Long-Term Results of Transscleral Fixation of Posterior Chamber Intraocular Lens

PURPOSE: To investigate the long-term results of transscleral fixation of posterior chamber intraocular lens (IOL) for unstable posterior capsular supporting structure. METHODS: We performed a retrospective review of 67 patients (67 eyes) with unstable posterior capsular supporting structure who underwent transscleral fixation at Soonchunhyang University Bucheon Hospital from March 2005 to January 2013. Transscleral fixation without scleral flap was performed by a single surgeon. We analyzed the causes of transscleral fixation and compared postoperative best-corrected visual acuity (BCVA) and spherical diopter. RESULTS: Among the 67 eyes of 67 patients, the causes of transscleral fixation included IOL subluxation (33 cases, 49.2%), IOL dislocation (11 cases, 16.4%), intraoperative posterior capsule rupture (8 cases, 11.9%), aphakia associated with previous intraocular surgery (7 cases, 10.4%), crystalline lens disorder with zonular dialysis (4 cases, 5.9%) and IOL opacity (4 cases, 5.9%). The mean BCVA before surgery was 1.26 +/- 0.94 (log MAR) and the visual acuity improved to 0.59 +/- 0.71, 0.60 +/- 0.69, 0.58 +/- 0.70, 0.55 +/- 0.70, 0.60 +/- 0.58 and 0.66 +/- 0.70 (1 week, 1 month, 3 months, 1 year, 3 years and 5 years, respectively, after the surgery; p < 0.05). CONCLUSIONS: Posterior chamber IOL transscleral fixation in unstable posterior capsular supporting structure is effective for increasing visual acuity and spherical diopter. Specifically, the most improvement was observed at one month after surgery. Transscleral fixation is an adequate surgical procedure for fast improvement of visual acuity with long-term effects.

Short-Term Comparison of Surgical Results between One-Haptic and Two-Haptics Transscleral Fixation of Intraocular Lens

PURPOSE: To compare the short-term clinical outcomes of transscleral fixation intraocular lens (IOL) with two haptics or one haptic. METHODS: We retrospectively reviewed the medical records of 26 patients with transscleral fixation of IOL (11 with one-haptic fixation, 15 with two-haptic fixation) except in patients whose visual acuity is not expected to improve due to retinal problems or ocular trauma. We analyzed the manifest refraction, visual acuity, refractive error preoperatively and postoperatively, preoperative IOL decentration, operating time, and postoperative complications. RESULTS: When comparing the two groups preoperatively, the mean lens decentration in the one-haptic group was 2.73 ± 2.88 mm and 4.59 ± 2.18 mm in the two-haptics group. The decentration in the two-haptic group was greater than in the one-haptic group, but not significantly. Visual acuity and refractive power were not significantly different between the groups. The mean operation time (minutes) was 65.00 ± 22.69 and 93.66 ± 29.54 in the one-haptic and two-haptic groups, respectively. The operation time in the one-haptic group was significantly shorter than in the two-haptic group (p = 0.020). When comparing visual acuity preoperatively and postoperatively, both groups showed significant improvement (p < 0.01). However, refractive error and postoperative IOL decentration were similar between the groups. CONCLUSIONS: The short-term surgical results of transscleral fixation using the two surgical techniques were not different; one-haptic transscleral fixation was preferred due to shorter operation time and lower patient discomfort.

Short-term Clinical Outcomes after Transscleral Fixation Using the Intrascleral Pocket Technique: A Retrospective Cohort Study Analysis

PURPOSE: To compare the two transscleral fixation (TSF) techniques of intrascleral pocket and conventional scleral flap with conjunctival division techniques in terms of short-term clinical effects. METHODS: This retrospective cohort study included all consecutive patients with aphakia in Gyeongsang National University Hospital in Jinju, Korea, who underwent TSF between January 2012 and December 2014. The medical records of all patients were retrospectively reviewed, and the endothelial cell count (ECC), refraction, best-corrected visual acuity (BCVA), intraocular pressure, slit lamp, and fundus examination results before and 1 day and 6 months after surgery were recorded. The postoperative complications and visual outcomes were also recorded. RESULTS: The intrascleral pocket and conventional-flap groups did not differ significantly in terms of demographics, presurgical BCVA, or ECC. However, the intrascleral pocket group had a significantly lower BCVA at 1 day and 6 months after surgery compared to the conventional-flap group. The two groups did not differ in terms of ECC 6 months after surgery. The intrascleral pocket group had no postoperative complications, but five patients in the conventional-flap group complained of irritation. In both groups, the intraocular lens was well positioned without tilting or subluxation, and astigmatism was significantly reduced at 1 day and 6 months after surgery. CONCLUSIONS: The intrascleral pocket technique of TSF does not involve conjunctival dissection and is a successful method of sulcus fixation. It stably corrects the intraocular lens and is easy to perform, which helps to reduce operation time. It also reliably yields rapid visual acuity recovery without complications.

Transscleral fixation of closed loop haptic acrylic posterior chamber intraocular lens in aphakic nonvitrectomized eyes.

Purpose: To evaluate the outcome of transscleral fixation of closed loop haptic acrylic posterior chamber intraocular lens (PCIOL) in aphakia in nonvitrectomized eyes. Materials and Methods: Patients with postcataract surgery aphakia, trauma with posterior capsule injury, subluxated crystalline lens, and per operative complications where sulcus implantation was not possible were included over a 1‑year period. Scleral fixation of acrylic hydrophilic PCIOL was performed according to the described technique, and the patients were evaluated on the day 1, 3, 14, and at 3 and 12 months postoperatively for IOL centration, pseudophakodonesis, change in best‑corrected visual acuity (BCVA), and any other complications. Results: Out of twenty‑nine eyes of 24 patients, who completed the study, 25 (86.2%) eyes had improved, 2 (6.9%) eyes showed no change, and 2 (6.9%) eyes had worsening of BCVA. Three (10.3%) eyes developed postoperative complications. A significant improvement in mean BCVA (P < 0.0001) was observed after the procedure. Mean duration of follow‑up was 26.2 months (range 22–35 months). Conclusion: The use of closed loop haptic acrylic IOL for scleral fixation appears to be safe and effective alternative to conventional scleral fixated polymethyl methacrylate intraocular lenses.

Refractive Change after Transscleral Fixation of Intraocular Lens

PURPOSE: To evaluate the anterior chamber depth (ACD), extent of intraocular lens (IOL) tilt, and decentration and refractive error after transscleral fixation of IOL. METHODS: We retrospectively reviewed the medical records of 17 cases with transscleral fixation of IOL (6 with aphakia, 5 with IOL dislocation, and 6 with lens subluxation). The acrylic IOL (MN60AC(R)) was fixated in 12 eyes and the polymethylmethacrylate IOL (CZ70BD(R)) was fixated in 5 eyes at 1.0 mm posterior from the limbus. We analyzed the ACD, extent of IOL tilt and decentration, manifest refraction, refractive error, higher order aberration, and corneal endothelium at 2 weeks, 1 month and 2 months postoperatively. RESULTS: The mean ACD was 3.36 +/- 0.11 mm, 3.30 +/- 0.12 mm, and 3.27 +/- 0.13 mm, the mean extent of IOL tilt was 4.61 +/- 0.12degrees, 4.65 +/- 0.14degrees, and 4.60 +/- 0.12degrees and the mean extent of IOL decentration was 0.43 +/- 0.01 mm, 0.45 +/- 0.01 mm, and 0.45 +/- 0.01 mm at 2 weeks, 1 month and 2 months postoperatively, respectively in eyes with transscleral fixation of IOL. The ACD was shallower and the extent of IOL tilt and decentration was greater than with IOL in-the-bag insertion patients. The mean refractive errors were -0.55 +/- 0.27 D, -0.63 +/- 0.24 D, and -0.69 +/- 0.19 D at the same period, respectively. CONCLUSIONS: Although postoperative refractive error is influenced by surgeon factors such as incision size, distance of fixation suture from limbus, and tightness of suture material, according to our results, an IOL 0.75 D more hyperopic than predicted should be selected in transscleral fixation of IOL at 1.0 mm posterior from the limbus. Additionally, each surgeon should assess their specific results and modify the lens calculations accordingly.

Sutureless Intrascleral Pocket Technique of Transscleral Fixation of Intraocular Lens in Previous Vitrectomized Eyes

In this case series, we assessed a new technique, the intrascleral pocket procedure of transscleral fixation (TF) of the intraocular lens (IOL) in post-vitrectomized eyes. We performed the transscleral fixation of IOL in four aphakic patients who underwent pars plana vitrectomy. Two points 180degrees apart were marked at the limbus. A 2-mm-sized intrascleral pocket was created by lamellar dissection using a crescent blade without conjunctival dissection. A 2.8-mm clear corneal incision (CCI) was made using a keratome. Prolene sutures were exteriorized through the CCI pocket and a three-piece foldable acrylic IOL was injected via CCI and the ends of the haptics were exteriorized through the CCI. The prolene sutures for each haptic in the intrascleral pocket bed were then tied and knots were buried under scleral flaps. No patient had complaints such as conjunctival irritation, and visual acuity was almost identical to preoperative best-corrected visual acuity at day 1 postoperatively. IOLs were well placed without tilting or subluxation. They had no wound dehiscence or endophthalmitis postoperatively. The intrascleral pocket procedure of TF without the need for conjunctival dissection is a successful method for sulcus fixation in post-vitrectomized eyes predisposed to developing glaucoma.

Clinical Results of Modified Ab Externo and One-Knot Technique

PURPOSE: To introduce a more efficient and time-saving scleral fixation technique for a posterior chamber foldable intraocular lens and to report the clinical results. METHODS: A foldable acrylic 3-Piece IOL was sutured to the sclera via a small corneal incision. The guiding hollow needle was not used, which differs from other ab externo techniques. Instead, the curved long needle was directly pulled out through the cornea. The scleral flap was not used to bury the scleral suture knot; Instead, the scleral suture knot was translocated at the temporal area. RESULTS: A total of 30 cases were studied retrospectively. The mean follow-up period was 2 years. The IOL was correctly positioned in all cases. There were no major complications, such as endophthalmitis or suture erosion through the conjunctiva. CONCLUSIONS: Based on the authors' experience, the modified ab externo and one-knot technique is a faster and easier technique than the conventional ab externo technique.

Clinical Results of Modified Ab Externo and One-Knot Technique

PURPOSE: To introduce a more efficient and time-saving scleral fixation technique for a posterior chamber foldable intraocular lens and to report the clinical results. METHODS: A foldable acrylic 3-Piece IOL was sutured to the sclera via a small corneal incision. The guiding hollow needle was not used, which differs from other ab externo techniques. Instead, the curved long needle was directly pulled out through the cornea. The scleral flap was not used to bury the scleral suture knot; Instead, the scleral suture knot was translocated at the temporal area. RESULTS: A total of 30 cases were studied retrospectively. The mean follow-up period was 2 years. The IOL was correctly positioned in all cases. There were no major complications, such as endophthalmitis or suture erosion through the conjunctiva. CONCLUSIONS: Based on the authors' experience, the modified ab externo and one-knot technique is a faster and easier technique than the conventional ab externo technique.

Knotless External Fixation Technique for Posterior Chamber Intraocular Lens Transscleral Fixation: A 5-Case Analysis

PURPOSE: To determine whether the knotless technique can be an alternative for the scleral flap-making technique in posterior chamber intraocular lens transscleral fixation when a scleral flap cannot be made. METHODS: Five patients underwent the knotless technique for posterior chamber intraocular lens transscleral fixation when a scleral flap could not be made. Partial thickness scleral anchoring sutures were repeated three times near the transscleral penetration site in both ends. The end of the anchoring suture was passed under the exposed part of the partial thickness scleral anchoring suture and pulled to adjust the position of the intraocular lens. Then, anchoring sutures were covered with a conjunctival flap. Complications and change of intraocular lens astigmatism were evaluated. RESULTS: During the 8-month postoperative follow-up period, one case of ciliary body hemorrhage due to intraoperative transscleral penetration and one case of mild intraocular lens tilting owing to the improper tension of the string were observed. Except for one case with a concurrent penetrating keratoplasty, intraocular lens astigmatism showed no significant change during the postoperative follow-up period and no significant difference compared to transscleral fixation with a scleral flap. CONCLUSIONS: Knotless technique for external fixation of posterior chamber intraocular lens transscleral fixation is a safe and easy technique and may be a good alternative for the scleral flap-making technique in posterior chamber intraocular lens transscleral fixation when a scleral flap cannot be made.

Surgical Results of Transscleral Fixation of Foldable Acrylic Intraocular lens with Unique Shape of Haptics

PURPOSE: To report the surgical results of transscleral fixation of foldable acrylic intraocular lens with a unique haptic shape (CORNEAL(R), ACR6D, France). METHODS: We analyzed the medical records of 18 patients (19 eyes) who had transscleral fixation of posterior chamber intraocular lens implantation from July 2004 to July 2006. RESULTS: According to the cause of operation, there were five eyes with complicated cataract, eight with trauma, and six with aphakia associated with a previous operation. The mean age of the patients was 55.9+/-21.2 years. The mean preoperative best-corrected visual acuity was 0.31+/-0.35, and the postoperative value was 0.63+/-0.29 (p<0.05). The mean preoperative spherical refractive equivalent was 6.58+/-5.33 diopter, and the postoperative value was -1.77+/-1.59 diopter. The mean refractive error was -1.13+/-1.57 diopter. This showed a myopic shift (p<0.05). The mean astigmatism decreased with time, and it stabilized two months after the operation. The trend was toward mild against-the-rule astigmatism. The mean follow-up duration was 11.0+/-7.6 months. CONCLUSIONS: In eyes with inadequate capsular support, transscleral fixation of posterior chamber intraocular lens implantation with CORNEAL(R) lenses is a safe and effective procedure for visual correction.

The Role of Vitrectomy in Transscleral Fixation of Posterior Chamber Intraocular Lens

PURPOSE: To evaluate the role of vitrectomy in transscleral fixation of posterior chamber intraocular lens (IOL) compared to scleral fixation without vitrectomy. METHODS: We reviewed the medical records of 8 eyes which had undergone transscleral fixation with vitrectomy using the three-port-system and 13 eyes which had undergone transscleral fixation only. The postoperative visual acuity, best-corrected visual acuity and changes in astigmatism were compared between the groups. RESULTS: Postoperative uncorrected and best corrected visual acuities were 0.68 and 0.8 in the vitrectomy group and 0.48 and 0.63 in the non-vitrectomy group, respectively. Changes in the amount of astigmatism were significantly less in the vitrectomy group (0.38 diopter) compared to those of the non-vitrectomy group (1.67 diopter). CONCLUSIONS: Transscleral fixation of IOL along with three-port-system vitrectomy resulted in good vision with a smaller degree of astigmatism. Adopting three-port-system vitrectomy seems to have caused the good results, because more complete removal of the lens and capsule remnants and adequate maintenance of IOP with accurate needling and IOL positioning was possible using the system.

A Clinical Study in Transscleral Fixation of Foldable Intraocular Lenses

PURPOSE: To evaluate the results and complications of transscleral fixation of the foldable intraocular lens(IOL). METHODS: We performed a retrospective review of the medical records of 26 patients who had undergone transscleral fixation of acrylic three-piece foldable IOL from January 2002 to April 2004 in our hospital. There were 5 eyes with aphakia, 2 with idiopathic lens subluxation, 3 with trauma, 5 with dislocation or opacification of IOL, and 11 with complicated cataract surgery. RESULTS: The mean age of the patients was 70.6 years (range, 47~87 years). The range of preoperative best corrected visual acuity (BCVA) was from light perception to 0.6. The mean preoperative refraction and mean preoperative target refraction were 2.0 +/- 6.51D (-8.5~13D) and -0.45 +/- 0.70D (-3.75~0.39D), respectively, in spherical equivalent. The mean preoperative corneal astigmatism was -1.0 +/- 0.65D (-0.25~-2.5D). The postoperative BCVA ranged between 0.02 and 1.0, and the mean refractive error was -0.66 +/- 1.15D (-3.3~1.75D) at the last follow-up visit. The mean corneal astigmatism was -1.55D +/- 1.67 (-9~-0.25D) at the last follow-up visit (p=0.99, paired t-test). CONCLUSIONS: Transscleral fixation of the foldable IOL through small incision results in fewer complications, due to the large incision and the shorter time, and therefore, instantly improved visual acuity.

Clinical Results of Black-Diaphragm Intraocular Lens Implantation

PURPOSE: We studied the clinical products of sulcus fixation of Black-diaphragm intraocular lens and transscleral fixation of Black-diaphragm intraocular lens in congenital and acquired aniridia patients. METHODS: We retrospectively analyzed the records of 12 aniridic eyes in 20 patients who underwent Black-diaphragm intraocular lens implantation from December 2001 to December 2003 at our hospital. We divided the aniridia eyes into sulcus fixation (group 1, 3 eyes of 3 patients) and transscleral fixation (group 2, 8 eyes of 8 patients) groups, and congenital aniridia (group A, 3 eyes of 3 patients) and acquired anirida (group B, 9 eyes of 9 patients) groups. We compared results between groups 1 and 2, and between groups A and B. RESULTS: The differences (in diopter) between preoperatively expected refractive error and postoperative refractive error were -1.27 +/- 1.06 in group 1 and -1.06 +/- 1.06 in group 2, and this difference between groups 1 and 2 was not significant. Postoperative visual acuity results in group A (0.18 +/- 0.03) were significantly better than those in group B (0.61 +/- 0.29). CONCLUSIONS: In Black-diaphragm intraocular lens implantation of aniridia patients, the differences between preoperatively expected refractive error and postoperative refractive error were not different between sulcus fixation and transscleral fixation. Better postoperative visual acuity results are anticipated in acquired aniridia patients than in congenital aniridia patients.

A Clinical Study on Transscleral Fixation of Posterior Chamber Intraocular Lens in Complete Vitrectomized Eyes

PURPOSE: We studied the result and cilincal significance of transscleral fixation of posterior chamber lens in complete vitrectomized eyes without capsular support. METHODS: We evaluated 30 aphakic eyes of 30 patients and according to the cause of pars plana vitrectomy, there were 9 eyes for intraocular foreign body, 8 eyes for lens dislocation, 8 eyes for retinal detachment, 3 eyes for vitreous hemorrhage, 2 eyes for endophthalmitis. RESULTS: The postoperative best-corrected visual acuity group was intraocular foreign body group and the group of lens dislocation, vitreous hemorrhage, retinal detachment, and endophthalmitis were in the descending order of visual acuity. The most common postoperative early complication was temporary hypotony and the others were hyphema, and temporary increased IOP. The most common postoperative late complication was exposed scleral fixation suture and the others were vitreous hemorrhage, cystoid macular edema, subluxation of intraocular lenses, retinal detachment. CONCLUSIONS: We experienced many postoperative temporary hypotony patients, but all cases were improved in short term period. The complication related to scleral fixation in vitrectomized eyes was imposed to smaller than the scleral fixation in vitreous support. But, in fact the development of retinal detachment or vitreous incarceration complication in the vitrectomized eye was not different from the eyes having vitreous support.

Scleral Fixation of Foldable Posterior Chamber Intraocular Lenses

PURPOSE: To evaluate the surgical result and complications of scleral fixation of foldable intraocular lenses. METHODS: We reviewed the medical records of 17 patients who had undergone scleral fixation of acrylic three-piece foldable intraocular lens. RESULTS: Uncorrected visual acuity were improved in all eyes with time. Postoperative best corrected visual acuity were better than preoperative best corrected visual acuity in 14 eyes from 1.18+/-0.84 to 0.26 +/-0.25 in logMAR visual acuity. Estimated refractive error were 0.01+/-0.34 diopter in spherical equivalent preoperatively and .0.59+/-1.00 diopter postoperatively (p=0.02, paired t-test). The corneal astigmatic changes (dK) of mild against-the-rule astigmatism decreased as time passed. There was no intraoperative bleeding. There were postoperative complications such as increased intraocular pressure in 2 eyes, corneal epithelial defect in 1 eye. CONCLUSIONS: In cases of scleral fixation, by using acrylic foldable intraocular lens through small incision, we were able to reduce corneal astigmatism and complications due to large incision and therefore, improve visual acuity instantly.

Transscleral Fixation of Posterior Chamber Intraocular Lens in Aphakia

We evaluated visual acuity, refractive error, corneal astigmatism, and complications after transscleral fixation of posterior chamber lenses in 46 aphakic eyes of 45 patients from January 1992 to April 1999. According to the causes of aphakia, there were 20 eyes for senile cataract surgery, 15 eyes for traumatic cataract surgery, 11 eyes for retinal detachment surgery including lensectomy. We used PMMA lenses in 35 eyes but foldable lenses in the remaining eyes. Anterior vitrectomy was done in 14 eyes. In 8 eyes which had some capsular support, one haptic was inserted at ciliary sulcus and the other haptic was sutured. Postoperative uncorrected visual acuity(UCVA)and best-corrected visual acuity(BCVA)were best in senile cataract surgery group according to the causes of aphakia, better in PMMA lens group according to the lens type, and better in the combined anterior vitrectomy group. But, there was no significant difference in the proportion of the cases that BCVA after 1 month of operation was not less than preoperative BCVA, according to the causes of aphakia, lens types, or combined anterior vitrectomy. The postoperative refractive error showed mild myopic shift, and the corneal astigmatic change was within 1. 5 diopter and stable up to 2 month after operation and did not differ significantly according to lens types. The incidence of complications was not high. In conclusion, transscleral fixation of posterior chamber lens in aphakia is effective.

Retinal Detachment after Transscleral Fixation of Posterior Chamber Intraocular Lens

To determine clinical features and outcomes of retinal detachments[RDs] following trans-scleral fixation of posterior chamber intraocular lens[PC-IOL], we reviewed the medical records of 249 eyes[239 patients] which had undergone trans-scleral fixation of PC-IOL and had been followed 6 months or longer. Retinal detachment occurred in 8 out of 249 eyes[3.2%]. The incidences of RDs were as follows:in 2/19 eyes[10.5%] with PC-IOL exchange for PC-IOL tilt, in 1/16 eyes[6.3%] with posterior capsule rupture during ECCE, in 1/26 eyes[3.8%] with ICCE, in 2/78 eyes[2.6%] with posterior capsule rupture during phacoemusification, in 2/106 eyes[1.9%] with aphakia, and in 0/4 eyes[0%] with anterior IOL exchange with PC-IOL. The sites of retinal break corresponded with the directions of needle during fixation in 5/8 eyes[62.5%] and all retinal breaks were located anterior to the equator. The timing of RD was between 2 weeks and 4.8 years after fixation although it occured within 2 months in most cases. Pars plana vitrectomy and scleral buckling were performed in 7 eyes and scleral buckling only in one eye. Retinal reattachment was achieved in seven eyes including three eyes which required two surgical interventions. The vitrectomy should be performed with meticulous care to reduce vitreous traction as much as possible during trans-scleral fixation of PC-IOL and a close follow-up examination for RD is required during the first two months.

Retinal Detachment Following Scleral Fixation of Posterior Chamber Intraocular Lens

The authors reviewed retrospectively retinal detachment(RD)s following posterior chamber intraocular lens(PC-IOL) implantation by transscleral suture fixation. One hundred twenty-two transscleral fixations of PC-IOL were performed from January, 1990 to December, 1992. The follow-up periods for this series ranged from 12 to 42 months. Six retinal detachments developed in this series. and the incidence of RD was 4.9%. There was no statistical difference between the primary operation group(unplanned posterior capsule rupture during extracapsular cataract extraction, lens dislocation/subluxation) and the secondary operation group(already aphakia after previous cataract surgery). The predisposing factors to RD were myopic eye(p=0.03), postoperative vitreous hemorrhage(p=0.001). In cases with RD, the locations of transscleral fixation sutures almost coincided with the meridians of the retinal breaks. The contributing factors to increased incidence of RD were thought to be vitreous loss during operations, vitreous traction by suturing needle or haptics of IOL, proliferative change by vitreous hemorrhage.

Implantation of Posterior Chamber Intraocular Lens by Trans-Scleral Fixation

We performed trans scleral fixation techniques for implantation of posterior chamber lens in 25 eyes, in case of incomplete zonular or capsular support. This was done by securing both haptics of the posterior chamber lens to the sclera at the ciliary sulcus with 10-Onylon suture. Postoperative follow-up time ranged from 12 to 23 months, with all patients having at least one year of follow up. At the last follow up visit, 16 eyes (72%) had a vision of 20/50 or better, and 13 eyes (52%) had a vision of 20/30 or better. The transscleral fixation related complications included retinal detatchment, glaucoma and cystoid macular edema. During the relatively longterm follow up period, we did not find any serious complications due to the intraocular lens and there was no significant postoperative changes in the visual acuities.