Intrascleral four-flanged intraocular lens fixation technique for lens dislocation with Marfan syndrome

DOI: https://doi.org/10.21203/rs.3.rs-1636580/v1

Abstract

Purpose

To observe the clinical efficacy of intrascleral four-flanged intraocular lens(IOL) fixation technique for lens dislocation with Marfan syndrome.

Methods

A retrospective analysis Observed twelve patients with Marfan syndrome(15 eyes) with lens dislocation who had underwent this operation(A 30g needle was used to puncture into the eye at 2, 4 o'clock or 8, 10 o'clock from the outside of the eye, respectively,.Both ends of the 7 − 0 polypropylene thread were guided through the two eyelets on the ipsilateral side of the Akreos AO IOL and out of the eyeball,and then the two ends of the suture were borned to form flanges. Finally two pairs (four) flanges are formed at 2,4 o'clock and 8,10 o'clock, which were riveted within the scleral tunnel, so as to fix the IOL). Corrected distance visual acuity(CDVA), intraocular pressure(IOP), tilt and decentration of the IOL and postoperative complications were evaluated.

Results

All operations were completed successfully. The CDVA prior to the fixation surgery was 3.36 ± 0.886 logMAR and on the first day aftet the surgery was 4.12 ± 0.928 logMAR. The CDVA was significantly improved following surgery (t = 0.660, p = 0.029). The CDVA on the last visit was 4.48 ± 0.736 logMAR, Compared with the first day after surgery, the difference is not statistically significant (t = 0.332, p = 0.249). No intraoperative complications were reported. Postoperatively, elevated IOP 4h after surgery was recorded in 6 eyes (40.0%), cystoid macular edema (CME) was seen in 2 eyes (13.33%), vitreous hemorrhage and flange exposure were seen in one eye each, corneal edema and anterior chamber inflammation were seen in 4 eyes each. The IOLs were centered without tilt and decentration.

Conclusions

The intrascleral four-flanged IOL for lens dislocation with Marfan syndrome experienced a low incidence of complication with excellent visual outcome. This technique is a simple, effective, and safe method.

Introduction

Lens dislocation in Patients with Marfan syndrome is usually binocular, and part of the lens dislocation develops gradually with age. Most of the dislocation directions are above, behind and above the temporal [7]. According to the literature of Hoffman[8] in 2013, the grading standard of lens dislocation is as follows: when the pupil is fully dilated, the dislocation accounting for less than 1/4 of the pupil area is mild dislocation, 1/4 ~ 1/2 is moderate dislocation, and more than 1/2 is severe dislocation. For patients with severe dislocation, intracapsular lens excision and posterior chamber IOL scleral fixation implantation are feasible [20]. Several fixation methods have been described, including scleral and iris fixation.

Scleral fixated posterior chamber IOL implantation avoids the complications associated with anterior chamber lenses such as iris damage, endothelial decompensation and uveitis[1]. However, many scleral fixation techniques involve multiple sclerostomy and complicated manipulation of needles inside the eye.. Complications include knot erosion, IOLs tilting, and decentration in the initial postoperative weeks and IOL dislocation due to suture breakage[2].Yamane et al[3] proposed a sutureless transconjunctival intrascleral technique, namely, the double-needle technique. The ends of the haptics are then heated by thermocautery, resulting in a flange. The flanged haptics are then tucked into the scleral wall. Canabrava [4] later developed the technique to create flanges at of the edge of a 5 − 0 polypropylene suture. In recent years, the tilt of the IOL has generally been paid attention to. Teichmann [5] found that most of the IOL loops were twisted after being fixed, causing the IOLs to tilt. In addition to the distortion of the haptic s, inaccurate fixed positions and two-point fixation can be the reasons for the tilt of the IOLs. Here, we propose a novel knotless intrascleral fixation technique using 7 − 0 polypropylene sutures and a four haptic IOLs (Akreos AO, Bausch + Lomb). This is to simplify the surgical procedure and improve the safety of intrascleral fixation and the stability of IOLs.

Methods

A retrospective analysis of 12 patients (15 eyes) with lens dislocation in Marfan syndrome who underwent IOL fixation with four-flange technique in Aier Eye Hospital of Wuhan University from January 2020 to July 2021.The corrected distance visual acuity (CDVA), refraction, and biometric data were extracted where available. Postoperatively, refraction and CDVA were evaluated by a trained optometrist. IOL position and tilt were evaluated in all patients using the anterior segment optical coherence tomography(AC-OCT) (Tomey Corporation, Nagoya, Japan).

Intraoperative and postoperative complications were documented. These included intraocular pressure(IOP), anterior chamber inflammation, corneal edema, vitreous hemorrhage and flange exposure.

Surgical Technique

All patients were performed the surgery under peribulbar anesthesia.

Figures A to I illustrate the key steps of this technique. Step1(figure A): Clear corneal primary and lateral incisions were made, the dispersive ophthalmic visco surgical device (OVD) (Viscoat, Alcon Laboratories) was injected into the anterior chamber to protect the endothelium. The anterior capsule was made by continuous circular capsularhexis(CCC). 3 or 4 capsular hooks were placed on the side of the lens dislocation according to the rupture scope of the suspensory ligament to stabilize the lens capsular bag. The I/A system was used to suck up the cortex and soft nuclear of the crystal. The lens capsular bag was cleaned by anterior vitrectomy. Step2(figure B): The puncture point of the scleral tunnel (2, 4, 8, 10 o’clock position, 2mm behind the limbus)were marked. Step3(figure C): The dispersive ophthalmic viscous surgical instrument was injected into the anterior chamber, followed by implantation of the intraocular lens.Step4(figure D): A 30-gauge hypodermic needle was inserted vertically into the anterior chamber at 2.0 mm posterior to the limbus at 4 o'clock after passing through an intrascleral tunnel parallel to the limbus. a 23-gauge microforceps was used to clamp the loop of the IOL passing it through the 30-gauge needle and then place the 7 − 0 polypropylene monofilament in the lumen of the 30-gauge needle. The needle was used as an external guide for the suture end within the sclera. Step5(figure E): Performed the same operation to draw the other end of the suture from the 2 o'clock position. Step6(figure F): The same maneuver was performed from 8, 10 o'clock position. Step7(figure G): Used the cut I/A system to suck up the visco and vitreous substances in the anterior and posterior chamber. Step8(figure H): Tighten the end of the suture and heated the suture heads with electrocoagulation pen to form flanges which riveted within the scleral tunnel. Step9(figure I): The pupil was dilated with carbacholine. Stromal hydration was applied to close the corneal incisions at the end of the procedure. A combination steroid-antibiotic ointment was placed on the eye and, then, the eye was covered with a patch.

Statistical Analysis

Data were analyzed using IBM SPSS 26.0 Statistics. Descriptive statistics are used to present the clinical outcomes. For statistical analysis, the paired t test was used for the analysis of paired continuous variables according to their distribution. P-values less than 0.05 on a two-sided test were considered statistically significant. Unless otherwise specified, data are presented as mean ± standard deviation (SD).

Results

Fifteen eyes of 12 patients were evaluated in the study. Mean age was was 29.25 ± 16.057 years, 83.33% of the patients were male, the follow-up time after surgery was 3 months. Patient characteristics are further detailed in Table 1.

Table 1

Patient Characteristics and Postoperative Complications

Patient

Age

(Years)

Gender

Affected eye

Complications

1

22

male

Left

none

2

20

male

right

none

 

20

 

left

elevated IOP

3

57

female

left

elevated IOP,CME

4

11

male

right

none

 

11

 

left

corneal edema,anterior chamber inflammation

5

39

male

right

corneal edema, anterior chamber inflammation

6

28

male

left

elevated IOP

7

19

male

right

none

 

19

 

left

elevated IOP

8

20

male

left

elevated IOP,flange exposure

9

18

male

right

elevated IOP, anterior chamber inflammation

10

23

female

right

vitreous hemorrhage,CME

11

31

male

left

corneal edema

12

63

male

right

corneal edema, anterior chamber inflammation

The mean CDVA prior to the fixation surgery was 3.36 ± 0.886 logMAR and on the fist day aftet the surgery was 4.12 ± 0.928 logMAR. The CDVA was significantly improved following surgery (t = 0.660,p = 0.029), The CDVA on the last visit was 4.48 ± 0.736 logMAR, Compared with the first day after surgery, the difference is not statistically significant (t = 0.332,p = 0.249).No intraoperative complications were reported. Postoperatively, elevated IOP, above 25 mmHg 4h after surgery was recorded in 6 eyes (40.0%), the IOP normalized within a week in all cases. Cystoid macular edema (CME) was seen in 2 eyes (13.33%). With local standard therapy, both patients' CME resolved within a few months. Vitreous hemorrhage, and flange exposure were seen in one eye each, corneal edema and anterior chamber inflammation were seen in 4 eyes each (Tables 2 and 3). There was no obvious tilt, decentration of the IOL in postoperative follow-up. (Tables 4 and 5, figure J).

Table 2

postoperative complications

ntraoperative complications no. of eyes (%)

Eyes (N = 15)

Number

(%)

vitreous hemorrhage

flange exposure

elevated IOP

corneal edema

CME

anterior chamber inflammation

1

1

6

4

2

4

6.67%

6.67%

40%

26.67%

13.33%

26.67%

Table 3

The UCVA before and after operation was compared

 

Preoperative

postoperation 1d

postoperation 3m

CDVA(logMAR)

3.36 ± 0.886

4.12 ± 0.928

4.48 ± 0.736

t

0.660 0.332

p

0.029 0.249

Table 4

The IOLtilt after operation were compared

 

postoperation 1d

postoperation 1m

postoperation 3m

title

3.70 ± 1.001

3.39 ± 0.678

3.45 ± 0.675

t

0.982 0.243

p

0.336 0.810

Table 5

The IOLdecentratio after operation were compared

 

postoperation 1d

postoperation 1m

postoperation 3m

decentratio

0.26 ± 0.08

0.26 ± 0.07

0.259 ± 0.074

t

0.121 -0.177

p

0.904 0 .861

Discussion

In patients with Marfan syndrome with severe lens dislocation, posterior chamber IOL suture fixation is a necessary treatment. In recent years, with the improvement of surgical techniques and the progress of surgical equipment, personalized surgical plans for such patients with lens subluxation are also constantly improved, hoping to provide a better guarantee for the maximum recovery of patients' visual function.

The traditional two-point scleral fixation method requires a relatively large corneal incision,which make postoperative outcomes unpredictable[6, 7].Canabrava et al[4]. have introduced a four-flanged intrascleral IOL fixation technique with 5 − 0 polypropylene that does not require flap creation, suture knots, or glue. In their research, an IOLwith fixation holes in the two haptics is used.After one thread passes through the fixed hole, the two ends are respectively fixed on two points of the sclera. Another type of four-point fixation is formed, but the IOL is still two-point fixation.

We use the Akreos AO (Bauus & Lomb) IOL which has four pre-formed closed holes within its haptics[8]. The 7 − 0 polypropylene sutures were passed through four small holes in the eyelet to fix the IOL on the four points of the sclera, making it very stable. The Akreos AO is a hydrophilic acrylic monolithic foldable IOL. There is no worry of breaking the eyelet. It can be implanted from a transparent corneal incision without sutures,which is conducive to a smoother and safer operation. There is less astigmatism and quick recovery of vision after surgery.Our surgery method looks very similar to Sergio[9], but it is not. Sergio puts the suture through the four loop holes of the IOL outside the eye, and then folds the lens and sends it into the eye.The IOL of the four loops occupies a relatively large space. When the IOL is put on the sutures and then folded and pushed into the eye, it is easy to cause the sutures to wrap around the lens loops, which is not easy to loosen in the narrow space of the anterior chamber. Surgery becomes complicated and the operation duration is prolonged. In our study, the IOL was first pushed into the anterior chamber, and the rest of the operation was actually four repetitions of inserting the needle and guiding the suture. Each operation was only around one loop of the intraocular lens, and there was no such entanglement troubles. The operation is simple and time-saving.

Two possible complications of our technique include damage to the the corneal endothelium or endophthalmitis. Once the corneal endothelium is damaged, serious complication may occur, such as corneal decompensation. In order to avoid this, do not directly use the needle to go through the loop hole of the IOL after entering the anterior chamber. It is recommended fixing the needle, using intraocular forceps to clamp the loop of the iris IOL and passing it through the 30G needle. In our study with a mean follow-up time of 3 months, there were no cases of postoperative infection. However, we acknowledge that endophthalmitis is a concern and has been reported at 1 month and 5months after transscleral fixation of a PC IOL.

When prolapsed vitreous was present in the anterior chamber, anterior vitrectomy was performed. It is imperative to perform an anterior vitrectomy if there is vitreous prolapse with IOL incarceration to release the PC IOL from vitreous adhesions, thereby preventing further vitreous traction with IOL manipulations that may lead to peripheral retinal tears and subsequent retinal detachment[10].

All operations were completed successfully. Comparing final CDVA (4.12 ± 0.928 logMAR) following fixation to the CDVA prior to the surgery(3.36 ± 0.886 logMAR) showed a statistically difference(t = 0.660,p = 0.029). The CDVA on the last visit was 4.48 ± 0.736 logMAR, compared with the first day after surgery, due to the recovery of corneal edema in some patients, the visual acuity has improved, but the difference is not statistically significant (t = 0.332,p = 0.249). After the operation, elevated IOP above 25 mmHg 4h after surgery was recorded in 6 eyes (40.0%), the IOP normalized within a week in all cases. Cystoid macular edema (CME) was seen in 2 eyes (13.33%), in both cases the CME resolved within a few months with topical standard treatment. Vitreous hemorrhage, and flange exposure were seen in one eye each, corneal edema and anterior chamber inflammation were seen in 4 eyes each (Table 1). The IOLs wer e centered without tilt and decentration.

In conclusion, in this study, we found that patients who had intrascleral four-flanged technique for PC IOL fixation experienced a low incidence of complication with excellent visual outcome. This technique is a simple, effective, and safe method for lens dislocation with Marfan syndrome.

Declarations

Competing Interests

Author Yong Wang and Li Zhou declare they have no financial interests.

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Aier eye hospital of wuhan university

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Author Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Li Zhou. The first draft of the manuscript was written by Li Zhou. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Acknowledgement

This project is supported by the Wuhan Clinical Medical Research Project: mapping and mutation detection of pathogenic genes in a Family with Marfan syndrome

permission for reproduced image The copied image J is from the images of the patients in this study examined in Aier Eye Hospital after operation, and is allowed to be used

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