Seminars in Ophthalmology, 2014; 29(1): 39–44 ! Informa Healthcare USA, Inc. ISSN: 0882-0538 print / 1744-5205 online DOI: 10.3109/08820538.2013.835834
Scleral-Fixated Posterior Chamber Intraocular Lens Implantation in Pediatric and Adult Patients
Ankara Training and Research Hospital, Ankara, Turkey
ABSTRACT Purpose: To evaluate the results of scleral-fixated posterior chamber intraocular lenses (SFIOL) in pediatric and adult patients. Methods: We carried out a retrospective analysis of 129 eyes of 120 patients (adult group, n = 96; pediatric group, n = 24) who underwent SFIOL implantation. Outcome measures were indications, corrected distance visual acuity (CDVA), change in visual acuity, and complications. Results: The median follow-up time was six months (minimum: 6; maximum: 55 months). The median preoperative CDVAs were similar between the groups (p = 0,253). The median postoperative CDVA was 0.2 (min: hand motion; max: 0.8) in pediatric patients and 0.5 (min: hand motion; max: 1.0) in adult patients in decimal notation, (p = 0.017). The CDVA improved at least one Snellen line or remained unchanged in all pediatric eyes, and in 87 (90.6%) adult eyes. The change in visual acuity was similar between the groups (p = 0.296). Conclusion: In both pediatric and adult patients, SFIOL implantation ends with favorable outcomes over the short term. Keywords: Aphakia, intraocular lens
pediatric
cataract,
pseudoexpholiation,
subluxated
cristalin
lens,
subluxated
penetrating keratoplasty and IOL implantation.3,7,9,10 Furthermore, the SFIOLs provide potential advantages for better visual acuity and binocularity by moving the effective IOL position from the anterior to posterior chamber. However, the surgical technique of SFIOL insertion is more difficult and requires manipulation at the ciliary body region, which can cause serious complications. The literature contains several reports with favorable results.3,9–15 The purpose of this retrospective study was to analyze the indications and outcomes of SFIOL implantation in pediatric and adult patients.
INTRODUCTION When the posterior capsule is ruptured and zonular support is inadequate, an intraocular lens (IOL) can be placed in the anterior chamber as an iris-fixated and closed- or open-loop anterior chamber intraocular lens (ACIOL), or in the posterior chamber as a sutured irisfixated and scleral-fixated posterior chamber intraocular lens (SFIOL).1–4 Implantation of an ACIOL is easier to perform than the alternative surgical procedures, but it is associated with a relatively high rate of complications caused by long-term anterior chamber irritation.3,5,6 Although modern, multiflex openlooped ACIOLs have lower complication rates than those reported with closed-loop ACIOLs,7,8 SFIOLs are indicated in such cases and in situations in which an ACIOL might cause complications, such as in young patients, in patients with shallow anterior chambers, anterior segment disruption, cornea guttata and diabetes, and in patients scheduled for combined
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Ayse Burcu, Zuleyha Yalniz-Akkaya, Iskan Abay, Mehmet Akif Acar, and Firdevs Ornek
PATIENTS AND METHODS This study was performed after the approval of the institutional board and according to the tenets of the Declaration of Helsinki. The medical records of 120 patients that underwent SFIOL implantation
Received 5 December 2012; revised 19 March 2013; accepted 7 August 2013; published online 10 October 2013 Correspondence: Ayse Burcu, Prof. Dr., Ahmet Taner Kislali mah, Park cad, Ronesans evleri A Blok no:32 Cayyolu, Ankara, Turkey TR06810. E-mail: [email protected]
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40 A. Burcu et al. between April 2004 and September 2009 and were followed for at least six months were reviewed retrospectively. Nine patients were operated on bilaterally. In order to obtain independency of variables provided that correlation between postoperative visual acuities was very high (Spierman’s correlation test, = 0.793, p = 0.011), only one eye of bilaterally operated patients were included in the analyses. The eyes were divided into two groups: Pediatric Group (age 16 years) and Adult Group (age 17 years). Scleral-fixated posterior chamber intraocular lens implantation was performed in patients with extensive capsular deficiency precluding safe and stable bag or sulcus implantation and in patients intolerant or not suitable for contact lens wear. Uveitis, endothelial dysfunction/corneal dystrophy, retinal hole/ fluid, extensive lattice degeneration, or major retinal diseases were contraindications for SFIOL implantation. All patients and the parents of pediatric patients were informed about complications of SFIOL procedure and the possible need for IOL removal or exchange in the future and written informed consent was obtained preoperatively. Intraocular lens power was calculated using the SRK II formula. The power was adjusted according to the patient’s age and the refractive error of the fellow eye. Primary scleral fixation was defined as implantation of an IOL in the same session following cristalin lens surgery, and secondary scleral fixation was as defined IOL implantation in aphakic and pseudophakic patients. The following techniques were employed for the operation.16 Conjunctiva was opened and triangular, partial thickness scleral flaps were created at the eight o’clock and two o’clock positions. Three-laminar corneal incision was performed and an ocular viscosurgical device was injected into the anterior chamber. In phakic patients, cataract surgery was performed by phacoemulsification, extracapsular or intracapsular extraction. Anterior vitrectomy was performed using a vitrector when needed. Polypropylene (10–0) suture on curved needles (PC-9; Alcon Laboratories, Inc., TX, USA) was tied to the eyelets of the haptics of a polymethylmethacrylate lens (CZ 70 BD; Alcon, Fort Worth, TX, USA). A guide needle (27-gauge needle) was inserted from the sclera, remaining under the flap, to the ciliary sulcus 0.8–1.0 mm away from the limbus. The tip of the fixation needle was engaged in the opening of the guide needle and pulled from the ciliary sulcus to the outside of the eye. The same procedure was performed with the second fixation needle. The IOL was introduced into the eye. By pulling both of the sutures, the haptics were drawn into the ciliary sulcus. The cornea was sutured using 10–0 monofilament nylon sutures (Alcon Laboratories Inc., TX, USA) in a continuous fashion. The
polypropylene sutures were tied and left long under the triangular scleral flaps. The scleral flaps and conjunctival incisions were closed using a 10–0 monofilament nylon sutures. At the end of the operation, subconjunctival corticosteroids and antibiotics were injected. Postoperative examinations were performed at one day, one week, four weeks, three months, and six months after the operation. Thereafter, examinations were scheduled at approximately six-month intervals (when amblyopia treatment was not indicated). Postoperatively, topical antibiotics (four times per day) were used for two weeks and corticosteroids (four times per day) were used for one month. Antiglaucoma medications were used when required. Main outcome measures were age, gender, followup time, preoperative and postoperative corrected distance visual acuity (CDVA), change in visual acuity (in Snellen lines), and complications. Outcome measures (unless noted otherwise) were those obtained at the most recent follow-up examination. Visual acuities, measured using a Snellen chart and recorded in decimal notation, were converted to a logarithm of the minimum angle of resolution (log MAR) units for statistical analysis, but expressed in decimals throughout the text. Visual acuity of counting fingers was converted to 2.00 log MAR and hand motion was converted to 3.00 log MAR.17 No patient had a perception of light with or without projection. Visual acuities were converted to categorical variables by classifying them as 0.1 or less, between 0.2 and 0.4, 0.5 or higher. Data analysis was performed using the Statistical Package for Social Sciences for Windows software (SPSS version 16.0, SPSS Inc., Chicago, IL, USA). Normality distribution of continuous variables (age, follow-up time, preoperative and postoperative CDVA), was tested by Kolmogorov-Smirnov test, Histogram, and P-P plots. As all continuous variables were distributed abnormally, descriptive statistics were demonstrated as median (minimum-maximum). Mann Whitney U test was used to compare the visual acuities between the groups. Categorical variables were presented in frequency (%). Pearson chi-square test was used to compare the categorical variables between the groups and Mc Nemar test was used to compare the preoperative and postoperative categorical variables in each group.
RESULTS Twenty-four pediatric (Pediatric Group) and 96 adult (Adult Group) patients underwent SFIOL implantation. The median follow-up time was six (range: 6– 55) months. Patient characteristics, indications for SFIOL implantation (lens status), significant preoperative ocular history, and surgical procedure are Seminars in Ophthalmology
Scleral-Fixated Intraocular Lens Implantation TABLE 1. Patient characteristics, indications, and surgical procedures. Pediatric Group (n = 24)
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Patient characteristics Sex (F:M) Median age (min-max) years Median follow-up (min-max) months Indications (Lens Status) Phakic Complicated phaco due to PSX Complicated ECCE Subluxated lens due to Marfan syndrome, ektopia lentis Complicated phaco due to lens-iris coloboma, microspherophakia Subluxated lens due to trauma Aphakic Congenital cataract surgery Operated traumatic perforation Complicated phaco Pseudophakic Blunt trauma related IOL dislocation Spontaneous IOL dislocation Complicated ACIOL Preoperative ocular history Eye trauma Corneal scarring Glaucoma Surgical procedures Primary implantation Secondary implantation Secondary implantation combined with PK
10/14 11.5 (4–16) 6 (6–55)
10 (41.7%) NA
Adult Group (n = 96) 32/64 67 (17–86) 6 (6–35)
37 (38.5%) 15 (15.6%)
NA 7 (29.2%)
8 (8.3%) 1(1.0%)
2 (8.3%)
NA
1 (4.2%)
13 (13.6%)
8 (33.3%) 5 (20.8%) 3 (12.5%) NA 6 (25.0%) NA
39 4 5 30 20 1
6 (25%) NA
12 (12.5%) 7 (7.3%)
4(16.6%) 2 (8.3%) NA
19 (19.8%) 18 (18.8%) 5 (5.2%)
10 (41.7%) 12 (50.0%) 2 (8.3%)
37 (38.5%) 46 (48.0%) 13 (13.5%)
(40.6%) (4.2%) (5.2%) (31.2%) (20.8%) (1.0%)
summarized in Table 1. The SFIOL implantation was performed in 47 patients as primary implantation and in 73 patients as secondary implantation. Fifteen of the secondary implantations were combined with penetrating keratoplasty. The median preoperative CDVA was 0.1 (min: hand motion; max: 0.6) in pediatric patients and 0.15 (min: hand motion; max: 0.9) in adult patients, with no statistically significant difference between the groups (p = 0.253, Mann Whitney U test). The median postoperative CDVA was 0.2 (min: hand motion; max: 0.8) in pediatric patients and 0.5 (min: hand motion; max: 1.0) in adult patients, which was statistically different between the groups (p = 0.017, Mann Whitney U test). The CDVA improved at least one Snellen line or stayed unchanged in all pediatric eyes, and in 87 2014 Informa Healthcare USA, Inc.
TABLE 2. Preoperative and postoperative visual acuities. Visual acuity Pediatric Group Adult Group (in decimal notation) (n = 24) n (%) (n = 96) n (%) p Value 0.178a
Preoperative CDVA 0.1 0.2–0.4 0.5
15 (62.5) 7 (29.2) 2 (8.3)
48 (50.0) 23 (24.0) 25 (26.0)
Postoperative CDVA 0.1 0.2–0.4 0.5 p Value
11 (45.8) 5 (20.8) 8 (33.3) 0.46c
24 (25.0) 9 (9.4) 63 (65.6) 50.0001d
16 (66.7)
58 (60.4)
8 (33.3) 0 (0.0)
29 (30.2) 9 (9.4)
Changes in CDVA Improved 1 Snellen line Unchanged Decreased 1 Snellen line
0.015b
0.296f
CDVA: Corrected distance visual acuity. Pierson Chi-square test (Statistical comparison of preoperative visual acuities between pediatric and adult groups) b Pierson Chi-square test (Statistical comparison of postoperative visual acuities between pediatric and adult groups) c McNemar test (Statistical comparison between preoperative and postoperative visual acuities in pediatric group) d McNemar test (Statistical comparison between preoperative and postoperative visual acuities in adult group) f Pierson Chi-square test (Statistical comparison of visual acuity changes between pediatric and adult groups). a
ACIOL Anterior chamber intraocular lens; ECCE Extracapsular cataract extraction; F:M Female:Male; IOL Intraocular lens; NA Not available, Phaco Phacoemulsification; PK Penetrating keratoplasty; PSX Pseudoexfoliation syndrome.
!
41
(90.6%) adult eyes, but the change in visual acuity was not statistically significant between the groups (p = 0.296, Pearson chi-square test). In adult patients, the causes for vision loss were cystoid macular edema sequela in four eyes (4.2%), glaucoma in one eye (1.0%), graft failure without rejection in one eye (1.0%), tilted IOL in two eyes (2.1%), bullous keratopathy in one eye (1.0%). Eyes with CDVA of 0.5 or higher were 8.3% (n = 2) in the Pediatric Group and 25.0% (n = 26) in the Adult Group preoperatively. These ratios increased to 33.3% (n = 8) and 65.6% (n = 63) after SFIOL implantation in the Pediatric Group and in the Adult Group, respectively (Table 2). The most common non-surgery-related cause for visual acuity of less than 0.2 was amblyopia in seven (29.2%) pediatric eyes and age-related macular degeneration in six (6.3%) adult eyes. In the Pediatric Group megalocornea (n = 1) and in the Adult Group, traumatic foveal choroidopathy (n = 3), traumatic partial leucoma (n = 5), and retinitis pigmentosa (n = 1) were the other causes. Perioperative and postoperative complications are listed in Table 3. The most important postoperative complication was endophthalmitis, diagnosed two days postoperatively in one pediatric case and treated with intravitreal, intravenous, and fortified topical antibiotics. Due to successful endophthalmitis management, his preoperative visual
42 A. Burcu et al. TABLE 3. Preoperative and postoperative complications. Pediatric Group Adult Group (n = 24) n (%) (n = 96) n (%)
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Preoperative and early postoperative period (within one week) Anterior chamber hemorrhage 1 (4.2) 9 (9.4) Transient vitreous hemorrhage NA 1 (1.0) Pupil distortion 1 (4.2) 4 (4.2) IOL capture 1(4.2) NA Leakage requiring resuturing NA 2 (2.1) Elevated intraocular pressure 3 (12.5) 14 (14.6) Endophthalmitis 1 (4.2) NA None 18 (75) 70 (72.9) Late postoperative period (after one Glaucoma Irregular astigmatism IOL tilt/decentration Suture exposure Cystoid macular edema Bullous keratopathy Allograft reaction Graft failure without rejection None
week) 1 (4.2) 2 (8.3) 1 (4.2) NA NA NA 1 (4.2) NA 20 (83.3)
8 4 2 1 6 2 2 1 72
(8.3) (4.2) (2.1) (1.0) (6.3) (2.1) (2.1) (1.0) (75.0)
IOL Intraocular lens, NA Not available.
acuity of 0.2 was preserved and additional complications did not occur during the 28 months postoperative follow-up. The most common early postoperative complication was ocular hypertension, which affected three eyes (12.5%) in the Pediatric Group and 14 eyes (14.6%) in the Adult Group; five adults had preoperative glaucoma. Ocular hypertension was transient in six eyes (two pediatric, six adult), and was controlled by antiglaucomatous agents in nine eyes (one pediatric, eight adults). No eyes required glaucoma surgery. Hyphema was noted within one week postoperatively in one (4.2 %) pediatric eye and in nine (9.4%) adult eyes that resolved without treatment. Transient vitreous hemorrhage occurred in (1.0%) one adult eye. Intraocular lens capture was noted on the first postoperative day in one (4.2%) pediatric patient, and was corrected by administration of cyclopentolate 1% followed by pilocarpine 2% b.i.d. for three days without recurrence. Pupillary distortion, not requiring surgical revision, was seen in five eyes (one pediatric, four adults) with previous ocular trauma. Postoperative corneal edema occurred in two adult eyes, one eye maintained preoperative CDVA, but the other lost three lines of CDVA, and penetrating keratoplasty was scheduled. Allograft reaction developed in one pediatric eye at the fifteenth month and in two adult eyes at the third and seventh months and completely recovered with treatment. Graft failure without rejection developed in one adult patient (age: 73 years) at the twenty-sixth month, repeated penetrating keratoplasty was rejected by the patient.
One adult eye had erosion of the polypropylene suture through the sclera after 37 months. To reduce the risk of ‘‘suture wick’’ endophthalmitis, the suture node was covered with a processed human pericardium graft. Suture exposure was not observed in the Pediatric Group. Slight IOL tilt was noted in one pediatric patient with good CDVA. Two adult patients had tilted IOL with a loss of two Snellen lines in vision; the IOL reposition was not performed, as patients refused further surgical procedures. Cystoid macular edema occurred in six adult eyes; in four of them, CDVA deteriorated in spite of periocular and topical corticosteroid treatment. We defined amblyopia as a visual acuity worse than a Snellen-equivalent of 0.2. Using this threshold, seven of the eyes (29.2%) at the time of the final follow-up visit had persistent amblyopia, which was treated preoperatively and postoperatively using occlusion therapy in children at age of nine years or younger. No patient had retinal detachment, hypotony, or spontaneous dislocation of the IOL caused by breakage of the polypropylene sutures during follow-up of 6–55 months. Seven eyes (5.8%) required postoperative operation. One adult patient underwent grafting with processed human pericardium for exposed polypropylene suture and two penetrating keratoplasty patients underwent re-suturing for a leaking corneal wound. One patient was added to keratoplasty waiting list. Three patients refused further surgery for tilted IOL and graft failure.
DISCUSSION Scleral-fixated posterior chamber implantation can provide favorable visual outcomes in cases with inadequate capsular or zonular support. Making the decision for optimal optical correction methods in pediatric patients without adequate capsular support is an especially big challenge. Rapid optical and visual rehabilitation are very important in order to decrease the risk of amblyopia. Unilateral aphakic glasses are generally not suitable due to the fact that aniseikonia and contact lenses may cause poor compliance in pediatric patients due to intermittent correction of refractive error, thus SFIOL implantation appears to be a good option. The SFIOL implantation was represented by some reports as a safe and effective modality for correction of aphakia in pediatric cases.13,15,18 Additionally, SFIOL may be superior to contact lenses in patients with trauma-related corneal irregularities.18 Amblyopia was the reason for lower final postoperative CDVA in pediatric patients (p = 0.017). However, the change of visual acuity of at least one Seminars in Ophthalmology
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Scleral-Fixated Intraocular Lens Implantation Snellen line was similar between the groups; all pediatric patients (100%) and 87 (90.6%) adult patients maintained or improved their final CDVA by more than one Snellen line. This can be interpreted that improvement in CDVA occurred more frequently but in smaller amounts in children than in adults. The change of visual acuity in our study was similar to previous studies.8–13,15,18–21 The CDVA can deteriorate not only due to operation but also due to non-surgeryrelated causes (e.g., preoperative pathologies, previous complicated surgeries, etc.).12,22,23 The SFIOL offers potential advantages by moving the site of IOL fixation from the anterior chamber to the posterior chamber, thus reducing the risk of corneal endothelial compromise, peripheral anterior synechia, and glaucoma. Sutured posterior chamber IOL implantation has several potential risks, such as suprachoroidal or vitreous hemorrhage, retinal detachment, lens tilt associated with inaccurate placement of the fixation suture, endophthalmitis related to erosion of the fixation suture through the conjunctiva, and spontaneous dislocation of the lens related to degradation or breakage of the suture. Endophthalmitis is one of the most serious visionthreatening complications of SFIOL implantation, and has been reported in relation to suture exposure.24,25 In our study, endophthalmitis was diagnosed two days postoperatively in one pediatric eye, which was not associated with suture exposure, and was treated successfully. Numerous trans-sclerally sutured SFIOL implantation techniques have been described to decrease suture exposure since this approach was first reported in 1981.26 When sutures are covered only by conjunctiva, suture exposure occurs in up to 50% of patients.27–29 The exposure rates decrease to 5–27.6% when sutures are covered with scleral flaps.29–31 To prevent suture exposure, cutting the suture ends long was proposed.29,32,33 Partial-thickness scleral flaps may delay, but not prevent, suture exposure of shortly cut sutures.29,32 In this study, we used partial-thickness triangular scleral flaps to cover and protect the suture knots, and the polypropylene sutures were tied and left long under the triangular scleral flaps. Only one adult patient developed suture exposure after 37 months, and the suture node was covered with a processed human pericardium. When the suture ends are left long enough to lie parallel to the sclera, the sharp ends do not cause erosion of the overlying tissues. We think that the low suture exposure rate in our study is related to the protection of the scleral flaps and the long suture ends. Regarding complications, ocular hypertension was common, affecting 12.5% of eyes in pediatric patients and 14.6% of eyes in adult patients in our study. Patients with postoperative hypertension had a higher frequency of history of glaucoma, trauma, !
2014 Informa Healthcare USA, Inc.
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hyphema, combined iridoplasty and penetrating keratoplasty. Nine eyes (one pediatric, eight adult) had persistently elevated IOP requiring antiglaucomatous agents, but no patients required glaucoma surgery. Spontaneous dislocation of SFIOL is reported to have variable frequency in eyes with long-term follow-up.11,23,34,35 The mean elapsed time from surgery to spontaneous dislocation was reported to be approximately four years.23 A histological study revealed that IOL stability results from intact scleral sutures and not from fibrous encapsulation or correct placement of the haptics in the ciliary sulcus.29 The weakening or unintentional removal of sutures would probably cause IOL dislocation. In a study with follow-up longer than 10 years,36 and in another study with mean follow-up time of 36 months,11 none of the patients developed IOL dislocation due to suture weakening as in our study. During the follow-up of 6–55 months neither of our patients developed spontaneous IOL dislocation due to suture breakage. Anterior chamber and vitreous hemorrhages were transient, and the other complications, such as pupillary distortion and IOL capture, did not affect the final visual acuity. Retinal detachment and hypotony did not occur in this study. Additional surgery was necessary in seven (5.8%) eyes. In conclusion, SFIOL implantation was associated with a favorable outcome in most pediatric and adult eyes. Complications may occur with similar ratios across the literature. Although complications leading to visual loss occur infrequently, the potential risk, particularly in high-risk patients, must not be overlooked. However, the relatively small sample size and follow-up period of our study can lead to the impression of low complication rates. Another unknown aspect requiring investigation is the long-term viability of 10–0 polypropylene suture in pediatric patients with longer life expectancy. The outlook of randomized, prospective, multi-center studies is needed to identify the unknown aspects of the topic.
ACKNOWLEDGEMENTS This study was partially presented as a poster at the 45th National Congress of the Turkish Ophthalmology Society in October 2011.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
44 A. Burcu et al.
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REFERENCES 1. Por YM, Lavin MJ. Techniques of intraocular lens suspension in the absence of capsular/zonular support. Surv Ophthalmol 2005;50:429–462. 2. Michaeli A, Assia EI. Scleral and iris fixation of posterior chamber lenses in the absence of capsular support. Curr Opin Ophthalmol 2005;16:57–60. 3. Wagoner MD, Cox TA, Ariyasu RG, et al. Intraocular lens implantation in the absence of capsular support: A report by the American Academy of Ophthalmology (Ophthalmic Technology Assessment). Ophthalmology 2003;110:840–859. 4. Dick HB, Augustin AJ. Lens implant selection with absence of capsular support. Curr Opin Ophthalmol 2001;12:47–57. 5. Epley KD, Shainberg M, Lueder GT, Tychsen L. Pediatric secondary lens implantation in the absence of capsular support. J AAPOS 2001;5:301–306. 6. Furuta M, Tsukahara S, Tsuchiya T. Pupillary elongation after anterior chamber lens implantation. J Cataract Refract Surg 1986;12:273–275. 7. Apple DJ, Brems RN, Park RB, et al. Anterior chamber lenses. Part I: Complications and pathology and a review of designs. J Cataract Refract Surg 1987;13:157–174. 8. Evans JR, Henning A, Pradhan D, et al. Randomized controlled trial of anterior-chamber intraocular lenses in Nepal: Long-term follow-up. Bull World Health Organ 2000; 78:372–378. 9. Buckley EG. Scleral fixated (sutured) posterior chamber intraocular lens implantation in children. J AAPOS 1999;3: 289–294. 10. McAllister AS, Hirst LW. Visual outcomes and complications of scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg 2011;37:1263–1269. 11. Kjeka O, Bohnstedt J, Meberg K, Seland JH. Implantation of scleral-fixated posterior chamber intraocular lenses in adults. Acta Ophthalmol 2008;86:537–542. 12. Krause L, Bechrakis NE, Heimann H, et al. Implantation of scleral fixated sutured posterior chamber lenses: A retrospective analysis of 119 cases. Int Ophthalmol. 2009;29: 207–212. 13. Bardorf CM, Epley KD, Lueder GT, Tychsen L. Pediatric transscleral sutured intraocular lenses: Efficacy and safety in 43 eyes followed an average of 3 years. J AAPOS 2004;8: 318–324. 14. Bading G, Hillenkamp J, Sachs HG, et al. Long-term safety and functional outcome of combined pars plana vitrectomy and scleral-fixated sutured posterior chamber lens implantation. Am J Ophthalmol 2007;144:371–377. 15. Hyun DW, Lee TG, Cho SW. Unilateral scleral fixation of posterior chamber intraocular lenses in pediatric complicated traumatic cataracts. Korean J Ophthalmol 2009; 23(3):148–152. 16. Lewis JS. Ab externo sulcus fixation. Ophthalmic Surg 1991; 22(11):692–695. 17. Holladay JT. Visual acuity measurements. J Cataract Refract Surg 2004;30(2):287–290. 18. Buckley EG. Hanging by a thread: The long term efficacy and safety of transscleral sutured intraocular lenses in
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children (an American ophthalmological society thesis). Trans Am Ophthalmol Soc 2007;105:294–311. Sharpe MR, Biglan AW, Gerontis CC. Scleral fixation of posterior chamber intraocular lenses in children. Ophthalmic Surg Lasers 1996; 27:337–341. Ozmen AT, Dogru M, Erturk H, Ozcetin H. Transsclerally fixated intraocular lenses in children. Ophthalmic Surg Lasers 2002;33:394–399. Sewelam A. Four-point fixation of posterior chamber intraocular lenses in children with unilateral aphakia. J Cataract Refract Surg 2003;29:294–300. Asadi R, Kheirkhah A. Long-term results of scleral fixation of posterior chamber intraocular lenses in children. Ophthalmology 2008;115:67–72. 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. Heilskov T, Joondeph BC, Olsen KR, Blankenship GW. Late endophthalmitis after transscleral fixation of a posterior chamber intraocular lens. Arch Ophthalmol 1989;107: 1427. Schechter RJ. Suture-wick endophthalmitis with sutured posterior chamber intraocular lenses. J Cataract Refract Surg 1990;16:755–756. Girard LJ. Pars plana phacoprosthesis (aphakic intraocular implant): A preliminary report. Ophthalmic Surg 1981;12: 19–22. Lane SS, Lindquist TD, Spigelman AV. Scleral fixation complications. Invest Ophthal Vis Sci 1990;31(suppl):573. Epstein E. Suture problems. J Cataract Refract Surg 1989; 16:116. Lubniewski AJ, Holland EJ, Van Meter WS, et al. Histologic study of eyes with transsclerally sutured posterior chamber intraocular lenses. Am J Ophthalmol 1990; 110:237–243. Kir E, Kocaturk T, Dayanir V, et al. Prevention of suture exposure in transscleral intraocular lens fixation: An original technique. Can J Ophthalmol 2008;43:707–711. Stark WJ, Gottsch JD, Goodman DF, et al. Posterior chamber intraocular lens implantation in the absence of capsular support. Arch Ophthalmol 1989;107:1078–1083. Davis RM, Best D, Gilbert GE. Comparison of intraocular lens fixation techniques performed during penetrating keratoplasty. Am J Ophthalmol 1991;111:743–749. Eryildirim A. Knotless scleral fixation for implanting a posterior chamber intraocular lens. Ophthalmic Surg 1995; 26:82–84. 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. Assia EI, Nemet A, Sachs D. Bilateral spontaneous subluxation of scleral-fixated intraocular lenses. J Cataract Refract Surg 2002;28:2214–2216. Mimura T, Amano S, Sugiura T, et al. 10-year follow-up study of secondary transscleral ciliary sulcus fixated posterior chamber intraocular lenses. Am J Ophthalmol 2003;136:931–933.
Seminars in Ophthalmology
Scleral-Fixated Posterior Chamber Intraocular Lens Implantation in Pediatric and Adult Patients
Ankara Training and Research Hospital, Ankara, Turkey
ABSTRACT Purpose: To evaluate the results of scleral-fixated posterior chamber intraocular lenses (SFIOL) in pediatric and adult patients. Methods: We carried out a retrospective analysis of 129 eyes of 120 patients (adult group, n = 96; pediatric group, n = 24) who underwent SFIOL implantation. Outcome measures were indications, corrected distance visual acuity (CDVA), change in visual acuity, and complications. Results: The median follow-up time was six months (minimum: 6; maximum: 55 months). The median preoperative CDVAs were similar between the groups (p = 0,253). The median postoperative CDVA was 0.2 (min: hand motion; max: 0.8) in pediatric patients and 0.5 (min: hand motion; max: 1.0) in adult patients in decimal notation, (p = 0.017). The CDVA improved at least one Snellen line or remained unchanged in all pediatric eyes, and in 87 (90.6%) adult eyes. The change in visual acuity was similar between the groups (p = 0.296). Conclusion: In both pediatric and adult patients, SFIOL implantation ends with favorable outcomes over the short term. Keywords: Aphakia, intraocular lens
pediatric
cataract,
pseudoexpholiation,
subluxated
cristalin
lens,
subluxated
penetrating keratoplasty and IOL implantation.3,7,9,10 Furthermore, the SFIOLs provide potential advantages for better visual acuity and binocularity by moving the effective IOL position from the anterior to posterior chamber. However, the surgical technique of SFIOL insertion is more difficult and requires manipulation at the ciliary body region, which can cause serious complications. The literature contains several reports with favorable results.3,9–15 The purpose of this retrospective study was to analyze the indications and outcomes of SFIOL implantation in pediatric and adult patients.
INTRODUCTION When the posterior capsule is ruptured and zonular support is inadequate, an intraocular lens (IOL) can be placed in the anterior chamber as an iris-fixated and closed- or open-loop anterior chamber intraocular lens (ACIOL), or in the posterior chamber as a sutured irisfixated and scleral-fixated posterior chamber intraocular lens (SFIOL).1–4 Implantation of an ACIOL is easier to perform than the alternative surgical procedures, but it is associated with a relatively high rate of complications caused by long-term anterior chamber irritation.3,5,6 Although modern, multiflex openlooped ACIOLs have lower complication rates than those reported with closed-loop ACIOLs,7,8 SFIOLs are indicated in such cases and in situations in which an ACIOL might cause complications, such as in young patients, in patients with shallow anterior chambers, anterior segment disruption, cornea guttata and diabetes, and in patients scheduled for combined
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Ayse Burcu, Zuleyha Yalniz-Akkaya, Iskan Abay, Mehmet Akif Acar, and Firdevs Ornek
PATIENTS AND METHODS This study was performed after the approval of the institutional board and according to the tenets of the Declaration of Helsinki. The medical records of 120 patients that underwent SFIOL implantation
Received 5 December 2012; revised 19 March 2013; accepted 7 August 2013; published online 10 October 2013 Correspondence: Ayse Burcu, Prof. Dr., Ahmet Taner Kislali mah, Park cad, Ronesans evleri A Blok no:32 Cayyolu, Ankara, Turkey TR06810. E-mail: [email protected]
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40 A. Burcu et al. between April 2004 and September 2009 and were followed for at least six months were reviewed retrospectively. Nine patients were operated on bilaterally. In order to obtain independency of variables provided that correlation between postoperative visual acuities was very high (Spierman’s correlation test, = 0.793, p = 0.011), only one eye of bilaterally operated patients were included in the analyses. The eyes were divided into two groups: Pediatric Group (age 16 years) and Adult Group (age 17 years). Scleral-fixated posterior chamber intraocular lens implantation was performed in patients with extensive capsular deficiency precluding safe and stable bag or sulcus implantation and in patients intolerant or not suitable for contact lens wear. Uveitis, endothelial dysfunction/corneal dystrophy, retinal hole/ fluid, extensive lattice degeneration, or major retinal diseases were contraindications for SFIOL implantation. All patients and the parents of pediatric patients were informed about complications of SFIOL procedure and the possible need for IOL removal or exchange in the future and written informed consent was obtained preoperatively. Intraocular lens power was calculated using the SRK II formula. The power was adjusted according to the patient’s age and the refractive error of the fellow eye. Primary scleral fixation was defined as implantation of an IOL in the same session following cristalin lens surgery, and secondary scleral fixation was as defined IOL implantation in aphakic and pseudophakic patients. The following techniques were employed for the operation.16 Conjunctiva was opened and triangular, partial thickness scleral flaps were created at the eight o’clock and two o’clock positions. Three-laminar corneal incision was performed and an ocular viscosurgical device was injected into the anterior chamber. In phakic patients, cataract surgery was performed by phacoemulsification, extracapsular or intracapsular extraction. Anterior vitrectomy was performed using a vitrector when needed. Polypropylene (10–0) suture on curved needles (PC-9; Alcon Laboratories, Inc., TX, USA) was tied to the eyelets of the haptics of a polymethylmethacrylate lens (CZ 70 BD; Alcon, Fort Worth, TX, USA). A guide needle (27-gauge needle) was inserted from the sclera, remaining under the flap, to the ciliary sulcus 0.8–1.0 mm away from the limbus. The tip of the fixation needle was engaged in the opening of the guide needle and pulled from the ciliary sulcus to the outside of the eye. The same procedure was performed with the second fixation needle. The IOL was introduced into the eye. By pulling both of the sutures, the haptics were drawn into the ciliary sulcus. The cornea was sutured using 10–0 monofilament nylon sutures (Alcon Laboratories Inc., TX, USA) in a continuous fashion. The
polypropylene sutures were tied and left long under the triangular scleral flaps. The scleral flaps and conjunctival incisions were closed using a 10–0 monofilament nylon sutures. At the end of the operation, subconjunctival corticosteroids and antibiotics were injected. Postoperative examinations were performed at one day, one week, four weeks, three months, and six months after the operation. Thereafter, examinations were scheduled at approximately six-month intervals (when amblyopia treatment was not indicated). Postoperatively, topical antibiotics (four times per day) were used for two weeks and corticosteroids (four times per day) were used for one month. Antiglaucoma medications were used when required. Main outcome measures were age, gender, followup time, preoperative and postoperative corrected distance visual acuity (CDVA), change in visual acuity (in Snellen lines), and complications. Outcome measures (unless noted otherwise) were those obtained at the most recent follow-up examination. Visual acuities, measured using a Snellen chart and recorded in decimal notation, were converted to a logarithm of the minimum angle of resolution (log MAR) units for statistical analysis, but expressed in decimals throughout the text. Visual acuity of counting fingers was converted to 2.00 log MAR and hand motion was converted to 3.00 log MAR.17 No patient had a perception of light with or without projection. Visual acuities were converted to categorical variables by classifying them as 0.1 or less, between 0.2 and 0.4, 0.5 or higher. Data analysis was performed using the Statistical Package for Social Sciences for Windows software (SPSS version 16.0, SPSS Inc., Chicago, IL, USA). Normality distribution of continuous variables (age, follow-up time, preoperative and postoperative CDVA), was tested by Kolmogorov-Smirnov test, Histogram, and P-P plots. As all continuous variables were distributed abnormally, descriptive statistics were demonstrated as median (minimum-maximum). Mann Whitney U test was used to compare the visual acuities between the groups. Categorical variables were presented in frequency (%). Pearson chi-square test was used to compare the categorical variables between the groups and Mc Nemar test was used to compare the preoperative and postoperative categorical variables in each group.
RESULTS Twenty-four pediatric (Pediatric Group) and 96 adult (Adult Group) patients underwent SFIOL implantation. The median follow-up time was six (range: 6– 55) months. Patient characteristics, indications for SFIOL implantation (lens status), significant preoperative ocular history, and surgical procedure are Seminars in Ophthalmology
Scleral-Fixated Intraocular Lens Implantation TABLE 1. Patient characteristics, indications, and surgical procedures. Pediatric Group (n = 24)
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Patient characteristics Sex (F:M) Median age (min-max) years Median follow-up (min-max) months Indications (Lens Status) Phakic Complicated phaco due to PSX Complicated ECCE Subluxated lens due to Marfan syndrome, ektopia lentis Complicated phaco due to lens-iris coloboma, microspherophakia Subluxated lens due to trauma Aphakic Congenital cataract surgery Operated traumatic perforation Complicated phaco Pseudophakic Blunt trauma related IOL dislocation Spontaneous IOL dislocation Complicated ACIOL Preoperative ocular history Eye trauma Corneal scarring Glaucoma Surgical procedures Primary implantation Secondary implantation Secondary implantation combined with PK
10/14 11.5 (4–16) 6 (6–55)
10 (41.7%) NA
Adult Group (n = 96) 32/64 67 (17–86) 6 (6–35)
37 (38.5%) 15 (15.6%)
NA 7 (29.2%)
8 (8.3%) 1(1.0%)
2 (8.3%)
NA
1 (4.2%)
13 (13.6%)
8 (33.3%) 5 (20.8%) 3 (12.5%) NA 6 (25.0%) NA
39 4 5 30 20 1
6 (25%) NA
12 (12.5%) 7 (7.3%)
4(16.6%) 2 (8.3%) NA
19 (19.8%) 18 (18.8%) 5 (5.2%)
10 (41.7%) 12 (50.0%) 2 (8.3%)
37 (38.5%) 46 (48.0%) 13 (13.5%)
(40.6%) (4.2%) (5.2%) (31.2%) (20.8%) (1.0%)
summarized in Table 1. The SFIOL implantation was performed in 47 patients as primary implantation and in 73 patients as secondary implantation. Fifteen of the secondary implantations were combined with penetrating keratoplasty. The median preoperative CDVA was 0.1 (min: hand motion; max: 0.6) in pediatric patients and 0.15 (min: hand motion; max: 0.9) in adult patients, with no statistically significant difference between the groups (p = 0.253, Mann Whitney U test). The median postoperative CDVA was 0.2 (min: hand motion; max: 0.8) in pediatric patients and 0.5 (min: hand motion; max: 1.0) in adult patients, which was statistically different between the groups (p = 0.017, Mann Whitney U test). The CDVA improved at least one Snellen line or stayed unchanged in all pediatric eyes, and in 87 2014 Informa Healthcare USA, Inc.
TABLE 2. Preoperative and postoperative visual acuities. Visual acuity Pediatric Group Adult Group (in decimal notation) (n = 24) n (%) (n = 96) n (%) p Value 0.178a
Preoperative CDVA 0.1 0.2–0.4 0.5
15 (62.5) 7 (29.2) 2 (8.3)
48 (50.0) 23 (24.0) 25 (26.0)
Postoperative CDVA 0.1 0.2–0.4 0.5 p Value
11 (45.8) 5 (20.8) 8 (33.3) 0.46c
24 (25.0) 9 (9.4) 63 (65.6) 50.0001d
16 (66.7)
58 (60.4)
8 (33.3) 0 (0.0)
29 (30.2) 9 (9.4)
Changes in CDVA Improved 1 Snellen line Unchanged Decreased 1 Snellen line
0.015b
0.296f
CDVA: Corrected distance visual acuity. Pierson Chi-square test (Statistical comparison of preoperative visual acuities between pediatric and adult groups) b Pierson Chi-square test (Statistical comparison of postoperative visual acuities between pediatric and adult groups) c McNemar test (Statistical comparison between preoperative and postoperative visual acuities in pediatric group) d McNemar test (Statistical comparison between preoperative and postoperative visual acuities in adult group) f Pierson Chi-square test (Statistical comparison of visual acuity changes between pediatric and adult groups). a
ACIOL Anterior chamber intraocular lens; ECCE Extracapsular cataract extraction; F:M Female:Male; IOL Intraocular lens; NA Not available, Phaco Phacoemulsification; PK Penetrating keratoplasty; PSX Pseudoexfoliation syndrome.
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(90.6%) adult eyes, but the change in visual acuity was not statistically significant between the groups (p = 0.296, Pearson chi-square test). In adult patients, the causes for vision loss were cystoid macular edema sequela in four eyes (4.2%), glaucoma in one eye (1.0%), graft failure without rejection in one eye (1.0%), tilted IOL in two eyes (2.1%), bullous keratopathy in one eye (1.0%). Eyes with CDVA of 0.5 or higher were 8.3% (n = 2) in the Pediatric Group and 25.0% (n = 26) in the Adult Group preoperatively. These ratios increased to 33.3% (n = 8) and 65.6% (n = 63) after SFIOL implantation in the Pediatric Group and in the Adult Group, respectively (Table 2). The most common non-surgery-related cause for visual acuity of less than 0.2 was amblyopia in seven (29.2%) pediatric eyes and age-related macular degeneration in six (6.3%) adult eyes. In the Pediatric Group megalocornea (n = 1) and in the Adult Group, traumatic foveal choroidopathy (n = 3), traumatic partial leucoma (n = 5), and retinitis pigmentosa (n = 1) were the other causes. Perioperative and postoperative complications are listed in Table 3. The most important postoperative complication was endophthalmitis, diagnosed two days postoperatively in one pediatric case and treated with intravitreal, intravenous, and fortified topical antibiotics. Due to successful endophthalmitis management, his preoperative visual
42 A. Burcu et al. TABLE 3. Preoperative and postoperative complications. Pediatric Group Adult Group (n = 24) n (%) (n = 96) n (%)
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Preoperative and early postoperative period (within one week) Anterior chamber hemorrhage 1 (4.2) 9 (9.4) Transient vitreous hemorrhage NA 1 (1.0) Pupil distortion 1 (4.2) 4 (4.2) IOL capture 1(4.2) NA Leakage requiring resuturing NA 2 (2.1) Elevated intraocular pressure 3 (12.5) 14 (14.6) Endophthalmitis 1 (4.2) NA None 18 (75) 70 (72.9) Late postoperative period (after one Glaucoma Irregular astigmatism IOL tilt/decentration Suture exposure Cystoid macular edema Bullous keratopathy Allograft reaction Graft failure without rejection None
week) 1 (4.2) 2 (8.3) 1 (4.2) NA NA NA 1 (4.2) NA 20 (83.3)
8 4 2 1 6 2 2 1 72
(8.3) (4.2) (2.1) (1.0) (6.3) (2.1) (2.1) (1.0) (75.0)
IOL Intraocular lens, NA Not available.
acuity of 0.2 was preserved and additional complications did not occur during the 28 months postoperative follow-up. The most common early postoperative complication was ocular hypertension, which affected three eyes (12.5%) in the Pediatric Group and 14 eyes (14.6%) in the Adult Group; five adults had preoperative glaucoma. Ocular hypertension was transient in six eyes (two pediatric, six adult), and was controlled by antiglaucomatous agents in nine eyes (one pediatric, eight adults). No eyes required glaucoma surgery. Hyphema was noted within one week postoperatively in one (4.2 %) pediatric eye and in nine (9.4%) adult eyes that resolved without treatment. Transient vitreous hemorrhage occurred in (1.0%) one adult eye. Intraocular lens capture was noted on the first postoperative day in one (4.2%) pediatric patient, and was corrected by administration of cyclopentolate 1% followed by pilocarpine 2% b.i.d. for three days without recurrence. Pupillary distortion, not requiring surgical revision, was seen in five eyes (one pediatric, four adults) with previous ocular trauma. Postoperative corneal edema occurred in two adult eyes, one eye maintained preoperative CDVA, but the other lost three lines of CDVA, and penetrating keratoplasty was scheduled. Allograft reaction developed in one pediatric eye at the fifteenth month and in two adult eyes at the third and seventh months and completely recovered with treatment. Graft failure without rejection developed in one adult patient (age: 73 years) at the twenty-sixth month, repeated penetrating keratoplasty was rejected by the patient.
One adult eye had erosion of the polypropylene suture through the sclera after 37 months. To reduce the risk of ‘‘suture wick’’ endophthalmitis, the suture node was covered with a processed human pericardium graft. Suture exposure was not observed in the Pediatric Group. Slight IOL tilt was noted in one pediatric patient with good CDVA. Two adult patients had tilted IOL with a loss of two Snellen lines in vision; the IOL reposition was not performed, as patients refused further surgical procedures. Cystoid macular edema occurred in six adult eyes; in four of them, CDVA deteriorated in spite of periocular and topical corticosteroid treatment. We defined amblyopia as a visual acuity worse than a Snellen-equivalent of 0.2. Using this threshold, seven of the eyes (29.2%) at the time of the final follow-up visit had persistent amblyopia, which was treated preoperatively and postoperatively using occlusion therapy in children at age of nine years or younger. No patient had retinal detachment, hypotony, or spontaneous dislocation of the IOL caused by breakage of the polypropylene sutures during follow-up of 6–55 months. Seven eyes (5.8%) required postoperative operation. One adult patient underwent grafting with processed human pericardium for exposed polypropylene suture and two penetrating keratoplasty patients underwent re-suturing for a leaking corneal wound. One patient was added to keratoplasty waiting list. Three patients refused further surgery for tilted IOL and graft failure.
DISCUSSION Scleral-fixated posterior chamber implantation can provide favorable visual outcomes in cases with inadequate capsular or zonular support. Making the decision for optimal optical correction methods in pediatric patients without adequate capsular support is an especially big challenge. Rapid optical and visual rehabilitation are very important in order to decrease the risk of amblyopia. Unilateral aphakic glasses are generally not suitable due to the fact that aniseikonia and contact lenses may cause poor compliance in pediatric patients due to intermittent correction of refractive error, thus SFIOL implantation appears to be a good option. The SFIOL implantation was represented by some reports as a safe and effective modality for correction of aphakia in pediatric cases.13,15,18 Additionally, SFIOL may be superior to contact lenses in patients with trauma-related corneal irregularities.18 Amblyopia was the reason for lower final postoperative CDVA in pediatric patients (p = 0.017). However, the change of visual acuity of at least one Seminars in Ophthalmology
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Scleral-Fixated Intraocular Lens Implantation Snellen line was similar between the groups; all pediatric patients (100%) and 87 (90.6%) adult patients maintained or improved their final CDVA by more than one Snellen line. This can be interpreted that improvement in CDVA occurred more frequently but in smaller amounts in children than in adults. The change of visual acuity in our study was similar to previous studies.8–13,15,18–21 The CDVA can deteriorate not only due to operation but also due to non-surgeryrelated causes (e.g., preoperative pathologies, previous complicated surgeries, etc.).12,22,23 The SFIOL offers potential advantages by moving the site of IOL fixation from the anterior chamber to the posterior chamber, thus reducing the risk of corneal endothelial compromise, peripheral anterior synechia, and glaucoma. Sutured posterior chamber IOL implantation has several potential risks, such as suprachoroidal or vitreous hemorrhage, retinal detachment, lens tilt associated with inaccurate placement of the fixation suture, endophthalmitis related to erosion of the fixation suture through the conjunctiva, and spontaneous dislocation of the lens related to degradation or breakage of the suture. Endophthalmitis is one of the most serious visionthreatening complications of SFIOL implantation, and has been reported in relation to suture exposure.24,25 In our study, endophthalmitis was diagnosed two days postoperatively in one pediatric eye, which was not associated with suture exposure, and was treated successfully. Numerous trans-sclerally sutured SFIOL implantation techniques have been described to decrease suture exposure since this approach was first reported in 1981.26 When sutures are covered only by conjunctiva, suture exposure occurs in up to 50% of patients.27–29 The exposure rates decrease to 5–27.6% when sutures are covered with scleral flaps.29–31 To prevent suture exposure, cutting the suture ends long was proposed.29,32,33 Partial-thickness scleral flaps may delay, but not prevent, suture exposure of shortly cut sutures.29,32 In this study, we used partial-thickness triangular scleral flaps to cover and protect the suture knots, and the polypropylene sutures were tied and left long under the triangular scleral flaps. Only one adult patient developed suture exposure after 37 months, and the suture node was covered with a processed human pericardium. When the suture ends are left long enough to lie parallel to the sclera, the sharp ends do not cause erosion of the overlying tissues. We think that the low suture exposure rate in our study is related to the protection of the scleral flaps and the long suture ends. Regarding complications, ocular hypertension was common, affecting 12.5% of eyes in pediatric patients and 14.6% of eyes in adult patients in our study. Patients with postoperative hypertension had a higher frequency of history of glaucoma, trauma, !
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hyphema, combined iridoplasty and penetrating keratoplasty. Nine eyes (one pediatric, eight adult) had persistently elevated IOP requiring antiglaucomatous agents, but no patients required glaucoma surgery. Spontaneous dislocation of SFIOL is reported to have variable frequency in eyes with long-term follow-up.11,23,34,35 The mean elapsed time from surgery to spontaneous dislocation was reported to be approximately four years.23 A histological study revealed that IOL stability results from intact scleral sutures and not from fibrous encapsulation or correct placement of the haptics in the ciliary sulcus.29 The weakening or unintentional removal of sutures would probably cause IOL dislocation. In a study with follow-up longer than 10 years,36 and in another study with mean follow-up time of 36 months,11 none of the patients developed IOL dislocation due to suture weakening as in our study. During the follow-up of 6–55 months neither of our patients developed spontaneous IOL dislocation due to suture breakage. Anterior chamber and vitreous hemorrhages were transient, and the other complications, such as pupillary distortion and IOL capture, did not affect the final visual acuity. Retinal detachment and hypotony did not occur in this study. Additional surgery was necessary in seven (5.8%) eyes. In conclusion, SFIOL implantation was associated with a favorable outcome in most pediatric and adult eyes. Complications may occur with similar ratios across the literature. Although complications leading to visual loss occur infrequently, the potential risk, particularly in high-risk patients, must not be overlooked. However, the relatively small sample size and follow-up period of our study can lead to the impression of low complication rates. Another unknown aspect requiring investigation is the long-term viability of 10–0 polypropylene suture in pediatric patients with longer life expectancy. The outlook of randomized, prospective, multi-center studies is needed to identify the unknown aspects of the topic.
ACKNOWLEDGEMENTS This study was partially presented as a poster at the 45th National Congress of the Turkish Ophthalmology Society in October 2011.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
44 A. Burcu et al.
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REFERENCES 1. Por YM, Lavin MJ. Techniques of intraocular lens suspension in the absence of capsular/zonular support. Surv Ophthalmol 2005;50:429–462. 2. Michaeli A, Assia EI. Scleral and iris fixation of posterior chamber lenses in the absence of capsular support. Curr Opin Ophthalmol 2005;16:57–60. 3. Wagoner MD, Cox TA, Ariyasu RG, et al. Intraocular lens implantation in the absence of capsular support: A report by the American Academy of Ophthalmology (Ophthalmic Technology Assessment). Ophthalmology 2003;110:840–859. 4. Dick HB, Augustin AJ. Lens implant selection with absence of capsular support. Curr Opin Ophthalmol 2001;12:47–57. 5. Epley KD, Shainberg M, Lueder GT, Tychsen L. Pediatric secondary lens implantation in the absence of capsular support. J AAPOS 2001;5:301–306. 6. Furuta M, Tsukahara S, Tsuchiya T. Pupillary elongation after anterior chamber lens implantation. J Cataract Refract Surg 1986;12:273–275. 7. Apple DJ, Brems RN, Park RB, et al. Anterior chamber lenses. Part I: Complications and pathology and a review of designs. J Cataract Refract Surg 1987;13:157–174. 8. Evans JR, Henning A, Pradhan D, et al. Randomized controlled trial of anterior-chamber intraocular lenses in Nepal: Long-term follow-up. Bull World Health Organ 2000; 78:372–378. 9. Buckley EG. Scleral fixated (sutured) posterior chamber intraocular lens implantation in children. J AAPOS 1999;3: 289–294. 10. McAllister AS, Hirst LW. Visual outcomes and complications of scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg 2011;37:1263–1269. 11. Kjeka O, Bohnstedt J, Meberg K, Seland JH. Implantation of scleral-fixated posterior chamber intraocular lenses in adults. Acta Ophthalmol 2008;86:537–542. 12. Krause L, Bechrakis NE, Heimann H, et al. Implantation of scleral fixated sutured posterior chamber lenses: A retrospective analysis of 119 cases. Int Ophthalmol. 2009;29: 207–212. 13. Bardorf CM, Epley KD, Lueder GT, Tychsen L. Pediatric transscleral sutured intraocular lenses: Efficacy and safety in 43 eyes followed an average of 3 years. J AAPOS 2004;8: 318–324. 14. Bading G, Hillenkamp J, Sachs HG, et al. Long-term safety and functional outcome of combined pars plana vitrectomy and scleral-fixated sutured posterior chamber lens implantation. Am J Ophthalmol 2007;144:371–377. 15. Hyun DW, Lee TG, Cho SW. Unilateral scleral fixation of posterior chamber intraocular lenses in pediatric complicated traumatic cataracts. Korean J Ophthalmol 2009; 23(3):148–152. 16. Lewis JS. Ab externo sulcus fixation. Ophthalmic Surg 1991; 22(11):692–695. 17. Holladay JT. Visual acuity measurements. J Cataract Refract Surg 2004;30(2):287–290. 18. Buckley EG. Hanging by a thread: The long term efficacy and safety of transscleral sutured intraocular lenses in
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Seminars in Ophthalmology
