Safety and Efficacy of Current Sclera Fixation Methods for Intraocular Lenses and Literature Overview

Abstract

Background Evaluation of the three currently most common techniques for intraocular lens (IOL) sclera fixation: (1) Prolene suture with Hoffman sclera pocket (2) four-point GoreTex suture technique (3) sutureless flanged intrascleral IOL fixation with double-needle (“Yamane”) technique.

Material and Methods Retrospective, clinical case series (chart review) at the Department of Ophthalmology, Ludwig-Maximilians-University (LMU), Munich, Germany. Enrolled in the study were 51 patients with 55 eyes. Best-corrected visual acuity (BCVA); manifest refraction (OR); corneal tomography (central corneal thickness, CCT); biometry; central macular thickness (CMT) by optical coherence tomography (OCT); intraocular pressure (IOP); and IOL type and IOL power were recorded and compared prior to and 3 – 12 months post IOL sclera fixation surgery. Pre- and postsurgery difference analysis was performed by Wilcoxon rank sum testing (z).

Results Intrascleral fixation by GoreTex suture was performed in 14 (25.5%) eyes, by Prolene suture in 19 (34.5%,) and by Yamane technique in 22 (40.0%) eyes. Within the 3 – 12 months follow-up post scleral fixation, a total of 2 (14.3%) eyes from the GoreTex, 3 (15.8%) from the Prolene and 1 (4.5%) eye from the Yamane group required refixation. Pre- and post-surgery analysis revealed a statistically significant difference in the total patient population BCVA (exact Wilcoxon test: z = − 3.202; p = 0.001; n = 55) and the Yamane subgroup (exact Wilcoxon test: z = − 2.068; p = 0.001; n = 22). The GoreTex (n = 14) and Prolene (n = 19) subgroups revealed no statistically significant differences versus preoperative baseline. Across groups, there was no statistically significant difference in IOP, CMT, and CCT. No retinal complications were observed, neither intraoperatively nor during follow-up.

Conclusion The volume of IOL revision surgery is increasing. Often, the only option left for visual rehabilitation is scleral IOL fixation. All three scleral fixation techniques studied demonstrated a good safety profile with no statistically significant impact on IOP, CMT, CCT, but with a notable revision rate. Visual rehabilitation to preoperative baseline levels (GoreTex [n = 14] and Prolene [n = 19]) and a statistically significant increase in visual acuity (total cohort [n = 55] and Yamane [n = 22]) seems possible. Unlike iris fixation, scleral fixation is surgically more complex and the surgeon must master a steeper learning curve.

Key words

intraocular lens (IOL) - secondary IOL - IOL exchange - IOL complications - scleral fixation - pseudophakia

• References/Literatur

• 1 Auffarth GU, Schmidbauer J, Apple DJ. [The life work of Sir Nicholas Harold Lloyd Ridley]. Ophthalmologe 2001; 98: 1012-1016 doi:10.1007/s003470170019
• 2 Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg 2006; 32: 1907-1912 doi:10.1016/j.jcrs.2006.05.029
• 3 Yamane S, Sato S, Maruyama-Inoue M. et al. Flanged Intrascleral Intraocular Lens Fixation with Double-Needle Technique. Ophthalmology 2017; 124: 1136-1142 doi:10.1016/j.ophtha.2017.03.036
• 4 Kelkar A, Kelkar J, Kothari A. et al. Comparison of Two Modified Sutureless Techniques of Scleral Fixation of Intraocular Lens. Ophthalmic Surg Lasers Imaging Retina 2018; 49: e129-e134 doi:10.3928/23258160-20181002-15
• 5 Yavuzer K, Evcimen Y. Sutureless transconjunctival intrascleral intraocular lens fixation: the modified Yamane technique. Arq Bras Oftalmol 2019; 82: 389-393 doi:10.5935/0004-2749.20190072
• 6 Kelkar AS, Kelkar JA, Kothari AA. et al. Comparison of flanged intrascleral intraocular lens fixation versus iris claw intraocular lens fixation: A retrospective study. Indian J Ophthalmol 2019; 67: 1838-1842 doi:10.4103/ijo.IJO_300_19
• 7 Kokame GT, Yanagihara RT, Shantha JG. et al. Long-term Outcome of Pars Plana Vitrectomy and Sutured Scleral-Fixated Posterior Chamber Intraocular Lens Implantation or Repositioning. Am J Ophthalmol 2018; 189: 10-16 doi:10.1016/j.ajo.2018.01.034
• 8 Vote BJ, Tranos P, Bunce C. et al. Long-term outcome of combined pars plana vitrectomy and scleral fixated sutured posterior chamber intraocular lens implantation. Am J Ophthalmol 2006; 141: 308-312 doi:10.1016/j.ajo.2005.09.012
• 9 Sindal MD, Nakhwa CP, Sengupta S. Comparison of sutured versus sutureless scleral-fixated intraocular lenses. J Cataract Refract Surg 2016; 42: 27-34 doi:10.1016/j.jcrs.2015.09.019
• 10 Dimopoulos S, Dimopoulos V, Blumenstock G. et al. Long-term outcome of scleral-fixated posterior chamber intraocular lens implantation with the knotless Z-suture technique. J Cataract Refract Surg 2018; 44: 182-185 doi:10.1016/j.jcrs.2017.11.009
• 11 Wasiluk E, Krasnicki P, Dmuchowska DA. et al. The implantation of the scleral-fixated posterior chamber intraocular lens with 9/0 polypropylene sutures – Long-term visual outcomes and complications. Adv Med Sci 2019; 64: 100-103 doi:10.1016/j.advms.2018.08.005
• 12 Brandt L, Petersen J, Callizo J. et al. [Complications in sutured scleral fixation of artificial lens implantation]. Ophthalmologe 2019; 116: 1200-1206 doi:10.1007/s00347-019-0896-0
• 13 Khan MA, Gupta OP, Smith RG. et al. Scleral fixation of intraocular lenses using Gore-Tex suture: clinical outcomes and safety profile. Br J Ophthalmol 2016; 100: 638-643 doi:10.1136/bjophthalmol-2015-306839
• 14 Patel NA, Shah P, Yannuzzi NA. et al. Clinical outcomes of 4-point scleral fixated 1-piece hydrophobic acrylic equiconvex intraocular lens using polytetrafluoroethylene suture. Clin Ophthalmol 2018; 12: 2145-2148 doi:10.2147/OPTH.S174211
• 15 Lewis JS. Ab externo sulcus fixation. Ophthalmic Surg 1991; 22: 692-695
• 16 Hoffman RS, Fine IH, Packer M. et al. Scleral fixation using suture retrieval through a scleral tunnel. J Cataract Refract Surg 2006; 32: 1259-1263 doi:10.1016/j.jcrs.2006.02.065
• 17 Field A. Discovering Statistics Using SPSS. 3rd ed.. ed. London: SAGE Publications Ltd.; 2009
• 18 Cohen J. Statistical Power Analysis for the behavioral Sciences. 2nd ed.. ed. New York City, NY, USA: Lawrence Erlbaum Associates; 1988
• 19 Malbran ES, Malbran jr. E, Negri I. Lens guide suture for transport and fixation in secondary IOL implantation after intracapsular extraction. Int Ophthalmol 1986; 9: 151-160 doi:10.1007/bf00159844
• 20 Stem MS, Todorich B, Woodward MA. et al. Scleral-Fixated Intraocular Lenses: Past and Present. J Vitreoretin Dis 2017; 1: 144-152 doi:10.1177/2474126417690650
• 21 Vounotrypidis E, Schuster I, Mackert MJ. et al. Secondary intraocular lens implantation: a large retrospective analysis. Graefes Arch Clin Exp Ophthalmol 2019; 257: 125-134 doi:10.1007/s00417-018-4178-3
• 22 Gelman RA, Garg S. Novel Yamane technique modification for haptic exposure after glued intrascleral haptic fixation. Am J Ophthalmol Case Rep 2019; 14: 101-104 doi:10.1016/j.ajoc.2019.03.009
• 23 Price MO, Price jr. FW, Werner L. et al. Late dislocation of scleral-sutured posterior chamber intraocular lenses. J Cataract Refract Surg 2005; 31: 1320-1326 doi:10.1016/j.jcrs.2004.12.060
• 24 Ganekal S, Venkataratnam S, Dorairaj S. et al. Comparative evaluation of suture-assisted and fibrin glue-assisted scleral fixated intraocular lens implantation. J Refract Surg 2012; 28: 249-252 doi:10.3928/1081597X-20120221-01