetrating keratoplasty for aphakic bullous keratopathy. Advantages over other techniques of posterior chamber lens implantation in the absence of capsular support include technical ease, avoidance of iris fixation, and more precise placement of scleral fixation sutures, thus minimizing IOL decentration.     

后囊破损的Ⅱ期后房型人工晶体植人术

目的探讨后囊破损Ⅱ期后房型人工晶体植入术的临床疗效。方法对２２例（２２只眼）后囊破损的白内障术后患者,根据后囊破损的大小和位置,分别采用睫状沟或囊袋内固定和缝线睫状沟单襻或双襻固定的Ⅱ期后房型人工晶体植入术。结果后囊破损的Ⅱ期后房型人工晶体植入术术后矫正视力≥０．５者占５９．１％（１３例）,术后前房及人工晶体表面渗出者占２２．７％（５例）,而同期所做的后囊破损的Ⅰ期后房型人工晶体植入术者术后矫正视力≥０．５者占４０％,术后前房及晶体表面渗出者占４０％。结论后囊破损的白内障患者,在破损的范围不能确定或范围过大时,主张选择Ⅱ期后房型人工晶体植入术。     

Evaluation of suturless scleral fixation with posterior chamber foldable intraocular lens implantation

AIM: To assess the sutureless scleral fixation technique for posterior chamber foldable intraocular lens (PCIOL) implantation in aphakic eyes with insufficient or no capsular support. METHODS: A technique for sutureless intrascleral fixation of the haptics of a standard 3-piece PCIOL was used which ensures sutureless fixation by permanent incarceration of the haptics in a scleral tunnel parallel to the limbus. All patients were evaluated for preoperative status [visual acuity, refractive error, K readings, intraocular pressure (IOP) measurement, slit lamp examination, fundus examination and optical biometry], postoperative status and complications. Ultrasound biomicroscopy (UBM) was done for 10 cases to evaluate optic tilt. RESULTS: The study evaluated 42 eyes of 42 patients. The follow-up period was 6mo. Improvement of best corrected visual acuity (BCVA) one line occurred in 10 cases (23.8%) and loss of one line in 3 cases (7.1%). Intraoperative complications included: haptic kink in 4 cases (9.5%), haptic breakage in 1 case (2.4%), haptic dislocation in 1 case (2.4%), haptic slippage in 3 cases (7.1%), IOL dislocation in 1 case (2.4%) and sclerotomy related bleeding in 1 case (2.4%). Postoperative complications included: transient mild vitreous hemorrhage in 3 cases (7.1%), choroidal detachment in 1 case (2.4%), cystoid macular edema (CME) in 1 case (2.4%), optic capture in 1 case (2.4%), subconjunctival haptic in 2 cases (4.8%), ocular hypotony in 4 cases (9.5%) and ocular hypertension in 1 case (2.4%). There were no cases of retinal detachment or endophthalmitis. UBM showed optic tilt in 3 cases (30%). CONCLUSION: Fixation of three-piece foldable IOL haptics in scleral tunnel parallel to the limbus- provided axial stability and proper centration of the IOL with minimal or no tilt in most cases and a low complication rate during the follow up period which lasted 6mo.     

应用超声生物显微镜观察后房型人工晶体植入术后的房角改变

目的用超声生物显微镜观察老年性白内障囊外摘除术及后房型人工晶体植入术后房角的变化及相关因素。方法用超声生物显微镜观察老年性白内障囊外摘除术及后房型人工晶体植入术后,３１例（４１只眼）的房角改变。结果虹膜周边前粘连６只眼,瞳孔变形１２只眼,均与人工晶体襻的位置有关;并非所有非囊袋内固定的人工晶体襻均位于睫状体沟;术后残留的晶体皮质,术后３个月仍存留,较多晶体皮质的残留可引起周边虹膜膨隆、房角变窄。结论后房型人工晶体植入术后房角的改变与人工晶体襻的位置及残留的晶体皮质有关;建议尽可能采用囊袋内植入人工晶体,避免过多的晶体皮质残留。     

改良YAMANE式巩膜层间无缝线后房型人工晶状体固定术的疗效观察

目的:观察YAMANE式巩膜层间无缝线后房型人工晶状体固定术的术后效果、安全性及并发症。方法:病例随访观察。选取2017-12/2018-09于华西医院眼科行YAMANE式巩膜层间无缝线后房型人工晶状体固定术患者5例,定期随访患者术后的裸眼视力(LogMAR)、最佳矫正视力(LogMAR)、等效球镜度数、眼压及人工晶状体位置等。结果:患者3例术后矫正视力达0.0,术后等效球镜度数与目标屈光度相差为0.11~0.62D。术后3mo,1例患者裸眼视力达术前最佳矫正视力0.2,另1例患者术前存在角膜白斑及黄斑前膜牵拉水肿,矫正视力达到了术前验光最佳矫正效果。随访期间所有患者的人工晶状体袢凸缘及袢均保持在巩膜层间良好的位置,人工晶状体位置居中,未见明显偏心及倾斜。所有病例术后均未出现低眼压及其它并发症。结论:YAMANE式巩膜层间无缝线后房型人工晶状体固定术切口小,无需制作巩膜瓣,不使用缝线及生物胶,手术时间短,人工晶状体位置居中且固定良好。此手术方式需要经过一定的学习曲线,掌握术中关键点操作,可以为患者带来快速、良好、稳定的术后效果,且术后并发症少。     

Intraocular lens decentration and posterior capsule opacification: anatomo-pathologic findings after implantation of AMOSI40 IOLS

PURPOSE: To evaluate the incidence of intraocular lens (IOL) decentration and posterior capsule opacification (PCO) after implantation of a three-piece posterior chamber silicone IOL in a series of eyes examined postmortem. METHODS: Twenty-three pseudophakic enucleated human cadaver eyes, implanted with AMO SI40NB IOLs after phacoemulsification, were analyzed. Eyes obtained postmortem were sectioned at the equatorial plane and the anterior segment photographed from a posterior view. Location of IOL optic and haptics, type of fixation, and centration of IOL was evaluated. PCO was graded and the presence of Nd:YAG laser posterior capsulotomy was noted. RESULTS: Mean age at the time of surgery was 77.83 years, mean time since implantation was 18.26 months. In all the eyes examined, IOL haptics were positioned in the capsular bag. Mean decentration was 0.20+/-0.16 mm. No correlation was found between IOL decentration and time since implantation. The degree of peripheral PCO ranged from none (13.0%) to mild (39.1%) to moderate (26.1%) to severe (21.7%). The degree of central PCO ranged from none (52.2%) to mild (30.4%) to moderate (4.3%). Three patients (13.0%) underwent Nd:YAG laser posterior capsulotomy. CONCLUSIONS: A very good centration can be obtained when silicone AMOSI40NB IOLs are correctly implanted with the haptics inside the capsular bag. About half of the implants showed no central PCO while Nd:YAG laser posterior capsulotomy rates documented a relatively low PCO 18 months after surgery. A careful in the bag haptics placement is needed in order to reduce the IOL decentration and to prevent central PCO.