Subluxated or malpositioned intraocular lenses (IOLs) and inadequate capsular support is a challenge for every ophthalmic surgeon. Iris suture of an IOL seems to be an easy technique for the management of dislocated 3-piece IOL, allowing the IOL to be placed behind the iris, far from the trabecular meshwork and corneal endothelium. The purpose of this study is to assess the results of pars plana vitrectomy (PPV) and iris suture of dislocated 3-piece acrylic IOLs.
In this retrospective, nonrandomized, interventional case consecutive study, of a total of 103 dislocated IOLs, 36 eyes were considered for analysis. All 36 eyes had subluxated or totally luxated 3-piece IOL and underwent iris suture at the Ophthalmology Department of Santa Maria Hospital-North Lisbon Hospital Center, Portugal, from January 2011 until November 2015. All patients underwent 3-port 23-G PPV. The optic zone of the dislocated IOL was placed anterior to the iris with the haptics behind, in the posterior chamber. Haptics were sutured to iris followed by placement of the optics behind iris plane. Postoperative measures included best-corrected visual acuity (BCVA), IOL position, intraocular pressure, pigment dispersion, clinical signs of endothelial cell loss, and development of macular edema.
A total of 36 eyes of 36 patients were included. All underwent successful iris fixation of dislocated 3-piece IOL. Mean overall follow-up was 15.9 months (range 3-58 months). At presentation, 16 eyes (44.4%) had a luxated IOL and 20 eyes (55.6%) a subluxated IOL. As underlying cause, 17 eyes (47.2%) had a history of complicated cataract surgery, 5 eyes (13.9%) had a traumatic dislocation of the IOL, and 6 eyes (16.7%) had a previous vitreoretinal surgery. A total of 8 eyes (22.2%) had late spontaneous IOL dislocation after uneventful cataract surgery. The mean preoperative BCVA was 1.09 ± 0.70 logarithm of the minimal angle of resolution (logMAR) units and mean postoperative BCVA was 0.48 ± 0.58 of logMAR units. The mean visual acuity improvement was 4.08 ± 5.33 lines on the logMAR scale. In this study, every IOL was stable at the last follow-up. As late complications, macular edema occurred in 1 patient and retinal detachment occurred in 2 patients. There were no cases of endophthalmitis.
Iris suture fixation of subluxated IOL is a good treatment option for eyes with dislocated IOLs, leading to long-term stability of the IOL. The advantage of this procedure is using the same IOL in a closed eye surgery. No astigmatic difference is expected as no large corneal incision is needed.
Eur J Ophthalmol 2017; 27(1): 45 - 48
Article Type: ORIGINAL RESEARCH ARTICLE
AuthorsMun Y. Faria, Nuno P. Ferreira, Mario Canastro
- • Accepted on 01/06/2016
- • Available online on 23/06/2016
- • Published in print on 19/01/2017
This article is available as full text PDF.
Phacoemulsification is one of the most common surgeries worldwide (1). Improvement in surgical devices and intraocular lenses (IOLs) has made modern cataract surgery a safe procedure with decreasing complication rates. However, following capsular rupture, IOL dislocation is a serious complication. Although most dislocations occur during the first week of the postoperative period, late IOL dislocation occurring 3 months or later postsurgery has been reported frequently as a result of insufficient capsular support, trauma, or zonular dehiscence (2, 3). Subluxated or malpositioned IOLs and inadequate capsular support is a challenge for every ophthalmic surgeon. Anterior chamber IOLs (ACIOLs), posterior chamber scleral sutured IOLs, or iris-fixated IOLs are common surgical options. A 2003 report by the American Academy of Ophthalmology came to the conclusion that there was no evidence of superiority of one or another option (3). Although modern ACIOL designs have been improved, corneal decompensation and chronic inflammation still occur frequently (4, 5).
Even when performed by experienced surgeons, IOL exchange may lead to endothelial cell loss and chronic corneal edema (6). Scleral fixation of IOLs, placed behind iris, avoids some of these problems. This technically challenging surgery also has disadvantages, such as IOL tilting, suture exposure, and intraocular hemorrhage. Iris suture of an IOL seems to be an easy technique for dislocated 3-piece IOL. It is placed behind the iris, far from the trabecular meshwork and corneal endothelium. Nevertheless, care must be taken to avoid pigment dispersion and peripheral anterior synechia after this technique (6).
Totally or partially dislocated 3-piece IOLs placed by the same surgeon at the Retina and Vitreous Department of Santa Maria Hospital from January 2011 to November 2015 were reviewed.
Inclusion criteria were eyes with subluxated or dislocated 3-piece IOL with vision of at least light perception (LP). All patients had at least 3 months of follow-up. The following cases were excluded: single-piece IOL, eyes with no LP (NLP), corneal decompensation, advanced glaucoma, iris neovascularization, or aniridia.
The data collected included demographic information, details on cataract extraction surgery, best-corrected visual acuity (BCVA) on the logarithm of the minimal angle of resolution (logMAR) scale, information on fixation surgery, and intraoperative and postoperative complications. For statistical analysis, the logMAR scale was used instead of the Snellen scale. Vision of counting fingers, hand movements, LP, and NLP were converted, respectively, to logMAR values of 1.7, 2.0, 2.5, and 3.0. Every eye with dislocated IOL had preoperative low or unstable vision.
Statistical analysis was performed using STATA v13.0.
The study followed the tenets of the Declaration of Helsinki. Informed consent was obtained from the patients.
All eyes in this study had a posterior subluxation or luxation of a 3-piece IOL to vitreous cavity or retina, not amenable to management with an anterior segment approach. All cases lacked sufficient capsular support to allow sulcus placement alone.
Twenty-three-gauge pars plana vitrectomy (PPV) was used to release all prolapsed vitreous in anterior chamber or pupillary area. Core and peripheral PPV was performed with careful attention to release the IOL from surrounding vitreous before removal. Capsule remnants were removed. Perfluorocarbon liquids were used whenever necessary, to protect the macula and also to ensure an easier and safer manipulation of IOL. After corneal endothelium viscoelastic protection, the prolapsed IOL in vitreous or retina was grasped carefully with a forceps and the optics of IOL were then positioned in the anterior chamber, leaving the haptics behind the iris (
A total of 36 eyes of 36 patients were eligible for this review. All eyes underwent successful iris fixation of dislocated 3-piece IOL. This study included 9 women (25%) and 27 men (75%). Mean overall follow-up was 15.9 months (range 3-58 months). Mean age was 70.5 ± 17.6 years (range 26-94 years).
Of the 36 eyes, 16 (44.4%) had a luxated IOL and 20 (55.6%) had a subluxated IOL. As underlying cause, 17 eyes (47.2%) had complications from previous cataract surgery, 5 eyes (13.9%) had a traumatic dislocation of the IOL, and 6 eyes (16.7%) had a previous vitreoretinal surgery. Eight eyes (22.2%) had a late spontaneous IOL dislocation after uneventful cataract surgery (2 were congenital cataracts). Time from implantation to dislocation depended directly on the underlying cause. Traumatic dislocations had the shortest period of time and spontaneous dislocation the longest. In these spontaneous dislocations, both IOL and capsular bag complexes were luxated, mostly in high myopia or pseudoexfoliation syndrome. Two of them had capsular tension rings. Iris reconstruction was performed before IOL fixation in 3 cases. Most of the surgeries were performed under peribulbar anesthesia.
The mean preoperative visual acuity (VA) was 1.09 ± 0.70 logMAR and mean postoperative VA was 0.48 ± 0.58 logMAR. The mean VA improvement was 4.08 ± 5.33 lines in the logMAR scale. Final BCVA was 0.3 or better in 17 eyes, 0.4 to 0.5 in 6 eyes, and 0.6 or worse in 13 eyes because of other posterior pole pathology. A myopic shift was present in every patient, because of more anterior position of IOL.
Intraoperatively, there was no case of iridodialysis, anterior chamber bleeding, IOL dislocation, or other complications.
After surgery, peaked pupil was present in 5 eyes (13.8%). Six eyes (16.6%) were treated medically for ocular hypertension in 1 eye due to a postoperative hyphema, which was eventually reabsorbed in 10 days. Corneal edema when present was transitory in all cases. No clinical signs of endothelium dysfunction were present, nor were peripheral anterior synechiae.
No resubluxations occurred during the follow-up period. As late complications, 2 eyes (5.5%) developed retinal detachment after 8 months and 10 months, respectively, and 1 eye (2.7%) developed an epiretinal membrane after 2 years. All 3 patients had pars plana vitrectomy. One patient developed cystoid macular edema that was controlled with medical therapy. There were no cases of endophthalmitis.
Aphakia and no capsular support is challenging for ophthalmic surgeons. Anterior chamber IOLs, although easy to implant, can result in endothelial decompensation or secondary glaucoma (4, 5). Iris-claw IOLs are frequently used, but need a 5.4-mm corneal incision. In eyes with decreased corneal endothelial cell density, shallow anterior chamber, or glaucoma, iris or scleral sutured posterior chamber IOLs seem to be more adequate (4, 7). However, scleral sulcus-fixated posterior chamber IOL implantation has risks that include hemorrhage, suture extrusion, endophthalmitis, anterior synechia, and IOL tilting (8). Ultrasound biomicroscopy has revealed variability in haptic position, sometimes far from the intended ciliary sulcus position (9). A recent publication by Kim and Kim (10) comparing clinical outcomes of iris fixation and scleral fixation surgical treatment of IOL dislocation came to the conclusion that both techniques had similar efficacy in the repositioning of dislocated IOL, but some disadvantages were associated with iris fixation, such as immediate postoperative inflammation and luxation recurrence.
As with all IOL iris fixation techniques, the usual awareness of long-term IOL stability with the use of polypropylene suture use has to be considered, as well as the possibility of pigment dispersion or uveitis-glaucoma-hyphema syndrome (11).
This study is unique in that it includes only cases with 3-piece IOL subluxations or posterior dislocations into the vitreous cavity or retina. One-piece IOLs are more common; when dislocated, they are excised through a small corneal incision and another adequate IOL placed. However, 3-piece IOLs are more frequent in complicated cataract with inadequate capsular support or longstanding uneventful surgeries. Three-piece IOLs are easier for iris capture as the angled haptics are placed behind the iris plane for suture.
All cases had PPV and iris suture fixation of the same preexisting dislocated IOL. In the complicated cases included in this study, PPV and iris suture fixation generally led to improved BCVA. The sutured IOLs were stable in all cases.
Using PPV, there is minimal conjunctival manipulation and low risk of bleeding. No corneal incisions are needed and the IOL optic is secured during suture passage with the help of vitreous retinal forceps, allowing needle passage in a stable midperipheral iris.
The present study contributes to the existing literature on the surgical technique when dealing with subluxated IOLs with iris suture. Soiberman et al (6) published a study on 27 eyes with iris suture and PPV, reporting low surgically induced astigmatism and stable positioning of the IOL. Garcia-Rojas et al (12) reported 30 eyes with IOL iris fixation with good clinical outcomes and no complications observed on macular optical coherence tomography. However, this last article was about aphakia and no capsular support, and a 3-piece IOL was introduced through corneal incision and haptics were fixated to iris. There was no dislocated IOL in vitreous or retina and no PPV was performed. Another series of 47 eyes with iris suture IOLs for aphakia in the absence of capsule support was reported by Condon et al (13). There was no IOL dislocation, only aphakia with no capsular support, and a foldable IOL was inserted through corneal incision and sutured to iris.
Sutured IOL to iris is a safe technique and provides effective results, with or without PPV. Nevertheless, patient selection is important, concerning systemic diseases, angle structures, iris anatomy, and corneal pathology.
For a posterior segment surgeon, this seems to be the best way to deal with posterior dislocation of a 3-piece IOL, as the same IOL already inside the eye is cautiously placed and fixed in the best anatomic position, behind the iris.
Our results reveal reasonable visual outcomes and safety with iris-sutured 3-piece acrylic IOL, considering the severe preoperative conditions. Of course, a learning curve of the surgical technique exists, particularly in suture placement.
There was long-term stability of iris suture fixation of subluxated IOLs in these 36 eyes. After a learning curve, the technique seems to be a good treatment option for eyes with dislocated IOLs. There were no cases of ocular hypertension, signs of endothelial dysfunction, pigment dispersion in irido-corneal structures, or other complications.
The advantage of this procedure is using the same IOL in a closed-eye surgery. No astigmatic difference is expected as no large corneal incision is needed.
The authors thank the members of their Retina and Vitreous Department: Eliana Neto, Helena Proença, Carlos Neves, and Manuel Monteiro-Grillo; they also thank David Sousa and Ines Leal for their work and cooperation and a recommendation to the authors’ board that supported the idea of the study.