Secondary Intraocular Lens Placement Research Articles

Cross-Sectional Survey of Vitreoretinal Surgery Fellowship Training in Secondary Intraocular Lens Placement.

Purpose: To assess current trends in vitreoretinal surgical fellowship training for placement of secondary intraocular lenses (IOLs). Methods: A cross-sectional survey was administered to vitreoretinal surgical fellowship graduates who completed their program between 2019 and 2023. Results: Completed responses were obtained from 70 (22.5%) of 311 eligible recipients. Training settings included academic (80%), hybrid academic/private practice (15%), and private practice (5%). During their fellowship, the majority of respondents reported 10 or fewer cases using anterior chamber (AC) IOLs (69%), 5 to 50 cases using scleral-sutured IOLs (64%), and 5 to 25 cases using sutureless scleral-fixated IOLs (52%). Most fellows (79%) did not have exposure to iris-fixated IOL placement during fellowship training. The Akreos AO60 (78%) and Envista MX60 (10%) IOLs were the most common choice for scleral-sutured placement. Most fellows (67%) placed fewer than 10 secondary IOLs through scleral tunnels. Overall, scleral-sutured IOL placement (Akreos Gore-Tex [polytetrafluoroethylene] sutured, 49%) and scleral-fixated IOLs (modified Yamane, 45%) were the preferred and most comfortable surgical techniques for recent graduates after completing training. There was a significant association between surgical case volume during fellowship training and self-reported competency for each type of secondary IOL (P ≤ .005). Conclusions: The majority of vitreoretinal surgical fellows receive limited training in the placement of AC IOLs or construction of scleral tunnels during their fellowship. Aligned with their experience during fellowship, recent graduates generally prefer implanting scleral-fixated or scleral-sutured IOLs. Analysis of trainees' exposure to various techniques and postgraduate surgical preferences may identify areas for improvement in surgical education.

Clinical Outcomes in Scleral Fixation Secondary Intraocular Lens with Yamane versus Suture Techniques: A Systematic Review and Meta-Analysis.

Background: The purpose of the study is to compare the visual outcomes and complications of sutured scleral fixation (SSF), a traditional and conservative surgical approach, and the newer and faster Yamane technique for secondary intraocular lens placement. Methods: A literature search was performed on PubMed, Embase, and Scopus on studies published between 1 July 2017 to 29 September 2023. Outcomes analyzed included the final best corrected visual acuity (BCVA) between 3 and 12 months to assess the effectiveness of the procedure, post-operative month (POM) 1 BCVA to assess the speed of visual recovery, endothelial cell count (ECC), absolute refractive error, surgical duration, and complication rates. Additional subgroup analyses were performed based on surgeon experience with the technique. Single-surgeon studies had an average of 26 procedures performed, whereas multiple-surgeon studies averaged only 9 procedures performed; these were then used to delineate surgeon experience. A sample-size weighted mean difference (MD) meta-analysis was performed across all variables using RevMan 5.4.1; p < 0.05 was considered statistically significant. Results: Thirteen studies with 737 eyes were included: 406 eyes were included in the SSF group, and 331 eyes were included in the Yamane group. There was no significant difference in the final BCVA between groups in both the single-surgeon versus multiple-surgeon studies (MD = -0.01, 95% CI: [-0.06, 0.04], p = 0.73). In the single-surgeon studies, the BCVA at POM1 was significantly improved in the Yamane group compared to SSF (MD = -0.10, 95% CI: [-0.16, -0.04], p = 0.002). In the multiple-surgeon studies, there was no significant difference in BCVA at POM1 (MD = -0.06, 95% CI: [-0.16, 0.04], p = 0.23). The Yamane group had a shorter surgical duration than SSF in both single-surgeon and multiple-surgeon studies (MD = -24.68, 95% CI: [-35.90, -13.46], p < 0.0001). The ECC, refractive error, and complication rates did not significantly differ amongst all groups. Conclusions: The Yamane technique demonstrated similar long-term visual outcomes and complication rates to the traditional SSF. Visual recovery was significantly faster in the Yamane group in the single-surgeon studies. The operative times were shorter across all Yamane groups. Based on these findings, it is advisable to consider the Yamane technique as a viable, and perhaps preferable, option for patients requiring secondary IOL placement, alongside traditional SSF methods.

Intraocular Lens Formula Comparison of Flanged Intrascleral Intraocular Lens Fixation with Double Needle Technique.

To analyze visual outcomes and accuracy of intraocular lens (IOL) calculation formulas in predicting postoperative outcomes in patients undergoing flanged intrascleral IOL fixation. Case Series. Twenty-three patients who had undergone secondary IOL placement using flanged intrascleral fixation technique. Retrospective chart review. Corrected distance visual acuity (CDVA) and postoperative spherical equivalent based on manifest refraction. Visual acuity improved from 20/577 to 20/58. Overall, the actual refraction was 0.06 D more myopic than predicted. Holladay 2, Sanders Retzlaff Kraff/Theoretical (SRK/T) and Barrett Universal II resulted in mild myopic surprise (-0.55, -0.18 and -0.20 D). Haigis and Hill-RBF (Radial Basis Function) resulted in mild hyperopic surprise (+0.28 and +0.28 D). Hoffer Q and Holladay 1 were the most accurate (-0.02D and -0.08 D). Flanged intrascleral IOL fixation improved vision even in patients with other posterior segment pathologies. The effective lens positioning is likely similar to in-the-bag positioning. Hoffer Q and Holladay 1 formulas with in-the-bag calculations were the most accurate.

A novel surgical approach for fixation of a posterior chamber intraocular lens of Rayner 620 H with Gore-Tex suture

PurposeTo report a novel surgical approach for the scleral fixation of the Rayner 620 H intraocular lens (IOL) with Gore-Tex suture and its outcomes at 6 months postoperatively.Methods19 consecutive patients who underwent novel surgical approach for the scleral fixation of Rayner 620 H IOL with Gore-Tex suture at Peking Union Medical College Hospital between June 2020 and June 2021 were included. Data on best-corrected visual acuity (BCVA), spherical equivalent, total astigmatism/axis, short-term and long-term complications, and corresponding management with a follow-up of 6 months were collected.ResultsNineteen patients (11 men and 8 women) with a mean age of 62.7 ± 10.6 years were included. The median BCVA improved significantly from 0.90 ± 0.90 (Snellen 20/160) preoperatively to 0.20 ± 0.30 (Snellen 20/32) at postoperative 6 months follow-up (P < 0.001). The stratification of the accuracy of refractive outcomes was 53% of patients within ± 0.5 D and 84% of patients within ± 1.0 D of the refractive target. Corneal edema (n = 3, 16%) and increased intraocular pressure (IOP) (n = 4, 11%) were short-term complications. Long-term complications included increased IOP (n = 1, 5%), and macular edema (n = 1, 5%).ConclusionThe novel surgical approach for scleral fixation of the Rayner 620 H IOL with Gore-Tex suture is a reasonable option for patients who need secondary IOL placement without adequate capsular support.

Recurrent Uveitis-Glaucoma-Hyphema Syndrome Due to Positional Pupillary Capture after Sutureless Scleral-Fixated Secondary Intraocular Lens Placement

Here, we present a case of floppy iris leading to positional pupillary capture by a sutureless, scleral-fixated intraocular lens (IOL) causing recurrent uveitis-glaucoma-hyphema (UGH) syndrome. The patient developed recurrent episodes of UGH syndrome after dislocated IOL removal and the placement of sutureless, scleral-fixated IOL. Gravitationally dependent pupillary capture was noted with the superior iris moving in front of and behind the IOL, depending on head positioning. Ultrasonography showed a floppy iris that moved with shifting gaze. The lack of the capsular bag may have contributed to extreme iris movements. This finding may be secondary to a combination of a lack of zonular support and capsular bag support as well as the lack of vitreous support following vitrectomy. When possible, secondary IOL placement behind a peripherally preserved capsular bag may reduce the risk of UGH.

Intraocular lens implantation in the absence of capsular support.

In the absence of capsular support, it is not always possible to safely place an intraocular lens (IOL) in the capsular bag at the time of surgery. Several techniques have thus been developed to enable safe placement of a secondary IOL outside the capsular bag. These techniques include placement of anterior chamber IOLs, iris-fixated IOLs (sutured, iris-claw), and scleral-fixated IOLs (sutured, sutureless). Secondary IOL placement can take place at the time of the initial surgery or in a second surgery. Each technique has its own unique advantages, as well as its potential complications. At this time, comparison studies have found no secondary IOL technique to be superior in terms of visual acuity or rate of complications. Additional comparison studies with longer follow-up times are needed to confirm these findings. The decision on which secondary IOL technique to perform depends on numerous factors including surgeon experience and comfort, as well as patient comorbidities.

Iris Retraction Without Hypotony.

PurposeAll published cases of iris retraction syndrome have been associated with low intraocular pressure. We report here a case clinically indistinguishable from iris retraction syndrome except for the absence of hypotony, which has not been previously described in the literature.ObservationsA 35-year-old woman with a history of atopic dermatitis developed a rapidly progressive anterior subcapsular cataract and acute uveitis. During follow-up, the presence of bilateral iris retraction was noted, while ocular pressure was either normal or elevated, and the position did not normalize with pupillary dilation. The clinical course was complicated by retinal detachment and posterior cyclitic membrane, which was managed with pars plana vitrectomy, lensectomy, and dissection of cyclitic membrane. The case was further complicated by ocular hypertension attributed to steroid response and formation of an epiretinal membrane. Following micropulse cyclophotocoagulation, placement of an Ahmed tube shunt, epiretinal membrane peel, and placement of secondary intraocular lens, our patient eventually had a good visual outcome.Conclusions and ImportanceHypotony is generally recognized as a key physiological step in the development of iris retraction syndrome. Our case demonstrates that posterior bowing of the iris can occur in the absence of hypotony, and suggests that an alternative mechanism involving posterior cyclitic membrane may be responsible.

Outcomes of Flanged Intrascleral Haptic Fixation with CT Lucia Three-Piece Intraocular Lens.

To report the clinical outcomes of the flanged intrascleral haptic fixation technique (FIHFT) with the Zeiss CT Lucia 602 three-piece intraocular lens (IOL). This was a retrospective case series of patients who received FIHFT secondary implantation of the Zeiss CT Lucia 602 IOL from January 2018 to August 2020. Clinical and refractive outcomes were assessed including best-corrected visual acuity (BCVA), refractive prediction error, and complications. Of the 22 patients in the series, 19 were included in the study. Mean vision improved from logarithm of the minimum angle of resolution (log-MAR) 1.14 to 0.54 (P = .03). BCVA of those without preoperative trauma improved from logMAR 0.68 to logMAR 0.25 (P = .02). Refractive spherical equivalent improved from 2.46 diopters (D) to 0.50 D (P = .07), but astigmatism increased from 1.09 D to 1.31 D (P = .67). FIHFT with the Zeiss CT Lucia 602 three-piece lens is a safe and effective option for secondary IOL placement. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:658-662.].

ONE-YEAR OUTCOMES OF A NOVEL SURGICAL APPROACH FOR FIXATION OF A POSTERIOR CHAMBER INTRAOCULAR LENS USING GORE-TEX SUTURE.

To report the 1-year outcomes of a novel surgical technique for the fixation of a CZ70BD intraocular lens with Gore-Tex suture using cow-hitch knots. A retrospective chart review of 15 patients (13 men and 2 women) who underwent fixation of a posterior chamber intraocular lens with Gore-Tex suture was performed. Short- and long-term outcomes data were collected 1 month and 1 year after surgery, respectively. Fourteen of the 15 patients met inclusion criteria and were included in the analysis. Mean visual acuity improved significantly from Snellen 20/491 preoperatively to Snellen 20/59 at postoperative month 12 (P = 0.002). The most common short-term complications included increased intraocular pressure (n = 6) and cystoid macular edema (n = 4). The most common long-term complications included increased intraocular pressure (n = 2) and iris capture of the intraocular lens (n = 2). One-year outcome data suggest that this technique is a reasonable surgical option for secondary intraocular lens placement in patients who lack capsular support.

Surgical management of negative dysphotopsia

To evaluate curative and preventative surgical strategies for negative dysphotopsia. Private practice, Los Angeles, California, USA. Retrospective case series. Patients with self-reported chronic negative dysphotopsia had corrective surgery as the therapeutic group. Second eye surgery, in cases with negative dysphotopsia in the previously operated eye, comprised the preventative group. Chronologically, several surgical strategies were used, including bag-to-bag intraocular lens (IOL) exchange, reducing posterior chamber depth, piggyback secondary IOL placement, bag-to-sulcus IOL exchange, and reverse optic capture. The primary outcome measure was improvement of negative dysphotopsia by 3months postoperatively. The therapeutic group comprised 40 eyes of 37 patients; 76.6% of causative IOLs were acrylic and 23.4% were silicone and all were bag-fixated. There were 21 eyes in the preventative group of which 11 were second eyes from the therapeutic group; the remaining 10 did not require surgery for the symptomatic eye. Successful outcomes for each surgical strategy were as follows: bag-to-bag IOL exchange (0/5), a reduction in posterior chamber depth with iris suture fixation of the bag-haptic complex (0/1), piggyback secondary IOL (8/11), secondary reverse optic capture (21/22), ciliary sulcus posterior chamber IOL exchange (7/8), and primary reverse optic capture (21/21). Negative dysphotopsia was associated with acrylic or silicone IOLs of either square- or round-edge design. Negative dysphotopsia was reduced, eliminated, or prevented when the IOL optic overlaid the anterior capsulotomy rather than when the capsule edge overlaid the optic. Bag-to-sulcus IOL exchange and reverse optic capture were highly successful in managing or preventing negative dysphotopsia.

Pars Plana Vitrectomy Combined With Either Secondary Scleral-Fixated or Anterior Chamber Intraocular Lens Implantation

To compare visual outcomes among eyes that underwent pars plana vitrectomy (PPV) in combination with either anterior chamber intraocular lens implantation (ACIOL) or scleral suturing of posterior chamber lens (PCIOL). Retrospective comparative case series. All eyes presented with aphakia or luxated or subluxated posterior chamber intraocular lens (IOL) following complicated cataract surgery, trauma, or spontaneous dislocation. Eyes involving visually significant macular pathology, past retinal detachment, follow-up of less than 6months, and surgeries requiring the removal of an ACIOL were excluded. The main outcomes measured were final best-corrected visual acuity (BCVA) and surgical complication rates. Fifty-seven eyes met inclusion criteria; median follow-up was 13.2months. Initial median BCVA for ACIOL patients was logMAR 1.301 (Snellen equivalent 20/400, range 20/20 to light perception); final median BCVA was logMAR 0.477 (Snellen equivalent 20/60, range 20/20 to light perception, P < .001). Initial median BCVA for PCIOL patients was logMAR 1.239 (Snellen equivalent 20/347, range 20/60 to light perception); final median BCVA was logMAR 0.301 (Snellen equivalent 20/40, range 20/20 to hand motions, P < .001). The change in BCVA between the 2 groups over the course of the study was similar (P > .05). More epiretinal membrane (ERM) formations occurred postoperatively in the ACIOL group (P= .011). Other complication rates were similar between both groups. PPV with secondary IOL placement is safe and effective, resulting in improved visual outcomes regardless of the technique used. Patients undergoing ACIOL placement have a higher incidence of ERM formation.

Secondary Intraocular Lens Placement Techniques and Applications.

Secondary Intraocular Lens Placement Techniques and Applications.

Intravenous catheter-assisted scleral fixation of an intraocular lens in eyes without adequate capsular support.

Sutureless scleral fixation is an effective technique for placement of a secondary intraocular lens. The authors propose a modification that may simplify intraoperative technical challenges. Description of surgical technique. Successful placement of stable secondary intraocular lens. This modified technique has the potential to reduce intraoperative complications. Studies including more patients with longer follow-up are needed to test the viability.

The role and efficacy of secondary intraocular lenses in the treatment of monocular infantile cataracts.

To determine if and when a secondary intraocular lens (IOL) can be beneficial to the successful treatment of a monocular infantile cataract. This retrospective study reviewed medical records of children undergoing treatment of a monocular congenital cataract from 1996 to 2009 at one pediatric ophthalmology practice. Patients had unilateral cataracts removed by age 8 months and a secondary IOL inserted prior to 6 years of age. At the final visit, the children had to perform linear Snellen visual acuity testing. Of 11 identified patients, 8 had treatment onset by age 4 months and 3 between 5 and 7 months of age. These 3 children had final acuities of 20/500 (n=2) and hand motion (n=1). Those undergoing treatment prior to age 5 months had Snellen acuities of 20/30 to 20/400. The best results were obtained by patients who were compliant with contact lenses and patching before insertion of a secondary IOL. If treatment of a monocular congenital cataract begins by 4 months of age (ie, the critical period for visual development) and patients remain compliant with occlusion therapy and an aphakic contact lens, then they will likely do well after IOL implantation. Furthermore, it appears that insertion of a secondary IOL will maintain vision that was established with a contact lens and patching and perhaps prevent deterioration that might still occur if compliance issues develop. However, secondary IOL placement will not dramatically improve the final visual result from that developed with occlusion and a contact lens.

Uncorrected visual acuity in children with monofocal pseudophakia

To report uncorrected distance and near visual acuity in pediatric eyes treated with primary monofocal intraocular lens (IOL) implantation. Boston Children's Hospital, Boston, Massachusetts, USA. Retrospective chart review. Records of children older than 5 years who had uneventful monofocal IOL implantation targeted for emmetropia within ± 1.00 diopter (D) spherical equivalent were reviewed. Eyes with secondary IOL placement and sulcus-fixated IOLs were excluded. Vision was tested using the Mentor BVAT or M&S system for distance and the standard Jaeger near card for near visual acuity. Keratometry, axial length, type of IOL, and preoperative and postoperative refractions were recorded. The main outcome measure was uncorrected visual acuity at distance and near. Good visual acuity was defined as 20/40 or better. Forty-one eyes of 25 children had uncorrected distance and near visual acuity recorded in the early postoperative period. The mean age was 11.2 years ± 3.6 (SD). Twenty eyes (49%) had good visual acuity at distance and near, 11 had good visual acuity at distance only, 6 had good visual acuity at near only, and 4 had worse than 20/40 at distance and near. Thirty eyes (70%) had with-the-rule astigmatism. All but 2 eyes (95%) had 20/70 or better uncorrected acuity at distance and near. In children with bilateral pseudophakia, 12 (75%) of 16 had 20/40 or better uncorrected acuity at distance and near. Monofocal IOL placement resulted in good uncorrected distance and near visual acuity in almost 50% of pediatric eyes and in 75% of patients when targeted within ± 1.00 D of emmetropia.

First Report of Traumatic Globe Rupture After Femtosecond Laser–Assisted Penetrating Keratoplasty

To describe the first reported case of traumatic globe rupture after femtosecond laser-assisted penetrating keratoplasty. A 21-year-old Hispanic man suffered a corneal laceration after blunt trauma leading to a visually significant corneal scar and aphakia. The patient underwent femtosecond laser-assisted penetrating keratoplasty using a zigzag-shaped wound with secondary intraocular lens placement. Eighteen months after surgery, he suffered another blunt trauma resulting in inferior dehiscence of his inferior penetrating keratoplasty wound, loss of uveal tissue, and extrusion of the scleral-fixated posterior chamber intraocular lens. The patient underwent repair of the wound dehiscence. Despite the theoretical advantages conferred by a shaped graft-host junction, a shaped penetrating keratoplasty wound created with femtosecond laser can still be subject to dehiscence from trauma.

Modified technique for removal of Soemmerring ring and in-the-bag secondary intraocular lens placement in aphakic eyes

We describe modifications to previously described techniques for evacuation of Soemmerring ring during secondary intraocular lens (IOL) implantation in aphakic eyes following previous pediatric cataract surgery. A new anterior capsulotomy is initiated using a cystotome to incise the anterior capsule close to its attachment to the posterior capsule. A curved microscissor is used to cut circumferentially, completing the capsulotomy, and a dispersive ophthalmic viscoelastic device (OVD) is used to viscoexpress Soemmerring ring material from the capsular bag. A 2-handed maneuver is used to manually divide the Soemmerring ring. Finally, slow-motion phacoemulsification is used to emulsify and remove the pieces. Viscoexpression of fragments of Soemmerring ring is done if there is a posterior capsulotomy. The residual capsular bag is filled with OVD and a foldable 3-piece IOL injected into the bag and dialed in. This technique allows complete evacuation of Soemmerring ring and placement of a secondary IOL in the capsular bag. Neither author has a financial or proprietary interest in any material or method mentioned.

Combined secondary intraocular lens placement with endocyclophotocoagulation in patients with aphakia and glaucoma

Combined secondary intraocular lens placement with endocyclophotocoagulation in patients with aphakia and glaucoma

Endophthalmitis

Endophthalmitis is an eye inflammation, involving the vitreous cavity and its surrounding tissues responsible for vision. In most cases, an infection triggers this inflammation. The infection can be caused by bacteria, fungi, viruses or parasites. The occurrence of this severe and devastating inflammation can be related to surgical procedures, penetrating ocular trauma, and endogenous infections. Post-operative endophthalmitis represents the most frequent event accounting for more than 70% of cases. They are schematically divided in three categories: i. acute-onset endophthalmitis (within few days from surgery); ii. delayed-onset endophthalmitis or chronic endophthalmitis (one month to years after surgery); iii. endophthalmitis related to glaucoma filtration surgery, bleb-associated endophthalmitis. This complication has been reported after both surgery breaking up the ocular integrity and external eye surgery. In the former group, secondary intraocular lens placement and pars plana vitrectomy are associated with the highest and lowest endophthalmitis rate, respectively. Because cataract surgery is the most frequently performed intraocular surgery, the 90% of post-operative endophthalmitis occurs after this surgical procedure. Clinical signs of post-operative endophthalmitis are variable in relation to the typology of the infecting agent, the level of the intraocular inflammation, and the duration of the disease. Its clinical diagnosis should be followed by the collection and culturing of aqueous and vitreous specimens; in fact, because the results of these cultures are often negative and positive, respectively, is essential to obtain specimens from both anterior and posterior ocular chambers for a proper clinical management of each patient. In the majority of cases, the infective agents of a post-operative endophthalmitis cannot be identified without any doubt, but several evidences indicate that the bacterial flora of eyelids and/or conjunctiva is the most common cause of this complication. Contaminated solutions and instruments, surgeon and operating-room personnel represent other potential sources of infection. In absence of a specific infectious condition, such as conjunctivitis, dacryocystitis and blepharitis (which should be diagnosed and treated before any intraocular surgery), the pre-operative administration of antibiotics has not been shown to reduce the incidence and/or the severity of post-operative bacterial endophthalmitis. On the contrary, numerous studies have documented that the pre-surgical application of povidone-iodine to skin and conjunctiva effectively downgrades endophthalmitis frequency. The Endophthalmitis Vitrectomy Study (EVS) has investigated about the management of post-operative endophthalmitis, considering the roles of pars plana vitrectomy and systemic antibiotics in addition to standard treatments with intravitreal antibiotic and topical or systemic corticosteroids. It demonstrated that immediate pars plana vitrectomy was beneficial for patients with very low residual vision, whereas systemic antibiotics had no effect on visual outcome or media clarity. Although EVS remains the major randomized study regarding this topic, there are some weak-points which leave its conclusions open to future modifications. Particularly, in the EVS cluster: i. the fourth-generation fluoroquinolones – characterized by a better efficacy profile in comparison with ceftazidime and amikacin – have been not tested; ii. only cases of acute-onset endophthalmitis – typically caused by coagulase-negative micrococci – were enrolled, resulting in a lack of data about the delayed-onset and bleb-associated endophthalmitis. For these reasons, the EVS outcomes should not be generalized to all forms of endophthalmitis, which could potentially benefit utilizing different or additional therapeutic approaches. Keywords: Endophthalmitis, eye inflammation, Endophthalmitis Vitrectomy Study (EVS), coagulase-negative micrococci, fluoroquinolones

Lens reabsorption following self-induced needling and subsequent intracapsular secondary intraocular lens placement

We present the case of a young man who inadvertently penetrated his cornea and lens with a needle used for injecting heroin. Three years later, the lens had completely reabsorbed leaving a fibrosed capsular bag. We describe the surgical techniques used to insert a secondary intraocular lens into the capsular bag with excellent visual outcome.