Repositioning Dislocated One-Piece IOLs by Modified Scleral Suture Fixation

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Repositioning Dislocated One-Piece IOLs by Modified Scleral Suture Fixation

https://doi.org/10.21203/rs.3.rs-2827951/v1

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Purpose: To evaluate the efficacy and safety of intraocular lens (IOL) repositioning by modified scleral suturing of 1-piece IOLs.

Methods: The surgical database of 1 surgeon was reviewed for consecutive cases of IOLs dislocated into the vitreous from April 2019 to January 2022, where a modified scleral suture-fixation technique was used with a minimum follow-up of 3 months. Preoperative and postoperative ophthalmic evaluation included the best-corrected visual acuity (BCVA), intraocular pressure (IOP), and detailed slit-lamp examinations.

Results: The eyes of 11 consecutive patients with in-bag dislocated IOLs were included. The etiological distribution of the 11 study subjects was as follows: 3 eyes undergoing prior vitrectomy, 3 high-myopia eyes, 2 eyes implanted with a capsular tension ring (CTR), 1 eye with trauma and 2 eyes with unknown etiologies. The interval between the original cataract surgery and the dislocation ranged from 3 to 120 months (48.09±44.48 months). The mean follow-up time was 14.55±5.34 months. At the most recent follow-up visit, all IOLs were stable with no significant lens tilt, and the mean BCVA of all patients improved significantly from 0.49±0.26 to 0.29±0.17 (logMAR, p<0.05, t =2.204). Surgical complications in this research included elevated lOP (2 eyes) and CME (1 eye), which all could be resolved by topical use of eyedrops.

Conclusion: Repositioning 1-piece IOLs in this modified manner is a simple, effective, and safe method that may also be suitable for other types of IOLs with similar structures.

Dislocated intraocular lens (IOL)

Repositioning

Modified scleral suture fixation technique

Modern cataract surgery yields excellent results and rapid visual recovery after intraocular lens (IOL) implantation in the capsular bag, which makes it the most common ophthalmic surgery performed worldwide[1]. The risk of complications from today’s standard cataract surgery is minor, and the visual outcome is often excellent if the patient has no other eye disease. Dislocated intraocular lenses (IOLs), which are uncommon and reported at a rate of 0.2–3% after surgery, are challenging but treatable complications and may be spontaneous or associated with trauma[2, 3].

A dislocated IOL can either be repositioned or exchanged, as described previously. Various procedures, such as sutured transscleral IOL fixation, iris-claw, flanged transscleral fixated IOLs (Yamane technique), and sutureless transscleral hook IOL fixation (Carlevale IOL), have been developed for IOL dislocation surgery[3]. IOL repositioning is mentioned in several articles as preferable to IOL exchange [4]. IOL repositioning is considered to be less traumatizing, and hypotony during surgery is easier to avoid with a minimally invasive procedure, thus reducing the need for anterior vitrectomy and the risk of serious complications such as choroidal expulsive hemorrhage and retinal detachment. Minor incisions may also be beneficial in terms of surgically induced astigmatism[5, 6]. It is also more economical to reposition existing IOLs, particularly in developing countries.

Among these methods, IOL repositioning by scleral suturing is the most commonly used procedure for IOL dislocations. There are a number of studies in the literature demonstrating the successful use of sutured transcleral IOL fixation for the management of dislocated IOLs[4, 7]. However, it has been debated whether 1-piece IOLs are suitable for repositioning surgery because thick haptics may be a potential reason for uveitis–glaucoma–hyphema (UGH) syndrome caused by iris chaffing[8, 9]. A recent study claims that the long-term efficacy and safety after repositioning of 1-piece IOLs appears to be as good as those for 3-piece or plate-haptic IOL designs[4]. In this study, we modified the procedure described by Chan et al. for the previous method of scleral suturing[10]. The IOLs, which were one-piece hydrophilic acrylic IOLs with closed loops in the haptics, were fixed in situ by using a loop at the end of a suture. This study focuses on presenting the detailed procedure of the modified approach and initially evaluating the efficacy and safety of IOL repositioning in this manner.

In this retrospective study, we performed a chart review of 11 consecutive patients who underwent modified scleral suturing for the management of dislocated IOLs between April 2019 and January 2022. All subjects had received Rayner aspheric monofocal IOL (920H, Hove, UK) implantation in their earlier cataract surgery. This type of IOL was a one-piece hydrophilic acrylic IOL with a closed loop in the haptics. All patients were informed of the risks and benefits of the surgery, and written informed consent was obtained. The study was conducted in accordance with the tenets of the Helsinki Declaration.

Preoperative and postoperative ophthalmic evaluations included the best-corrected visual acuity (BCVA, logMAR), intraocular pressure (IOP) measurement by a noncontact tonometer (NCT), and anterior segment and detailed fundus examinations by slit lamp. Informed consent was obtained from all patients prior to any procedure. Preoperative biometry (measured using the IOL Master, Carl Zeiss Meditec, AG) was performed in all cases, and a standby IOL was kept in case it would be required during the surgery. The patients underwent pars plana vitrectomy (PPV), anterior vitrectomy (AV), or neither according to the actual situation. All surgeries were performed by a single surgeon (Ou Yang).

Surgical technique

All surgical procedures were performed using a retrobulbar block with 10% ropivacaine and 2% lidocaine mixed in equal volumes. A 25G pars plana vitrectomy (PPV) (Constellation Vision System, Alcon, Fort Worth, Texas, USA.) was commenced with core and peripheral vitrectomy when IOLs were dislocated in the vitreous cavity. The dislocated IOLs were manipulated with vitreoretinal forceps and the vitrectomy cutter to reach the pupillary zone, and one of the IOL haptics was adjusted to the center of the pupillary zone. Sodium hyaluronate 1.4% (Healon GV, Johnson & Johnson Vision) was used to maintain the anterior chamber (AC), protect the corneal endothelium and facilitate IOL handling during the procedure. The haptics were fixated in situ by using the loop at the end of a suture and the haptic loop of the dislocated IOLs. In brief, two 1 mm corneal incisions close to the limbus at 1:30 and 10:00 o’clock were made by a 15° corneal puncture knife. A needle with a 9 − 0 polypropylene suture entered the eye through the corneal incision at 1:30. The needle passed through the haptic loop and then exited the eye from the corneal incision at 10:00 o’clock by docking into a 27-gauge needle (Fig. 1A), carefully pulling out the needle in case the loop of the suture crossed the haptic loop (Fig. 1B). The needle reentered the eye through the corneal incision at 10:00 o’clock, passed through the loop of the suture above the haptic, and then exited the eye by docking into a 27-gauge needle at 2.5 mm from the limbus where the haptic–bag complex was to be fixated, mostly at 3:00 o’clock (Fig. 1C). A similar method of manipulation was used for the other haptic. Another needle with a 9 − 0 polypropylene suture entered the eye 2.5 mm from the limbus at 9:00 o’clock. The needle passed through the haptic loop and then exited the eye from the corneal incision at 1:30 o’clock by docking into a 27-gauge needle, carefully pulling out the needle in case the loop of the suture crossed the haptic loop. The needle reentered the eye through the corneal incision at 1:30 o’clock, passed through the loop of the suture above the haptic, and then exited the eye by docking into a 27-gauge needle from the first entry. Then, the suture was tensioned on both sides to adjust the IOLs to an appropriate position. A 2-1-1 knot was carefully tied and rotated into the scleral tunnel to prevent erosion of the conjunctiva. Standard PPV was performed if the eye was not previously vitrectomized. Vitreous traction in the AC was removed with a vitrector. Ophthalmic viscosurgical devices were removed. Finally, the infusion cannula was removed, and the conjunctiva was sutured to cover the stitches. The details of the surgical procedure were subject to change based on the patient's specific condition.

We report the results of 11 patients who received scleral fixation using this technique (Table 1). All patients had significantly improved visual acuity. No surgical complications were encountered. Individual information regarding each patient is provided in Table 1.

Table 1

Clinical features, management and outcome in 11 eyes
Case	Sex	Age at cataract surgery (years)	The interval between dislocation and cataract surgery (months)	Etiologies of IOL dislocation	Complications and further management	Preoperative BCVA	BCVA at the most recent follow-up visit	Follow-up (months)
1	F	66	3	Complicated original cataract surgery: Zonular dehiscence (CTR implantation)	IOP elevation Topical glaucoma medication	0.92	0.52	21
2	M	57	38	High myopia	None	0.52	0.22	23
3	F	81	14	Prior vitrectomy	None	0.40	0.10	8
4	M	73	20	Prior vitrectomy	None	0.30	0.22	13
5	M	63	122	High myopia	IOP elevation Topical glaucoma medication	0.60	0.22	19
6	M	78	49	Complicated original cataract surgery: Zonular dehiscence (CTR implantation)	None	0.22	0.10	13
7	M	91	25	High myopia	None	0.10	0.10	7
8	F	62	138	Prior vitrectomy	None	0.82	0.52	16
9	M	81	68	Unknown	None	0.52	0.40	13
10	M	72	37	Trauma	Cystoid macular edema (CME) Topical steroids and nonsteroidal anti-inflammatory medications	0.70	0.52	9
11	F	75	15	Unknown	None	0.30	0.22	18

The eyes of 11 consecutive patients with in-bag dislocated IOLs were included in the study (Table 1). Out of 11 patients, 7 were male (63%), and 4 were female (37%). Three of the eyes had previously undergone vitrectomies several years earlier. Three eyes had high myopia before cataract surgery. In 2 eyes, capsular tension rings were found inside the bag and were not removed because of their solid bonding with the IOLs by the stiff and fibrotic capsular bag. One of the cases was a posttraumatic dislocation. There were no other identified risks of IOL dislocation in 2 eyes. No IOL was changed during the procedure, and all IOLs were sutured to the sclera in situ.

The mean age of patients undergoing cataract surgery was 72.63 ± 10.03 years. The interval between the original cataract surgery and the dislocation ranged from 3 to 120 months (average 48.09 ± 44.48 months). The mean follow-up time was 14.55 ± 5.34 months. (Table 1). At the most recent follow-up visit, all 11 eyes had stable or improved BCVA, and the mean postoperative BCVA had improved significantly from 0.49 ± 0.26 to 0.29 ± 0.17 (logMAR, t = 2.204, p < 0.05).

Some complications were noted after the primary surgery, but none resulted in diminished visual acuity. Surgical complications for dislocated IOLs included elevated lOP (2 eyes) and cystoid macular edema (CME) (1 eye). Eyes with elevated IOP were treated with topical glaucoma medication. The eye that developed CME was treated with topical steroids and nonsteroidal anti-inflammatory medications (NSAIDs). There were no intraoperative haptic fractures and no subsequent IOL dislocations during the follow-up. All IOLs were stable with no significant lens tilt. There were 2 patients who complained of suture-associated discomfort, which was resolved by artificial tear eye drops, but there were no cases of suture erosion.

The aim of this study was to present the detailed procedure of a modified approach and initially evaluate the efficacy and safety of IOL repositioning in this manner. In general, the clinical outcomes were favorable for all patients, and no severe complications occurred after surgery. All IOLs were stable with no significant lens tilt, and the mean BCVA of all patients improved significantly from 0.49 ± 0.26 to 0.29 ± 0.17 (logMAR, p < 0.05, t = 2.204) by the most recent follow-up visit. Surgical complications in this research included elevated lOP (2 eyes) and CME (1 eye), which all could be resolved by the topical use of eyedrops. Serious complications, such as UGH syndrome, IOL redislocation, retinal detachment, choroidal expulsive hemorrhage, endophthalmitis, and suture breakage or erosion, were not observed in this research. The modified scleral suturing technique repositioning the IOL with two 9 − 0 polypropylene sutures is considered to be safe and effective for late in-the-bag IOL dislocation.

Dislocated intraocular lenses (IOLs) are one of the most feared but treatable complications after cataract surgery. The rate of in-the-bag IOL dislocations has been reported to increase yearly over the past decade. The frequency of IOL dislocation after cataract surgery has been reported to be 0.2–3%[2, 3, 11]. The wide variability in reported incidence rates has been suggested to arise from a number of reasons, such as unequal distribution of predisposing conditions across populations and varying follow-up lengths. Different conditions are associated with late in-the-bag IOL dislocation. Previous studies have established pseudoexfoliation syndrome (PEX) as one of the most important predisposing factors[3, 12, 13]. Other associated conditions include previous vitreoretinal surgery, myopia/increased axial length, uveitis, retinitis pigmentosa, certain connective tissue disorders, and trauma—that is, both direct blunt trauma and indirect trauma, the latter in the form of head injuries or working with vibrating machines[2, 3, 12, 14]. Recent research suggests that the different types of materials and designs of IOL used in cataract surgery may be another cause. Plate–haptic silicone IOLs have been associated with an increased risk of anterior capsule opacification with secondary capsule contraction, which may subsequently increase the risk for dislocation[15, 16]. The possible preventive role of CTR should also be discussed. However, no prospective comparative studies specifically addressing this issue have been published. One prospective cohort study found a higher proportion of late dislocation in eyes with CTR. The probable reason is that the implantation of CTR may induce some damage to the zonular fibers, which may increase the vulnerability for later dislocation. Thus, no final conclusion regarding a possible preventive role of CTR has been reached thus far[17, 18]. The etiological distribution of the 11 patients included in this research was as follows: 3 eyes undergoing prior vitrectomy, 3 eyes with high myopia, 2 eyes implanted with a CTR, 1 eye with trauma and 2 eyes with unknown etiologies. This is slightly different from what has been reported in the literature. No cases were associated with PEX, which may be attributed to the varying incidence of PEX among different ethnic groups.

A variety of methods to manage dislocated IOLs have been reported, all in principle variants of either repositioning the existing IOL or exchanging it for a new IOL. However, no definite clinical recommendations have been made in terms of the choice between IOL repositioning and IOL exchange[6, 19]. The choice to manage dislocated IOLs is highly dependent on the surgeon’s preference and individual case features, such as the integrity of the capsule, type of IOL and coexisting ocular pathologies. Although some researchers have reported that there were no significant differences in visual acuity or complication rates between eyes undergoing IOL repositioning and those undergoing IOL exchange, IOL repositioning by scleral suturing is mentioned in a number of articles as the recommended operation method for most cases of IOL dislocation. The reason may be that IOL exchange is inherently more traumatic, with a larger incision required and an increased risk for vitreous loss, iris trauma, corneal endothelial damage, and postoperative astigmatism[5, 6]. The dislocated IOLs are always repositioned by iris fixation or scleral fixation. In both approaches, the scleral fixation of the IOLs at the ciliary sulcus allows the anchoring of the haptics to secure and stabilize the structure, and the IOLs are localized closer to the original anatomic location. Therefore, most of the time, a dislocated IOL was fixed in situ at the ciliary sulcus by scleral fixation sutures to secure the haptic(s). Numerous methods of scleral fixation have been reported in previous studies[3, 4, 7, 20]. The step that involves looping the suture around the IOL haptic(s) is the largest variable and most technically difficult between different scleral fixation methods. In this study, all subjects received Rayner aspheric monofocal IOL (920H, Hove, UK) implantation in their primary cataract surgery; the device is a one-piece hydrophilic acrylic IOL with closed-loop haptics. The haptics of the dislocated IOLs were fixated in situ with a slipknot tied to the haptic loop by passing the needle through the loop at the end of a suture. There are several advantages to the minimally invasive and scleral fixation technique used in this study. The IOP during the procedure was more stable, and the surgery process was less traumatic with the small scleral and corneal puncture sites, thus reducing the risk for serious complications such as retinal detachment or choroidal expulsive hemorrhage. All needle passes were guided by docking into a 27-gauge needle. As a result, there was no blind needle passage under the iris, and the fixation was at the exact scleral position identified externally. Suture passes were made at an orientation that led the IOL to obtain optimal centration. All IOLs remained stable with no significant lensing tilt at the most recent follow-up visit. We have found that a slipknot passed around the haptic loop through the stiff fibrotic capsule is sufficient to prevent slippage of the suture. In this way, we reduced the amount of manipulation required to tie the knot around the haptic, which can reduce the intraoperative risk caused by extra manipulation. As a result, there were no serious complications, such as retinal detachment, choroidal expulsive hemorrhage, endophthalmitis, and suture breakage or erosion, in the present study.

One-piece IOLs were used in this study. Several researchers have debated whether a 1-piece IOL is suitable for repositioning because of the potential risk of UGH syndrome due to iris chaffing from thick haptics. Although, in principle, any IOL in the AC or sulcus could cause UGH syndrome, the disease triad has been reported to be associated with a 1-piece IOL inside the capsular bag. In recent studies, UGH syndrome was identified as an important long-term complication that may mimic several different pathologies and, therefore, represent a diagnostic challenge[8, 9]. This reminds us to pay extra attention to UGH syndrome after surgery. Fortunately, none of the patients in this study had UGH syndrome, suggesting that 1-piece IOLs are as good as other types of IOLs. This result is in agreement with a recent prospective cohort study reported by Marius Dalby et al.[4]. In conclusion, this technique is a simple, effective, and safe way to reposition dislocated 1-piece IOLs. Although this technique has only been used for one-piece hydrophilic acrylic IOLs with a closed loop in the haptics, we believe that it is also suitable for other types of IOLs with similar structures. This will be explored in our future research.

There are several limitations to our study. First, this retrospective study was subject to potential inherent limitations related to the study design. Second, the follow-up was not long enough. The mean follow-up time was 14.55 ± 5.34 months, and a long-term follow-up is needed to evaluate complaints such as stability of the IOL and suture breakage or erosion. Third, a relatively small population was included in this study due to the particular type of IOL enrolled. Thus, additional randomized trial studies with a higher number of subjects and a longer follow-up period are needed to further confirm our findings.

In summary, repositioning 1-piece IOLs in this modified manner is a simple, effective, and safe method. As long as the IOLs are similar in structure to the type of IOL used in this study, this surgical technique appears to be well suited for the treatment of IOL dislocations.

Acknowledgements: We gratefully acknowledge the valuable cooperation of the medical staff in The Second Affiliated Hospital of Guangzhou University of Chinese Medicine and The Third Affiliated Hospital of Sun Yat-Sen University Lingnan Hospital, for collecting the data.

Statement of Ethics: This retrospective observational study adhered to the principles of the Declaration of Helsinki and received ethical approval from Ethics Committee of Guangdong Hospital of Traditional Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, ZE2022-330-01)

Disclosure Statement: The authors have no conflicts of interest to declare.

Funding Sources: None.

Author Contributions: Yang Ou designed the study; Binwu Lin and Weilan Huang a performed data collection and management; Binwu Lin performed data analysis and interpretation; Binwu Lin and Weilan Huang wrote and reviewed the manuscript.

Klein R, Klein BE (2013) The prevalence of age-related eye diseases and visual impairment in aging: current estimates. Invest Ophthalmol Vis Sci 54: ORSF5-ORSF13 DOI 10.1167/iovs.13-12789
Ascaso FJ, Huerva V, Grzybowski A (2015) Epidemiology, Etiology, and Prevention of Late IOL-Capsular Bag Complex Dislocation: Review of the Literature. J Ophthalmol 2015: 805706 DOI 10.1155/2015/805706
Kristianslund O, Dalby M, Drolsum L (2021) Late in-the-bag intraocular lens dislocation. J Cataract Refract Surg 47: 942-954 DOI 10.1097/j.jcrs.0000000000000605
Dalby M, Drolsum L, Kristianslund O (2021) Repositioning surgery of different intraocular lens designs in eyes with late in-the-bag intraocular lens dislocation. J Cataract Refract Surg 47: 1147-1152 DOI 10.1097/j.jcrs.0000000000000588
Dalby M, Kristianslund O, Drolsum L (2019) Long-Term Outcomes after Surgery for Late In-The-Bag Intraocular Lens Dislocation: A Randomized Clinical Trial. Am J Ophthalmol 207: 184-194 DOI 10.1016/j.ajo.2019.05.030
Kristianslund O, Raen M, Ostern AE, Drolsum L (2017) Late In-the-Bag Intraocular Lens Dislocation: A Randomized Clinical Trial Comparing Lens Repositioning and Lens Exchange. Ophthalmology 124: 151-159 DOI 10.1016/j.ophtha.2016.10.024
Smiddy WE, Ibanez GV, Alfonso E, Flynn HW, Jr. (1995) Surgical management of dislocated intraocular lenses. J Cataract Refract Surg 21: 64-69 DOI 10.1016/s0886-3350(13)80482-8
Samuelson TW (2016) Managing an unstable subluxated intraocular lens with uncontrolled intraocular pressure and progressing glaucoma: July consultation #1. J Cataract Refract Surg 42: 1098-1099 DOI 10.1016/j.jcrs.2016.06.010
Durr GM, Ahmed IIK (2021) Intraocular Lens Complications: Decentration, Uveitis-Glaucoma-Hyphema Syndrome, Opacification, and Refractive Surprises. Ophthalmology 128: e186-e194 DOI 10.1016/j.ophtha.2020.07.004
Chan CC, Crandall AS, Ahmed, II (2006) Ab externo scleral suture loop fixation for posterior chamber intraocular lens decentration: clinical results. J Cataract Refract Surg 32: 121-128 DOI 10.1016/j.jcrs.2005.06.050
Mayer CF, Hirnschall N, Wackernagel W, Pregartner G, Seidel G, Falb T, Findl O, Ardjomand N (2018) Late dislocation of a hydrophilic intraocular lens: risk ratios for predisposing factors and incidence rates. Acta Ophthalmol 96: e897-e898 DOI 10.1111/aos.13701
Fernandez-Buenaga R, Alio JL, Perez-Ardoy AL, Larrosa-Quesada A, Pinilla-Cortes L, Barraquer R, Alio JL, 2nd, Munoz-Negrete FJ (2013) Late in-the-bag intraocular lens dislocation requiring explantation: risk factors and outcomes. Eye (Lond) 27: 795-801; quiz 802 DOI 10.1038/eye.2013.95
Bhattacharjee H, Saxena RK, Medhi J (2015) Bilateral spontaneous anterior dislocation of intraocular lens with the capsular bag in a patient with pseudoexfoliation. Indian J Ophthalmol 63: 796-798 DOI 10.4103/0301-4738.171520
Davis D, Brubaker J, Espandar L, Stringham J, Crandall A, Werner L, Mamalis N (2009) Late in-the-bag spontaneous intraocular lens dislocation: evaluation of 86 consecutive cases. Ophthalmology 116: 664-670 DOI 10.1016/j.ophtha.2008.11.018
Werner L, Pandey SK, Escobar-Gomez M, Visessook N, Peng Q, Apple DJ (2000) Anterior capsule opacification: a histopathological study comparing different IOL styles. Ophthalmology 107: 463-471 DOI 10.1016/s0161-6420(99)00088-3
Gonvers M, Sickenberg M, van Melle G (1997) Change in capsulorhexis size after implantation of three types of intraocular lenses. J Cataract Refract Surg 23: 231-238 DOI 10.1016/s0886-3350(97)80346-x
Ahmed, II, Abadir A (2007) Spontaneous IOL-CTR dislocation. J Cataract Refract Surg 33: 176; author reply 176 DOI 10.1016/j.jcrs.2006.09.042
Saravan VR, Singh G, Sathyan P, Narendran V (2006) Management of posterior dislocation of IOL-CTR-CB complex. J Cataract Refract Surg 32: 1985-1986 DOI 10.1016/j.jcrs.2006.08.040
Grzybowski A, Kanclerz P (2017) Population-based analysis of intraocular lens exchange and repositioning. J Cataract Refract Surg 43: 1484 DOI 10.1016/j.jcrs.2017.09.020
Mello MO, Jr., Scott IU, Smiddy WE, Flynn HW, Feuer W (2000) Surgical management and outcomes of dislocated intraocular lenses. Ophthalmology 107: 62-67 DOI 10.1016/s0161-6420(99)00017-2

No competing interests reported.

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Repositioning Dislocated One-Piece IOLs by Modified Scleral Suture Fixation

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