Influence of a Capsular Tension Ring on Capsular Bag Behavior of a Plate Haptic Intraocular Lens: An Intraindividual Randomized Trial.

PURPOSE: To evaluate the influence of a capsular tension ring (CTR) on rotational stability, decentration, tilt, and axial stability of an 11.0-mm plate haptic intraocular lens (IOL). DESIGN: Intraindividual, randomized, double-masked, controlled clinical trial. PARTICIPANTS: Patients scheduled for sequential same-day bilateral cataract surgery. METHODS: All patients were randomized to receive a CTR and a plate haptic IOL in one eye and a plate haptic IOL in the fellow eye only. Intraocular lens axis assessment was performed at the end of surgery, 1 hour, 1 week, 1 month, and 6 months using a high-precision evaluation method. Decentration and tilt of the crystalline and pseudophakic lenses were assessed before surgery and at 1 week and 6 months using an anterior segment OCT. MAIN OUTCOME MEASURES: Rotational stability from the end of surgery to 6 months and at all follow-up visits, decentration and tilt at 6 months, and differences in axial shift between 1 week and 6 months. RESULTS: One hundred thirty eyes of 65 patients were included in the study. Absolute rotation from the end of surgery to 6 months was 2.8 ± 3.9° and 3.2 ± 5.3° for the CTR and control groups, respectively (P = 0.613). Intraocular lens decentration and IOL tilt at 6 months were 0.29 ± 0.1 mm and 0.24 ± 0.1 mm and 6.7 ± 2.8° and 5.6 ± 1.6° for the CTR and control groups, respectively (P = 0.058; P < 0.01). A posterior IOL shift of 0.31 ± 0.31 mm and 0.19 ± 0.14 mm was observed in the CTR and control groups, respectively. CONCLUSIONS: Concomitant implantation of a CTR and a plate haptic IOL did not improve the overall rotational stability of the IOL compared with the control group. Against expectations, higher values of decentration, tilt, and axial shift were observed in the CTR group. The simultaneous use of a CTR and a plate haptic IOL in the absence of zonular weakness at the time of cataract surgery should be considered with caution. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Outcomes and predictive factors in multifocal and extended depth of focus intraocular lens implantation.

PURPOSE OF REVIEW: Options for addressing presbyopia with intraocular lens (IOL) implantation have become more varied and sophisticated. We reviewed recent literature on multifocal and extended depth of focus (EDOF) IOLs in order to provide insight on their respective advantages, with emphasis on the visual outcomes of each design. RECENT FINDINGS: Increased patient age, spectral domain optical coherence tomography (SD-OCT) abnormalities, abnormal optical axis measurements, and better preoperative visual acuity have been implicated as predictors of worse postoperative vision or visual quality in multifocal IOLs. Despite differences in objective outcomes, patient-reported outcomes such as satisfaction are consistently similar between multifocal and EDOF IOLs. EDOFs may have slightly lower rates of spectacle independence than trifocals, but there is more support for their use in the setting of with other ocular conditions. SUMMARY: Multifocal and EDOF IOLs are both viable options for patients who wish to preserve near vision. Given their similar objective performance in many aspects, enabling patients to make informed decisions based on their expectations and visual requirements is critical to postoperative satisfaction. Evidence for advanced technology IOL implantation in pediatric patients remains inconclusive.

Immediately sequential bilateral cataract surgery.

PURPOSE OF REVIEW: This review aims to clarify the advantages and disadvantages of immediately sequential bilateral cataract surgery (ISBCS) based on recent studies, illustrate the safety of this approach, the cost-effectiveness, and present the importance of inclusion protocols for the best results. RECENT FINDINGS: In recent studies, the authors found no evidence of an increased risk of bilateral devastating complications such as endophthalmitis with ISBCS based on descriptive evidence compared to delayed sequential bilateral cataract surgery (DSBCS). Furthermore, recent studies on cost analyses showed that ISBCS resulted in fewer costs and significant cost savings to third-party payers, patients, and society compared to DSBCS. SUMMARY: The ISBCS surgical approach decreases hospital visits, reduces costs, and provides rapid visual rehabilitation and neuro adaptation. The risk of bilateral simultaneous complications is now recognized to be very rare with intracameral antibiotics and compliance with correct protocols. With new generations of optical biometry and lens calculation formulas, refractive surprises are occasional for normal eyes. However, refractive surprise is controversial, especially in the implantation of presbyopia correction intra-ocular lenses, which must be evaluated carefully in the ISBCS approach.

Cataract surgery after corneal refractive surgery: preoperative considerations and management.

PURPOSE OF REVIEW: Corneal refractive surgery (CRS) is one of the most popular eye procedures, with more than 40 million cases performed globally. As CRS-treated patients age and develop cataract, the number of cases that require additional preoperative considerations and management will increase around the world. Thus, we provide an up-to-date, concise overview of the considerations and outcomes of cataract surgery in eyes with previous CRS, including surface ablation, laser in-situ keratomileusis (LASIK), and small-incision lenticule extraction (SMILE). RECENT FINDINGS: Challenges associated with accurate biometry in eyes with CRS have been mitigated recently through total keratometry, ray tracing, intraoperative aberrometry, and machine learning assisted intraocular lens (IOL) power calculation formulas to improve prediction. Emerging studies have highlighted the superior performance of ray tracing and/or total keratometry-based formulas for IOL power calculation in eyes with previous SMILE. Dry eye remains a common side effect after cataract surgery, especially in eyes with CRS, though the risk appears to be lower after SMILE than LASIK (in the short-term). Recent presbyopia-correcting IOL designs such as extended depth of focus (EDOF) IOLs may be suitable in carefully selected eyes with previous CRS. SUMMARY: Ophthalmologists will increasingly face challenges associated with the surgical management of cataract in patients with prior CRS. Careful preoperative assessment of the ocular surface, appropriate use of IOL power calculation formulas, and strategies for presbyopia correction are key to achieve good clinical and refractive outcomes and patient satisfaction. Recent advances in CRS techniques, such as SMILE, may pose new challenges for such eyes in the future.

Surgical options and clinical outcomes for high myopia.

PURPOSE OF REVIEW: Higher degrees of myopia are currently being treated with refractive surgery. However, there is limited characterization and outcomes data for this cohort. This article aims to review the literature on highly myopic patients who had refractive surgery and present a retrospective analysis of 149 patients (270 eyes) with high to extreme myopia (≤-5.0D SE) who underwent refractive surgery [laser-assisted subepithelial keratomileusis (LASIK), photorefractive keratectomy (PRK), or implantable collamer lense (ICL)] at a single practice. RECENT FINDINGS: There is substantial literature on the efficacy of LASIK, PRK, and phakic intraocular lenses for refractive error correction, but a dearth of studies on patients with high to extreme myopia undergoing different types of refractive surgery. Our study reveals that this cohort of patients has excellent outcomes with minimal complications. SUMMARY: Our study reveals that the average preoperative myopia was highest in ICL patients (-10.03D), followed by PRK (-7.21D), and LASIK (-7.04D) patients. Not surprisingly, eyes with high myopia and thin corneas were offered and elected ICLs for their procedure. Highly myopic patients achieved outcomes consistent with data reported in the literature- average postoperative uncorrected visual acuity was 20/20 for LASIK and ICL eyes and 20/25 for PRK eyes.

Application of sutureless corneal incision for patients with congenital ectopia lentis - Is it feasible, effective and safe?

Purpose: To compare the clinical outcomes, feasibility, and safety between groups with sutured and sutureless wound closure in congenital ectopia lentis (CEL) patients. Methods: Patients with CEL who received phacoemulsification combined with intrascleral fixation of capsular hook (CH) and implantation of capsular tension ring (CTR) and in-the-bag intraocular lens (IOL) were included in this study. Results: A total of 68 eyes of 34 patients aged 18 years or younger were enrolled in this study. Incisions of 21 patients (34 eyes) did not require sutures while sutures were applied in 21 patients (34 eyes). Postoperative uncorrected distance visual acuity, best corrected distance visual acuity and intraocular pressure measurements were comparable on follow-up visits (P > 0.05). The magnitude of surgically induced astigmatism was significantly greater (P = 0.001) in the suture group (Median: 0.47; IQ: 1.63, 2.97) than in the sutureless group (Median: 0.88; IQ: 0.63, 1.35). No cases of endophthalmitis and retinal detachment were found postoperatively in either group, while suture-related complications were observed in the sutured group, including loose suture with discomfort in 5 (14.71%) eyes, loose suture with mucus infiltration in 3 (8.82%) eyes. In total, 22 sutures (64.71%) of 34 eyes required removal. Conclusions: Sutureless clear corneal incision in CEL patients can achieve satisfactory clinical results comparable to sutured wound closure in terms of the efficacy and safety. Advantages of this approach are the reduced risk of suture-related complications, no need for additional surgery under general anesthesia for suture removal, and less cost.

Trifocal versus extended depth of focus (EDOF) intraocular lenses after cataract extraction.

BACKGROUND: Cataract, defined as an opacity of the lens in one or both eyes, is the leading cause of blindness worldwide. Cataract may initially be treated with new spectacles, but often surgery is required, which involves removing the cataract and placing a new artificial lens, usually made from hydrophobic acrylic. Recent advancements in intraocular lens (IOL) technology have led to the emergence of a diverse array of implantable lenses that aim to minimise spectacle dependence at all distances (near, intermediate, and distance). To assess the relative merits of these lenses, measurements of visual acuity are needed. Visual acuity is a measurement of the sharpness of vision at a distance of 6 metres (or 20 feet). Normal vision is 6/6 (or 20/20). The Jaegar eye card is used to measure near visual acuity. J1 is the smallest text and J2 is considered equivalent to 6/6 (or 20/20) for near vision. OBJECTIVES: To compare visual outcomes after implantation of trifocal intraocular lenses (IOLs) to those of extended depth of focus (EDOF) IOLs. To produce a brief economic commentary summarising recent economic evaluations that compare trifocal IOLs with EDOF IOLs. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register), MEDLINE, Embase, and three trial registries on 15 June 2022. For our economic evaluation, we also searched MEDLINE and Embase using economic search filters to 15 June 2022, and the NHS Economic Evaluation Database (EED) from 1968 up to and including 31 December 2014. We did not use any date or language restrictions in the electronic searches. SELECTION CRITERIA: We included studies comparing trifocal and EDOF IOLs in adults undergoing cataract surgery. We did not include studies involving people receiving IOLs for correction of refractive error alone (or refractive lens exchange in the absence of cataract). DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Two review authors working independently selected studies for inclusion and extracted data from the reports. We assessed the risk of bias in the studies, and we assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included five studies that compared trifocal and EDOF lenses in people undergoing cataract surgery. Three trifocal lenses (AcrySof IQ PanOptix, ATLISA Tri 839MP, FineVision Micro F) and one EDOF lens (TECNIS Symfony ZXR00) were evaluated. The studies took place in Europe and North America. Follow-up ranged from three to six months. Of the 239 enroled participants, 233 (466 eyes) completed follow-up and were included in the analyses. The mean age of participants was 68.2 years, and 64% of participants were female. In general, the risk of bias in the studies was unclear as methods for random sequence generation and allocation concealment were poorly reported, and we judged one study to be at high risk of performance and detection bias. We assessed the certainty of the evidence for all outcomes as low, downgrading for the risk of bias and for imprecision. In two studies involving a total of 254 people, there was little or no difference between trifocal and EDOF lenses for uncorrected and corrected distance visual acuity worse than 6/6. Sixty per cent of participants in both groups had uncorrected distance visual acuity worse than 6/6 (risk ratio (RR) 1.06, 95% confidence intervals (CI) 0.88 to 1.27). Thirty-one per cent of the trifocal group and 38% of the EDOF group had corrected distance visual acuity worse than 6/6 (RR 1.04, 95% CI 0.78 to 1.39). In one study of 60 people, there were fewer cases of uncorrected near visual acuity worse than J2 in the trifocal group (3%) compared with the EDOF group (30%) (RR 0.08, 95% CI 0.01 to 0.65). In two studies, participants were asked about spectacle independence using subjective questionnaires. There was no evidence of either lens type being superior. One further study of 60 participants reported, "overall, 90% of patients achieved spectacle independence", but did not categorise this by lens type. All studies included postoperative patient-reported visual function, which was measured using different questionnaires. Irrespective of the questionnaire used, both types of lenses scored well, and there was little evidence of any important differences between them. Two studies included patient-reported ocular aberrations (glare and halos). The outcomes were reported in different ways and could not be pooled; individually, these studies were too small to detect meaningful differences in glare and halos between groups. One study reported no surgical complications. Three studies did not mention surgical complications. One study reported YAG capsulotomy for posterior capsular opacification (PCO) in one participant (one eye) in each group. One study reported no PCO. Two studies did not report PCO. One study reported that three participants (one trifocal and two EDOF) underwent laser-assisted subepithelial keratectomy (LASEK) to correct residual myopic refractive error or astigmatism. One study reported a subset of participants who were considering laser enhancement at the end of the study period (nine trifocal and two EDOF). Two studies did not report laser enhancement rates. No economic evaluation studies were identified for inclusion in this review. AUTHORS' CONCLUSIONS: Distance visual acuity after cataract surgery may be similar whether the lenses implanted are trifocal IOLs or EDOF (TECNIS Symfony) IOLs. People receiving trifocal IOLs may achieve better near vision and may be less dependent on spectacles for near vision. Both lenses were reported to have adverse subjective visual phenomena, such as glare and halos, with no meaningful difference detected between lenses.

Chord mu and chord alpha as postoperative predictors in multifocal intraocular lens implantation.

PURPOSE: With the aging population, the prevalence of presbyopia and the popularity of multifocal intraocular lenses is also growing worldwide. Unfortunately, in some cases, they are still associated with postoperative visual disturbances. Recent literature started to evaluate angle kappa- and angle alpha-derived metrics of chord mu and chord alpha as possible predictive values for visual outcomes after multifocal intraocular lens implantation but the published results are inconsistent between studies. Thus, this article aims to review the role of chord mu and chord alpha as postoperative predictors after multifocal intraocular lens implantation and lay the foundation for further research. METHODS: Relevant articles were identified using the following keywords: "presbyopia," "multifocal intraocular lens," "angle kappa," "angle alpha," "Chord mu," and "Chord alpha" up to June 2022. An attempt was made to present the majority of publications that addressed the topic. CONCLUSIONS: Chord mu and chord alpha have a predictive role on the outcomes after multifocal intraocular lens implantation but to a different extent. Cataract surgeons should take them into consideration and avoid implanting a multifocal intraocular lens for patients with speculated critical values of chord mu and alpha above 0.5-0.6 mm, depending on the device used for measurement and the multifocal intraocular lens implanted. Currently, chord alpha seems to be a more stable, more widely applicable, and reliable determinant in predicting postoperative outcomes and in patient selection prior to multifocal intraocular lens implantation when compared to chord mu. To draw conclusions on the topic, a controlled study is needed.

Effect of ciliary sulcus angle on the prediction of the vault for phakic implantable collamer lens in the KS formula.

PURPOSE: We aimed to explore the effects of the ciliary sulcus angle (CSA) on accurate prediction of the vault after phakic implantable collamer lens (EVO ICL Model V4c) using the KS formula. METHODS: Patients were classified according to the size of CSA: group A, narrow angle (CSA < 30°); group B, normal angle (CSA = 30-90°); and group C, wide angle (CSA > 90°). Further, differences between the actual vault dimensions at 3 months postoperatively and the preoperatively predicted vault dimensions in the three groups were analyzed. RESULTS: This study included 223 eyes of 223 individuals. In groups A-C, the difference in the preoperative vault dimensions of the three groups predicted with the KS formula was not statistically significant (P = 0.056). The actual vault dimensions at 3 months postoperatively were significantly different between the three groups (P < 0.001). Moreover, the difference between the actual and predicted vaults by the KS formula was statistically significant (P < 0.001). In the 3 months, after surgery, the percentages of patients with a low vault (< 250 µm) were 0%, 3%, and 29% in groups A, B, and C, respectively. Further, the percentages of patients with an ideal vault (250-750 µm) in the postoperative period were 66%, 84%, and 71% in groups A, B, and C, respectively. Finally, the percentages of patients with a high vault (> 750 µm) in the postoperative period were 34%, 13%, and 0% in groups A, B, and C, respectively. Notably, the distribution of the vault among the three groups was statistically significant (P < 0.001). CONCLUSION: The size of CSA significantly affects the predictiveness of the vault by the KS formula, with the most pronounced effect on the angles < 30° and > 90°. Therefore, CSA should be considered when selecting the lens size using the KS formula preoperatively. CLINICAL TRIAL REGISTRATION NUMBER: ChiCTR2200065501.

A mini-invasive surgical technique for Carlevale IOL implantation: case series study and description of concomitant surgery.

PURPOSE: To examine the feasibility and outcomes of a modified technique for the implantation of scleral fixated Carlevale intraocular lens (IOL) (I71 FIL SSF. Soleko IOL Division, Pontecorvo, Italy), and to analyze the occurrence of adverse events. METHODS: This is a retrospective observational study conducted revising patients charts from 2018 to 2023. Thirty-five eyes of 33 patients were included. Patients requiring IOL explantation had either IOL dislocation or opacification. The implantation of the Carlevale IOL was performed with the subconjunctival positioning of the anchors without any scleral flap. All maneuvers were performed transconjunctivally. The anatomical outcomes considered were IOL positioning, and the absence of postoperative complications. The functional outcomes analyzed were best correctedvisual acuity (BCVA) and refraction. RESULTS: In all the cases, the IOL was well positioned and centered postoperatively. No cases of conjunctival erosion were recorded. The best corrected visual acuity (BCVA) was 0.9±0.6 logMar (mean±standard deviation) preoperatively and 0.5±0.5 logMar (mean±standard deviation) postoperatively. The mean preoperative spherical equivalent was +6.8±7.7 dioptres, while postoperatively it was -1.1±1.6 dioptres. The most frequent procedure associated to secondary IOL implantation was posterior vitrectomy (25 eyes, 71.4%), which was performed with 25-gauge transconjunctival cannulas in the ciliary sulcus. The follow-up period was 24.5±16.9 months (mean±standard deviation). CONCLUSION: The described mini-invasive technique for Carlevale IOL implantation is safe and effective. It can be recommended either as a stand-alone operation or associated to concurrent surgical procedures.

Tolerance to residual astigmatism of an isofocal intraocular lens.

PURPOSE: To evaluate the impact of residual astigmatism on the optical and visual performance of an enhanced-monofocal isofocal intraocular lens (EM Isopure, BVI medical, Belgium) compared to a monofocal one (Micropure, BVI medical, Belgium). METHODS: Laboratory investigation and prospective, comparative and randomized clinical study. Optical quality was assessed on an optical bench for 2.0, 3.0, and 4.5 mm pupils. The effect of residual astigmatism was investigated from through-focus images recorded with increasing amounts of regular positive astigmatism induced with a deformable mirror. To evaluate the impact of residual astigmatism, 28 eyes of 28 patients were randomly assigned to either group. Residual astigmatism was induced with positive and negative cylinder lenses at 90 and 180°. Visual acuity (VA) was measured at each step. RESULTS: The optical performance of both IOLs was quite similar for 2.0 and 3.0 mm pupils. For 4.5-mm pupil, the EM Isopure showed a significant reduction of its optical quality in comparison with the monofocal IOL. When visual performance was evaluated, no statistically significant differences were found for any power of induced astigmatism. More differences were found when positive induced astigmatism was compared within each group, and VA was better when the astigmatism was induced at 180° vs. 90°. The greatest differences were found for and induced positive astigmatism of + 1.50D (p = 0.009 for Isopure and p = 0.023 for Micropure). CONCLUSIONS: The tolerance to residual astigmatism of the EM Isopure lens is similar to that of a reference monofocal lens with pupils up to 3.5 mm.

Effect of Posterior Keratometry on the Accuracy of 10 Intraocular Lens Calculation Formulas: Standard Keratometry versus Total Keratometry.

PURPOSE: To investigate the effect of posterior keratometry (PK) on the accuracy of 10 intraocular lens (IOL) power calculation formulas using standard keratometry (K) and total keratometry (TK). METHODS: This is a retrospective consecutive case-series study. The IOL power was calculated using K and TK measured by IOLMaster 700 in 6 new-generation formulas (Barrett Universal II, Emmetropia Verifying Optical (EVO) 2.0, RBF Calculator 3.0, Hoffer QST, Kane, and Ladas Super Formula) and 4 traditional formulas (Haigis, Hoffer Q, Holladay 1, and SRK/T). The arithmetic prediction error (PE) and mean absolute PE (MAE) were evaluated. The locally-weighted scatterplot smoothing was performed to assess the relationship between PE and PK. RESULTS: A total of 576 patients (576 eyes) who underwent cataract surgery were included. Compared with using K, all formulas using TK showed a hyperopic shift in the whole group. Specifically, for eyes with PK exceeding -5.90 D, all formulas using TK exhibited a hyperopic shift (all P < 0.001), while eyes with PK less than -5.90 D showed a myopic shift (all P < 0.001). The MAE of new-generation formulas calculated with TK and K showed no statistical differences, while the MAE of traditional formulas with TK was larger (TK: 0.34 ~ 0.43 D; K: 0.33 ~ 0.42 D, all P < 0.05). CONCLUSIONS: The prediction bias of formulas with TK increased as PK deviated from -5.90 D. TK did not improve the prediction accuracy of new-generation formulas, and even performed worse in traditional formulas.

Refractive predictive errors using Barrett II, Hoffer-Q, and SRKT formulae for pediatric IOL implantation.

PURPOSE: To compare the accuracy of the Barrett II universal (BU II) formula, Hoffer-Q, and SRKT formulae following lensectomy and IOL implantation in a large pediatric cohort. METHODS: Retrospective study of children who underwent lensectomy and IOL implantation between 2015 and 2023 at Hadassah-Hebrew University Medical Center, Jerusalem, Israel. RESULTS: One hundred and fifty-one eyes of 104 children aged 6.0 ± 3.9 years were included. The mean prediction error (PE) was - 0.08 ± 1.54 diopters (D) with BU II, 0.24 ± 1.46 D with Hoffer-Q, and 0.71 ± 1.92 D with SRKT (P = 0.10). In eyes with axial length (AL) < 22 mm, BU II and Hoffer-Q had a smaller PE than SRKT (P = 0.024). In eyes with AL ≥ 22 mm, BU II had a smaller PE than Hoffer-Q (P = 0.048). In children 24 months or older at surgery, BU II had a smaller PE than SRKT and Hoffer-Q (P = 0.012). However, in younger children, no difference was found between the formulae (P = 0.61). For mean k-values ≥ 44.5 D, BU II and Hoffer-Q had a smaller PE than SRKT (P = 0.002). An absolute prediction error < 1.0 D was obtained with BU II in 66% of eyes and SRKT in 35% (P = 0.01). CONCLUSIONS: The BU II formula performed well with a small prediction error. No significant difference in PE was detected overall between the formulae. However, only BU II demonstrated a stable prediction error at varying axial lengths, K-readings, and ages. As the biometric parameters of the developing eye change with growth, the BU II formula offers a reliable and stable option for pediatric IOL calculation.

Efficacy and safety of the implantation of a single-piece angulated foldable IOL in the sulcus.

PURPOSE: To study the visual results and tolerance of a Zeiss CT Lucia 601P intraocular lens (IOL) implanted in the sulcus after complicated cataract surgery or during IOL exchange for clouded IOL. METHODS: In total, 64 patients who underwent sulcus implantation were recalled to the hospital to undergo subjective and objective refraction, best corrected visual acuity measurement, tonometry, optical coherence tomography, laser flare photometry, biometry, and wavefront aberrometry. RESULTS: In spite of a large variation in preoperative refraction, the target refraction was obtained within 1.5 diopters in approximately 97% of patients and within 0.5 diopter in 53% of patients. Average BCVA was high (Snellen 0.86) and related to concomitant (mostly retinal) pathologies in eyes with poorer visual performance. Wavefront aberrometry showed no evidence of IOL tilting or decentration after long-term implantation in the sulcus. Tonometry was not different from the fellow eye of the patient (p > 0.5). In 53 patients with bilateral pseudophakia, the laser flare photometry was not significantly different from the fellow eye (p < 0.05). CONCLUSION: This study demonstrates that this single-piece angulated foldable acrylic IOL can be considered for implantation in the sulcus. The visual results are favorable, and the IOL can be well-positioned and tolerated in the sulcus. Moreover, there were no safety issues found since there was no evidence of elevated IOP or chronic uveitis.

CONTRIBUTION FACTORS OF EFFECTIVE LENS POSITION, TILT, AND DECENTRATION DURING FLANGED SCLERAL FIXATION OF INTRAOCULAR LENS: A Model Eye Study.

PURPOSE: The authors aimed to elucidate the factors related to effective lens position, tilt, and decentration of scleral fixed intraocular lenses (IOLs) with a flanged haptic technique in an artificial eye model using anterior segment optical coherence tomography. METHODS: Two bent 27-gauge needles were passed through a 1.0- or 2.0-mm scleral tunnel, 2.0 mm posterior to the limbus and 180° apart. Both haptics of a three-piece IOL were docked with guide needles and externalized. Factors related to the IOL position were analyzed using anterior segment optical coherence tomography and a stereomicroscope. RESULTS: The 1.0-mm scleral tunnel induced a significantly longer effective lens position than the 2.0-mm tunnel and suture fixation ( P < 0.05 and P < 0.01, respectively). Discrepancy in scleral tunnel length induced higher decentration of the optic to the opposite side of the haptic-embedded shorter tunnel and tilt perpendicular to the fixed axis than that in the scleral tunnel of the same length ( P < 0.001 and P < 0.05, respectively). If the scleral fixation points of both haptics are not exactly 180° apart, the IOL may become decentered and tilted ( P < 0.01 and P < 0.05, respectively). CONCLUSION: In the flanged haptic technique, the length, balance, and position of both scleral tunnels determine IOL effective lens position, tilt, and decentration.

LONG-TERM OUTCOMES OF SUTURELESS INTRASCLERAL INTRAOCULAR LENS FIXATION IN CHILDREN AND ADULTS: Single-Surgeon Case Series With and Without Haptic Flanging With Up to 11 Years of Follow-Up.

PURPOSE: Report and compare long-term outcomes and complications of sutureless scleral tunnel (SST) and flanged haptic (FH) scleral-fixated intraocular lens, with spontaneous intraocular lens (IOL) dislocation as primary outcome measure. METHODS: Retrospective single-surgeon case series of 95 SST and 458 FH eyes from 2011 to 2022 (553 total eyes). Demographics, surgical indications, ocular history, visual acuity, and complication rates were collected. RESULTS: Reoperation-requiring spontaneous IOL dislocation rate was significantly different ( P = 0.0167) between FH (3.7%) and SST (10.5%). Mean follow-up was 3.31 ± 0.30 versus 1.58 ± 0.07 years for SST and FH, respectively. There was no significant difference between preoperative (20/305 vs. 20/300) or final postoperative (20/77 vs. 20/62) visual acuity. Other complications included any cystoid macular edema (20.0% vs. 25.3%), elevated intraocular pressure (16.8% vs. 9.6%), IOL tilt requiring reoperation (5.3 vs. 0%), haptic exposure (2.1% vs. 3.3%), and reverse pupillary block (4.2% vs. 1.1%). CONCLUSION: Haptic flanging resulted in fewer eyes meeting the primary end point of IOL dislocation. We reported the longest-to-date follow-up of both nonflanged SST IOL fixation and our FH-modified Yamane technique. Our FH-modified Yamane technique represents a safe, durable, and potentially superior option for scleral-fixated intraocular lens.

RELAY INTRASCLERAL 6-0 POLYPROPYLENE-ASSISTED INTRAOCULAR LENS FIXATION: A Retrospective Comparison With Modified Yamane Technique.

PURPOSE: To describe a new surgical technique that uses a relay suture to optimize sutureless scleral fixation of intraocular lens in eyes with capsular insufficiency and to evaluate the outcomes of this technique versus Flanged, double needle-guided, scleral fixation of intraocular lens with haptic trimming (modified Yamane approach). METHODS: Relay intrascleral 6-0 polypropylene sutures with flanges generated at the intraocular ends were used to fixate and securely hold a rigid intraocular lens with haptic eyelets against the inner scleral wall. The results were analyzed at 3-, 6-, and 12-month follow-up. RESULTS: This retrospective cohort study found that compared with the control group (n = 27), the relay-sutured group (n = 26) had greater mean changes in corneal astigmatism (0.44 vs. -0.52 diopters [D]) and fewer mean degrees of intraocular lens astigmatism (0.62 vs. 1.1 D). The mean intraocular lens decentration was comparable between both the groups; however, in the control group, there was a significant increase in intraocular lens tilt degrees from 3 to 12 months. Moreover, significantly higher proportions of patients with persistent macular edema and iris-optic capture were seen in the control group. CONCLUSION: The relay-sutured technique may be an alternative to flapless scleral fixation of intraocular lens and provides a stable intraocular lens position with acceptable complication rates.

A Novel Surgical Technique for Transscleral Gore-Tex Suture-Assisted Rescue of Dislocated CZ70BD Intraocular Lenses Using 27-Gauge Instrumentation.

PURPOSE: To report a novel technique for refixation of dislocated CZ70BD intraocular lens (IOL). METHODS: Vitrectomy trocars are placed along the horizontal meridian 5 mm apart. A CV-8 Gore-Tex suture is introduced through a bare sclerotomy into the midvitreous cavity. Under chandelier illumination, a 27 G broad platform forceps is threaded through the eyelet of the dislocated CZ70BD IOL. Using another pair of intraocular forceps, the free intraocular end of the Gore-Tex suture is fed to the broad platform forceps and externalized, thus repositioning the IOL. Particular attention is drawn to pass the suture in an over and under configuration to avoid IOL tilt. An identical procedure is repeated for the other eyelet if the IOL is completely dislocated. The 23 gauge or 25 gauge instruments should not be used for this technique because they do not fit loosely through the eyelets of the IOL. RESULTS: Three eyes were successfully operated on using this technique with at least 6 months of follow-up. There was significant improvement in best-corrected visual acuity after the operation. Postoperative IOL centration and alignment were satisfactory. CONCLUSION: The described surgical technique is effective for transscleral Gore-Tex-assisted refixation of dislocated CZ70BD IOL.

LONG-TERM OUTCOME OF TRANSSCLERAL FOUR-POINT FIXATION OF AKREOS INTRAOCULAR LENS WITH CLOSED CONTINUOUS-LOOP SUTURE.

PURPOSE: To report the long-term clinical outcomes of transscleral four-point fixation of Akreos intraocular lens using a closed continuous-loop suture technique. METHODS: This was a retrospective, multicenter, interventional case series. Primary outcome measures were best-corrected visual acuity, intraocular pressure, corneal endothelial cell density, and complications with a minimum of 1-year follow-up. RESULTS: One hundred and ninety-two eyes of 177 patients from two surgical hospital sites were identified. The mean best-corrected visual acuity improved from 0.88 ± 0.74 logarithm of the minimum angle of resolution (Snellen 20/152) preoperatively to 0.42 ± 0.52 logarithm of the minimum angle of resolution (Snellen 20/53) postoperatively ( P < 0.001). The mean preoperative intraocular pressure was 17.51 ± 8.67 mmHg, and the mean postoperative intraocular pressure at final follow-up was 15.08 ± 4.18 mmHg ( P = 0.001). The mean corneal endothelial cell density significantly reduced from 2,259 ± 729 cells/mm 2 to 2077 ± 659 cells/mm 2 , representing a cell loss of 5.73% ( P < 0.001). The intraocular lens was fixed well during follow-up. There were no intraoperative complications noted. Postoperative complications included transient ocular hypertension in 15 eyes (7.81%), hypotony in two eyes (1.04%), retinal detachment in one eye (0.52%), and macular edema in one eye (0.52%). CONCLUSION: The transscleral four-point fixation Akreos intraocular lens using the closed continuous-loop suture technique was effective and safe with satisfactory visual acuity with a minimum of 1-year follow-up.

A Modified Girth-Hitch Suture Technique to Rescue Single-Haptic Dislocation of Scleral-Fixated Intraocular Lenses.

PURPOSE: To describe the technique of modified girth-hitch suture for one-side transscleral fixation to rescue a single-haptic dislocation. METHODS: In this surgical technique report, dislocated scleral-fixated posterior-chamber intraocular lenses (IOLs) were secured to the sclera using a 10-0 polypropylene suture looped around the IOL haptic. Three types of IOL were secured in this study (four cases of one-piece polymethyl methacrylate (PMMA) IOL, one case of three-piece acrylic IOL with PMMA loop, and one case of acrylic foldable IOL with a two-plate loop design). RESULTS: Six patients, who had subluxation of the scleral-fixated posterior-chamber IOL due to single-knot dehiscence, underwent refixation of scleral-fixated IOL surgery using this technique. In all cases, successful repositioning with stable and central fixation of the IOLs was achieved. No intraoperative or postoperative complications were noted. CONCLUSION: Internal refixation with a girth-hitch suture is a relatively quick and convenient method for the management of a dislocated IOL haptic on one side.