Inadequate capsular support for intraocular lens (IOL) implantation in the bag or ciliary sulcus is seen in congenital conditions of ectopia lentis (eg, Marfan syndrome, homocystinuria, Ehlers–Danlos syndrome, or Weill–Marchesani syndrome) and aphakia after complicated cataract surgery or traumatic subluxation.1
In the presence of little to no capsular support, the surgeon has the following options for lens implantation: an anterior chamber IOL, posterior chamber IOL over a residual capsule, iris-fixated IOL, iris-claw lens, scleral-fixated IOL, or scleral-fixated posterior chamber IOL.
An anterior chamber IOL is associated with complications such as corneal endothelial damage, pseudophakic bullous keratopathy, uveitis, glaucoma, hyphema, and cystoid macular edema.2 With the advent of the scleral-fixated IOL technique, these complications have been minimized.
Correction of aphakia differs in children when compared to adults. Due to axial elongation and changes in corneal curvature, refractive changes occur in childhood. The average corneal curvature flattens from 52.00 diopters at birth to 43.50 diopters at 18 months of age. In addition, axial length increases from an average of 16.8 mm at birth to 23.6 mm in adulthood. The immature visual system of young children puts them at risk of developing amblyopia, so treating aphakia in the pediatric age group is a challenge.
Scleral-sutured and -glued IOLs have been used in the past. With the use of fibrin glue, there is always a theoretical possibility of the transmission of viral infections. Therefore, it is mandatory to obtain informed consent from the patient before the procedure.3 Sutured scleral-fixated IOLs have disadvantages such as intraocular hemorrhage during needle passage through the ciliary body, persistent suture track, a higher risk of endophthalmitis, and suture slippage from the haptic causing subluxation, tilt, or dislocation of the IOL.4 Sutureless intrascleral haptic fixation has become more popular because this technique has circumvented the issues related to sutures and glue and provides long-term IOL stability.5–10
These techniques have been studied in adults, but their effectiveness in the pediatric age group has not been reported. We evaluate the visual outcomes and complications after sutureless, flapless, and glueless intrascleral fixation of a posterior chamber IOL in a series of patients between 5 and 20 years old.
Patients and Methods
The case records of 15 eyes of 11 patients between the ages of 5 and 20 years were reviewed at Sankara Eye Hospital, Coimbatore, between January 2015 and July 2016. Eyes with no posterior capsular support for standard posterior chamber IOL implantation underwent a sutureless, flapless, and glueless technique of posterior chamber IOL implantation and were observed for a period of 6 months. A single-group, open-label, clinical study with assessment before and after the procedure was performed. Inclusion criteria were as follows: gross ectopia lentis (> 6 clock hours), inadequate posterior capsular support after intracapsular cataract extraction, and traumatic subluxation/dislocation of a crystalline cataractous lens. Patients with microcornea, central corneal opacity, chronic uveitis, optic nerve pathology, congenital glaucoma, retinal pathology requiring pars plana vitrectomy as a primary procedure, and macular pathology interfering with final visual outcome were excluded from the study. A full preoperative ophthalmic evaluation was performed that included uncorrected (UCVA) and best corrected (BCVA) visual acuity, anterior segment and dilated fundus examination, and white-to-white horizontal diameter and intraocular pressure measurement. Keratometry was performed with an autokeratorefractometer and IOL power with the Sanders–Retzlaff–Kraff II formula. Undercorrection was achieved according to the standard protocol of 10% for patients between 2 and 8 years of age. Patients were observed at 1 week, 1 month, and 6 months for postoperative assessment of UCVA and BCVA, intraocular pressure, fundus examination, and IOL stability. Early and late postoperative complications were recorded.
Kawaji et al.11 modified Gabor's technique and used it with adults. We used a similar technique in our study. A 2-mm linear incision involving 50% scleral thickness using a 1- to 1.5-mm keratome blade was made adjacent and perpendicular to the limbus between the 9- and 11-o'clock positions (superotemporally) and the 2- and 4-o'clock positions (inferonasally) in the right eye. A similar incision was made between the 9- and 11-o'clock positions (superonasally) and the 2- and 4-o'clock positions (inferotemporally) in the left eye. A 3- to 3.5-mm scleral tunnel parallel to the limbus was then fashioned in diametrically opposite directions (Figure 1A). A 24-gauge needle/25-gauge trocar was used to make two sclerotomies 1.5 mm from the limbus (Figure 1B). A 6-mm superior scleral tunnel was made after completing limited conjunctival peritomy. Lensectomy and anterior vitrectomy were performed via the pars plana approach. A three-piece polymethylmethacrylate IOL was inserted through the scleral tunnel and a 25-gauge microvitreoretinal forceps was used to externalize the haptics (Figure 1C). The haptics were then tucked into the tunnels using McPherson forceps (Figure 1D). A superior peripheral iridotomy was then performed. IOL centration was confirmed at the end of the surgery.
(A) A 2-mm scleral groove with tunnel formation. (B) Sclerotomy with a 24-gauge needle within the groove. (C) Grasping of the leading haptic using a microvitreoretinal forceps. (D) Tucking of the haptic using a McPherson forceps.
Of the 15 eyes of the 11 patients (10 male and 5 female), 8 (53%) were right eyes and 7 (47%) were left eyes. Table 1 shows the mean UCVA and BCVA logarithm of the minimum angle of resolution (logMAR) values preoperatively and at 1 week, 1 month, and 6 months postoperatively.
Preoperative Versus Postoperative Visual Acuity Outcomes (N = 15)
Table 2 shows the comparison of the mean preoperative UCVA and BCVA logMAR values between the primary implantation (n = 10) and secondary implantation (n = 5) groups. There was no statistical difference at 1 week, 1 month, and 6 months postoperatively between the two groups.
Postoperative UCVA and BCVA Outcomes Between Primary and Secondary IOL Implantation at 1 Week, 1 Month, and 6 Months
Table 3 shows the comparison of the mean preoperative UCVA and BCVA logMAR values between males and females. The two groups showed similar outcomes with no statistical significance at 1 week, 1 month, and 6 months postoperatively.
Postoperative UCVA and BCVA Outcomes Between Males and Femalesat 1 Week, 1 Month, and 6 Months
Of the 15 eyes, 2 had early postoperative complications. One eye had vitreous hemorrhage (primary implantation) and the other had hyphema (secondary implantation) on the first postoperative day. Both were treated conservatively and, at the 1 week follow-up visit, both the vitreous hemorrhage and hyphema had resolved. The final visual outcomes were similar in the two groups at the end of 6 months. No late postoperative complications were noted.
On comparison of mean preoperative UCVA and BCVA logMAR values between the complication and no complication groups, no statistical differences were noted at 1 week, 1 month, and 6 months postoperatively (Table 4).
Comparison of UCVA and BCVA Outcomes of Patients With and Without Complications at 1 Week, 1 Month, and 6 Months
The purpose of our study was to evaluate visual outcomes and complications after sutureless, flapless, and glueless intrascleral fixation of a posterior chamber IOL in children and young adults because adequate data are not available in this age group. Postoperatively, we observed the patients at 1 week, 1 month, and 6 months. The low cost of a polymethylmethacrylate IOL as compared to a hydrophobic lens was mainly considered because most patients in our study belonged to low socioeconomic strata. Also, the overall diameter of a three-piece polymethylmethacrylate IOL is 13 mm as compared to the 12.5-mm diameter of the foldable hydrophobic lens. Because the long-term stability of IOLs has not been studied previously in children using this technique, a larger diameter was preferred. However, hydrophobic lenses could also be used.
In our study, 15 eyes of 11 patients with an age range of 5 to 20 years and a mean age of 12.5 years were studied. Of the 15 eyes, 5 (33%) were from female patients and 10 (67%) were from male patients. Hsu et al.12 and Narang and Narang13 studied children with a mean age of 7.5 and 7.7 years, respectively, and reported good postoperative results with sutured IOLs in this age group.
Preoperatively, 10 (67%) eyes had a subluxated lens (7 eyes due to Marfan syndrome, 2 eyes due to trauma, and 1 idiopathic eye) in which primary implantation of the IOL was performed (Figure 2). Five (33%) eyes had aphakia with inadequate posterior capsular support in which a secondary IOL was implanted. Patients who underwent secondary implantation were primarily operated on between 6 months and 2 years of age (n = 5). The second surgery was performed after a minimum period of 6 months, depending on the age at presentation to our ophthalmology department. The second surgery was performed between the ages of 2 and 4 years. Shashidhar et al.14 found that mean postoperative BCVA logMAR values in primary scleral-fixated IOL implantation were not significantly different from those of secondary implantation. However, secondary implantation of a scleral-fixated IOL had a lower early complication rate than that of primary implantation. The same results were found in a study completed by Lee et al.4 In our study, we found that the final visual outcome and complication rate does not depend on the indication for IOL implantation because the final BCVA and complications between the groups with primary and secondary IOL implantations revealed similar results with no statistically significant difference.
A 5-year-old boy with traumatic subluxation of the lens (A) preoperatively, (B) 1 day postoperatively showing well-centered intraocular lens and patent peripheral iridotomy, and (C) slit photograph showing the haptic in the scleral groove
Preoperative mean UCVA was 1.34 ± 0.35 logMAR. Postoperative mean UCVA showed significant improvement at 1 week (0.79 ± 0.41 logMAR; P < .0001), 1 month (0.48 ± 0.23 logMAR; P < .0001), and 6 months (0.36 ± 0.18 logMAR; P < .0001). There was a statistically significant improvement in UCVA.
Preoperative mean BCVA was 0.69 ± 0.37 logMAR. Postoperative mean BCVA showed significant improvement at 1 month (0.31 ± 0.21 logMAR; P = .001) and 6 months (0.19 ± 0.19 logMAR; P < .0001). In a study conducted by Hsu et al.,12 the mean preoperative BCVA was 0.86 ± 0.17 logMAR, which improved to 0.23 ± 0.09 logMAR postoperatively (P < .001). In a study conducted by Narang and Narang,13 the preoperative mean UCVA was 0.08 ± 0.03 (decimal). Postoperatively, there was a significant improvement in UCVA to 0.27 ± 0.1 (decimal) (P < .05). The preoperative BCVA was 0.25 ± 0.14 (decimal). Postoperatively, there was a significant improvement to 0.57 ± 0.24 (decimal) (P < .05).
There were no intraoperative complications in our study. Of the 15 eyes studied, 1 eye had vitreous hemorrhage and 1 eye had hyphema at 1 week postoperatively, both of which subsequently resolved at 6 months of follow-up. Thirteen (87%) eyes did not have any complication. No late postoperative complications were reported. Kawaji et al.11 also reported similar complications (eg, vitreous hemorrhage, cystoid macular edema, and iris capture of the IOL) in their study.
This study has several limitations, such as its small sample size and short postoperative follow-up period. However, our study has shown that this novel technique achieves good visual outcomes. Significant intraoperative and postoperative complications such as endophthalmitis, retinal detachment, and IOL subluxation/dislocation were not encountered. This procedure could be used safely and effectively for the management of conditions having inadequate or no capsular support.
- Gicquel JJ, Langman ME, Dua HS. Iris claw lenses in aphakia. Br J Ophthalmol. 2009;93:1273–1275. doi:10.1136/bjo.2009.159871 [CrossRef]
- Drolsum L. Long-term follow-up of secondary flexible, open-loop, anterior chamber intraocular lenses. J Cataract Refract Surg. 2003;29:498–503. doi:10.1016/S0886-3350(02)01614-0 [CrossRef]
- Kumar DA, Agarwal A, Agarwal A, Prakash G, Jacob S. Glued intraocular lens implantation for eyes with defective capsules: a retrospective analysis of anatomical and functional outcome. Saudi J Ophthalmol. 2011;25:245–254. doi:10.1016/j.sjopt.2011.04.001 [CrossRef]
- Lee VY, Yuen HK, Kwok AK. Comparison of outcomes of primary and secondary implantation of scleral fixated posterior chamber intraocular lens. Br J Ophthalmol. 2003;87:1459–1462. doi:10.1136/bjo.87.12.1459 [CrossRef]
- Yamane S, Inoue M, Arakawa A, Kadonosono K. Sutureless 27-gauge needle-guided intrascleral intraocular lens implantation with lamellar scleral dissection. Ophthalmology. 2014;121:61–66. doi:10.1016/j.ophtha.2013.08.043 [CrossRef]
- Totan Y, Karadag R. Trocar-assisted sutureless intrascleral posterior chamber foldable intra-ocular lens fixation. Eye (Lond). 2012;26:788–791. doi:10.1038/eye.2012.19 [CrossRef]
- Maggi R, Maggi C. Sutureless scleral fixation of intraocular lenses. J Cataract Refract Surg. 1997;23:1289–1294. doi:10.1016/S0886-3350(97)80104-6 [CrossRef]
- Gabor SG, Pavlidis MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg. 2007;33:1851–1854. doi:10.1016/j.jcrs.2007.07.013 [CrossRef]
- Rodríguez-Agirretxe I, Acera-Osa A, Ubeda-Erviti M. Needle-guided intrascleral fixation of posterior chamber intraocular lens for aphakia correction. J Cataract Refract Surg. 2009;35:2051–2053. doi:10.1016/j.jcrs.2009.06.044 [CrossRef]
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- Kawaji T, Sato T, Tanihara H. Sutureless intrascleral intraocular lens fixation with lamellar dissection of scleral tunnel. Clin Ophthalmol. 2016;10:227–231. doi:10.2147/OPTH.S101515 [CrossRef]
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Preoperative Versus Postoperative Visual Acuity Outcomes (N = 15)
|Visual Acuity||Mean ± Standard Deviationa||P|
| Uncorrected||1.34 ± 0.35||–|
| Best corrected||0.69 ± 0.37||–|
| 1 week|
| Uncorrected||0.79 ± 0.41||< .0001|
| Best corrected||0.53 ± 0.42||.214|
| 1 month|
| Uncorrected||0.48 ± 0.23||< .0001|
| Best corrected||0.31 ± 0.21||.001|
| 6 months|
| Uncorrected||0.36 ± 0.18||< .0001|
| Best corrected||0.19 ± 0.19||< .0001|
Postoperative UCVA and BCVA Outcomes Between Primary and Secondary IOL Implantation at 1 Week, 1 Month, and 6 Monthsa
|Visual Acuity||Primary Group (n = 10)||Secondary Group (n = 5)||P|
| UCVA||1.30 ± 0.36||1.43 ± 0.34||.526|
| BCVA||0.76 ± 0.42||0.52 ± 0.17||.239|
| 1 week|
| UCVA||0.72 ± 0.37||0.93 ± 0.50||.430|
| BCVA||0.45 ± 0.27||0.70 ± 0.64||.452|
| 1 month|
| UCVA||0.46 ± 0.25||0.52 ± 0.21||.656|
| BCVA||0.27 ± 0.22||0.38 ± 0.16||.346|
| 6 months|
| UCVA||0.34 ± 0.20||0.40 ± 0.14||.564|
| BCVA||0.18 ± 0.19||0.20 ± 0.21||.857|
Postoperative UCVA and BCVA Outcomes Between Males and Femalesat 1 Week, 1 Month, and 6 Monthsa
|Visual Acuity||Males (n = 10)||Females (n = 5)||P|
| UCVA||1.33 ± 0.35||1.37 ± 0.39||.852|
| BCVA||0.60 ± 0.43||0.84 ± 0.08||.272|
| 1 week|
| UCVA||0.70 ± 0.47||0.98 ± 0.20||.131|
| BCVA||0.51 ± 0.52||0.58 ± 0.13||.688|
| 1 month|
| UCVA||0.42 ± 0.21||0.60 ± 0.25||.216|
| BCVA||0.26 ± 0.22||0.40 ± 0.14||.165|
| 6 months|
| UCVA||0.29 ± 0.12||0.50 ± 0.21||.092|
| BCVA||0.14 ± 0.17||0.28 ± 0.21||.250|
Comparison of UCVA and BCVA Outcomes of Patients With and Without Complications at 1 Week, 1 Month, and 6 Monthsa
|Visual Acuity||Complication (n = 2)||No Complication (n = 13)||P|
| UCVA||1.46 ± 0.38||1.30 ± 0.34||.452|
| BCVA||0.84 ± 0.65||0.62 ± 0.22||.559|
| 1 week|
| UCVA||0.97 ± 0.61||0.72 ± 0.33||.499|
| BCVA||0.87 ± 0.69||0.40 ± 0.21||.059|
| 1 month|
| UCVA||0.52 ± 0.25||0.46 ± 0.23||.687|
| BCVA||0.37 ± 0.25||0.28 ± 0.19||.533|
| 6 months|
| UCVA||0.30± 0.14||0.38 ± 0.19||.400|
| BCVA||0.17 ± 0.23||0.19 ± 0.18||.909|