Intraocular Lens Placement in the Absence of Capsular Support: Visual Outcomes and Complications in a Philippine Tertiary Hospital

doi:10.21203/rs.3.rs-1558259/v1

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Research Article

Intraocular Lens Placement in the Absence of Capsular Support: Visual Outcomes and Complications in a Philippine Tertiary Hospital

https://doi.org/10.21203/rs.3.rs-1558259/v1

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Purpose:

Surgical correction of aphakia without capsular support continues to be a challenge. Rapid rise in technology has provided advancements in techniques in surgical management of aphakia. Locally, we have limited data on the outcomes of the different techniques. This study aimed to determine visual outcomes and complications associated with different techniques of intraocular lens implantation in the absence of capsular support.

Setting:

The study was conducted at the Philippine General Hospital in Manila, Philippines.

Design:

This was a retrospective chart review study in a single center.

Methods:

We reviewed the medical charts of 207 patients who underwent intraocular lens implantation without capsular support. Excluded were patients with incomplete follow up, pediatric patients, and lost records. Best corrected visual acuity at day 1, 1st month, 3rd month and 6th month postoperatively, and the complications were noted.

Results:

Mean age was 60 with 51% (n=105) were females. Loss of capsular support was most frequently caused by intraoperative complication (n=146, 70%) and trauma. Retropupillary fixation iris claw intraocular lens was frequently used (n=93, 44.9%). Across all patients, visual acuities showed excellent outcomes with 20/50 or better. The presence of dense cataracts (p=0.0088) was associated with postoperative complications. Across IOL types, the most frequent postoperative complication was increase in IOP. Statistically significant results were set at P <0.05.

Conclusion:

Intraocular lenses used in aphakia showed good postoperative visual acuities. Complications include elevated intraocular pressures, corneal edema, and pigment dispersion. Knowledge on the outcomes maximizes the chances of optimal surgical and visual outcomes.

Aphakia

phacoemulsification

retropupillary iris claw

anterior chamber lens

Philippines

This study identified the outcomes and complications associated with IOL implantation without capsular support. Visual outcomes were excellent however, most frequent complication was increase in IOP. This provided additional knowledge to improve outcomes.

Cataract, as one of the leading causes of visual impairment and treatable blindness worldwide, is generally a surgical disease. The advent of modern equipment and techniques nowadays has employed rapid improvements in the field of surgical management of lenticular opacities. The idea of surgical removal of cataract is with respect to the original placement of the natural lens, and our goal of surgery for optimum outcomes is to replace the cataract with an intraocular lens placed in its natural, intact posterior capsular bag. Successful intraocular lens (IOL) placement in cataract surgery is equivalent to IOL being placed in the capsular bag, and this maximizes the chances of optimal surgical and refractive outcomes^1,2. However as in any surgery, complications are unavoidable and cause distress to the surgeon and the patient. Certain causes to compromised capsular integrity results from a myriad of conditions such as ocular traumas, inherent zonular weaknesses, and complicated cataract surgeries. In such cases of inadequate capsular support, the surgeon must use be able to maneuver and use alternative surgical techniques or approaches to place an IOL in the eye and not leave a patient aphakic.

Surgical correction of aphakia without capsular support remains a challenge, but there are different options. The following are the surgical options for IOL implantation in times of posterior capsular rupture performed in the institution: anterior chamber intraocular lens³, retropupillary fixation intraocular lens⁶, transscleral-sutured intraocular lens, glued intraocular lens¹ and iris-sutured intraocular lens.

The fast rise in technology has yet provided rapid developments in techniques in surgical management of aphakia worldwide and yet locally, we have limited data on the outcomes of these different techniques following intraocular lens implantation without capsular support, more particularly outcomes on the newer techniques.

This study aimed to determine visual outcomes and complications associated with different techniques of intraocular lens implantation in the absence of capsular support. Specifically, this study aimed to describe demographics of patients who underwent intraocular lens implantation in the absence of capsular support based on age, gender, and laterality. We identified the etiologies for the loss of capsular support (i.e., intraoperative complication, dislocated lens secondary to an inherent zonular / lens disease, dislocated lens due to trauma, dislocated intraocular lens), and identified preoperative (i.e., presence of small pupil, dense cataracts, phacodonesis, myopia, trauma) and intra-operative (i.e., posterior capsular rent and/or dropped nuclear fragments) risk factors affecting visual outcomes. We also determined if intraocular lens implantation is performed either primary (same sitting with lens extraction) or secondary (staged procedure), and identified the postoperative complications (i.e., increased intraocular pressure (IOP) with or without the need for glaucoma co-management, dropped intraocular lens, corneal edema, corneal decompensation, intraocular lens decentration, retinal detachment, pigment dispersion and others).

We reviewed the medical charts of 207 patients who underwent intraocular lens implantation in the absence of capsular support. Our study was approved by the University of the Philippines-Manila Ethics Review Board prior to the conduct of the study. Patients with preexisting retinal pathology, glaucoma, corneal, and optic nerve pathology were included, however they were excluded in the analyses of visual outcomes. Exclusion criteria were patients with less than 2 months of follow up, pediatric patients, and lost and incomplete medical records.

The following parameters were recorded: best corrected visual acuity at day 1, 1st month, 3rd months and 6th months (if applicable) postoperatively, and the complications noted at this time. Primary variables including demographics (age, gender, laterality), peri-operative risk factors such as ocular comorbidities, type of cataract surgery, type of IOL implanted and correlation between the parameters mentioned were recorded.

Data collected subjected for statistical analyses. Frequencies and percentages determined for categorical variables. Descriptive statistics namely mean, mode and standard deviations were reported for numeric variables. Snellen BCVA was converted into logarithm of the minimal angle of resolution (logMAR) units for analysis. Chi-square and Fisher's exact tests were used to determine the possible relation between two cat egorical variables. Analysis of Variance (ANOVA) were used to compare averages of numeric variables by IOL type. Data analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Released 2011, Armonk, NY, USA). P < 0.05 was considered statistically significant.

A total of 207 eyes from 205 patients were included in the study, with a mean age of 60, and more than half of the patients being above 60 years of age (n = 110). The patients were almost equally distributed between males (n = 102, 49%) and females (n = 105, 51%). There were more patients operated on the right (n = 114, 55%). Demographics of patients are seen in Table 1.

Table 2 showed that loss of capsular support was most frequently caused by intra-operative complications (n = 146, 70%). The intraocular lens implantation was performed as primary (same sitting with lens extraction) or secondary (staged procedure) with almost equal frequency (n = 106, 51%, n = 101 49%).

In Table 3, almost 60% of the patients had no preoperative risks, and among those who did, the most frequent were dense cataract (n = 25, 17.1%) and trauma (n = 19, 13%).

The distribution of the type of intraocular lens were summarized in Table 4. Retropupillary fixation iris claw intraocular lens was used in 93 eyes (44.9%), transscleral-sutured intraocular lens in 64 eyes (30.9%), and anterior chamber intraocular lens in 48 eyes (23.2%). One patient had iris-sutured intraocular lens. In this study, the trends of intraocular lens preference were determined. Supplemental Fig. 1 showed that for every different type of surgery, different IOLs were preferred by surgeons. Anterior chamber IOLs were more used in ECCEs, iris claw IOLs in phacoemulsification and transscleral IOLs in intracapsular lens extraction. However, despite the increasing number of anterior chamber IOLs used in ECCEs, a different trend of IOL use was seen per year. Supplemental Fig. 2 showed that there is increasing preference towards use of iris claw intraocular lenses from 2015 to 2019 in the institution. The easier use for iris claw intraocular lenses paved way to a quicker IOL implantation, hence less intraoperative time, and less complications.

Across all eyes, the logarithm of the minimal angle of resolution (logMAR) decreased as they progressed farther from the preoperative day, with the significant decrease starting at Day 30 (1 month) (Table 5). At each time point, there was a significant difference in the average logMAR between the three IOL types, except at Day 1. On the preoperative time point, the average logMAR for eyes with anterior chamber intraocular lens was significantly higher than for the other two IOL types (p-value = 0.0024) (Table 5). At Day 30, the average logMAR for eyes with transscleral-sutured intraocular lens was significantly higher than for the other two IOL types (p-value = 0.0003) (Table 5). The same pattern can be seen at Day 90 (p-value = 0.0025) and at Day 180 (p-value = 0.0303) (see supplemental Fig. 3).

Table 6 showed that regardless of IOL type, the most frequently experienced postoperative complication was an increase in intraocular pressure, with 47 eyes (32%). From these 47 eyes, 10 eyes progressed to glaucoma. Mean intraocular pressure was 25mmHg. For eyes with anterior chamber intraocular lens, 7 eyes (23%) experienced corneal edema and 3 eyes (10%) experienced pigment dispersion. Other complications were cystoid macular edema, bullous keratopathies, and choroidal effusions. For eyes with retropupillary fixation iris claw intraocular lens, corneal edema in 19 eyes (27.1%) was frequently noted. For eyes with transscleral-sutured intraocular lens, the complications were corneal edema, retinal detachments, corneal decompensation, macular edema, and vitreous hemorrhage. The presence of preoperative risk factors was correlated with postoperative complications, where dense cataracts were significantly associated (p-value = 0.0088).

Various techniques of addressing the clinical dilemma of placing an intraocular lens in the absence of capsular support are present and well-published. However, the fast-changing times showed different trends and innovations in the art of placing an intraocular lens. Locally, a study done by Villanueva et al at the Philippine General Hospital from 2010 to 2015 showed more preference towards use of anterior chamber intraocular lenses¹⁴. Visual outcomes were excellent, and there were varying complications noted in the study. Comparable to this, this study showed a contrast to Villanueva et al study. The most common type of IOL used were the anterior/angle supported IOL and transsclerally sutured IOL, 50 (45.45%) and 42 (38.18%) respectively. From 2015 to 2019, a shift towards implantation of iris claw intraocular lenses was seen. It was also evident that from 2010, glued, sutured and transscleral intraocular lenses were preferred, but comparing this with 2015, almost all surgeries used anterior chamber intraocular lenses and iris claw IOLs. Iris claw intraocular lenses provided the surgeons with faster surgical time, smaller incisions resulting to better refractive results, placement of the IOL near the sulcus and bag approximated an almost similar refractive result with that of in-the-bag placement and availability.

Visual outcomes-wise, we saw a significantly improved vision in all eyes across different intraocular lenses. A study done by Huang et al in 2011 on outcomes of cataract surgery was performed using a population-based, cross-sectional study conducted in people aged 50 years or more in the Liwan District of Guangzhou, China. Visual outcomes were noted to be significantly improved. Results revealed favorable visual outcomes with almost 50 percent of the population underwent phacoemulsification surgery, and the rest is shared by extracapsular and intracapsular methods of cataract extraction. Another study by Mohammadi in 2015 at Tehran, Iran revealed almost 90 percent of the eyes from the population study underwent phacoemulsification with intraocular lens implantation and had favorable visual outcome results.

The complications recorded were retinal abnormalities, glaucoma and post capsular opacification. Complications varied across studies. Mohamaddi et al in 2015 reported that the leading contributory reasons for unfavorable outcome, in descending order were maculopathy, posterior capsule opacification, corneal opacity, and degenerative myopia. Olawaye et al in 2011 performed an observational descriptive, longitudinal study of consecutive patients undergoing cataract surgery where they reported that the most common complication reported was glaucoma. A study done by Vounotrypidis in 2018 investigated preoperative ocular risk factors and indications for secondary intraocular lens implantation and compared postoperative complications, visual and refractive outcomes in a tertiary referral center in Germany. Leading causes for surgery were IOL dislocation (75%), followed by secondary aphakia (19%) and IOL opacifications (6%). Postoperatively, they reported anterior chamber hemorrhage and postoperative hypotony. Villanueva et al in 2015 has reported corneal edema and increased intraocular pressure were the most common postoperative complication in all types of intraocular lens implantation.

Intraocular lenses used in aphakia showed good postoperative visual acuities. Complications include elevated intraocular pressures, corneal edema, and pigment dispersion. There is a notable trend towards iris claw retropupillary lenses as time passed. Knowledge on the outcomes maximizes the chances of optimal surgical and visual outcomes.

WHAT WAS KNOWN

In aphakic eyes, IOL implantation is possible, but techniques and preferences differ across regions.
Visual outcomes vary across different IOLs and are correlated with the approach and difficulty of the surgery.

WHAT THIS PAPER ADDS

In aphakic eyes, a shift of trend towards use of retropupillary iris claw lenses from anterior chamber IOL lenses were preferred by surgeons locally. This was associated with the easier implantation, less learning curve, and less complications with retropupillary iris claws.
No superiority of retropupillary iris claw lenses in terms of visual acuity.

FUNDING DECLARATION STATEMENT

The study is funded by the investigators. No external funding source for the study.

AUTHOR CONTRIBUTION

Torrefranca – drafted and conducted the study; Drafted and finalized the final manuscript

Carino – drafted and conducted the study; Drafted and finalized the final manuscript

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Tables 1-6 are not available with this version

No competing interests reported.

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Reviewers agreed at journal
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Reviewers invited by journal
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Editor assigned by journal
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Submission checks completed at journal
18 Apr, 2022
First submitted to journal
14 Apr, 2022

You are reading this latest preprint version

Intraocular Lens Placement in the Absence of Capsular Support: Visual Outcomes and Complications in a Philippine Tertiary Hospital

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Abstract

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Discussion

Conclusion

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WHAT WAS KNOWN

WHAT THIS PAPER ADDS

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Competing Interests

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