EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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52 EW RESIDENTS August 2013 EyeWorld journal club Review of "Complications and visual intraocular lens implantation in eyes with by Samantha Williamson, MD, Williams Watkins Jr., MD, Sumeer Thinda, MD, Richard Hwang, MD, Yuna Rapoport, MD, and Laura L. Wayman, MD, director of resident education, Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tenn. Laura L. Wayman, MD Surgeons have anxiously awaited a large study of glued IOL outcomes. The August JCRS publishes the first such large study, and I asked the Vanderbilt residents to review this paper for our August "EyeWorld journal club" column. –David F. Chang, MD, chief medical editor P lacement of an intraocular lens (IOL) in an eye with inadequate capsular support remains a surgical challenge. As a result of evolving techniques and advances in IOL design, a number of options are available today. In the United States, surgeons may employ anterior chamber IOLs, scleral-sutured lenses, sutureless scleral-fixated IOLs, and iris-fixated lenses.1 Lens choice may be predicated on patient comorbidities, including corneal endothelial dysfunction, aniridia, inadequate anterior chamber depth, glaucoma, and history of intraocular inflammation. Complications and visual outcomes after glued foldable intraocular lens implantation in eyes with inadequate capsules Dhivya Ashok Kumar, MD, Amar Agarwal, MS, FRCS, FRCOpth, Sathiya Packiyalakshmi, Msc, Soosan Jacob, MS, FRCS, Athiya Agarwal, MD, DO J Cataract Refract Surg (Aug) 2013; 39: 1211-1218 Purpose: To evaluate the complications and visual outcomes of glued intrascleral-fixated foldable intraocular lens (IOL) in eyes with deficient capsules. Setting: Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India. Design: Case series. Methods: Data were evaluated from the records of patients with a primary glued foldable IOL for intraoperative capsular loss or subluxated lens or secondary glued foldable IOL for aphakia. Exclusion criteria included preoperative glaucoma, aniridia, macular scar, traumatic subluxation, combined surgeries, incomplete operative medical records, and postoperative follow-up less than six months. The intraoperative and postoperative complication rates, reoperation rate, and visual outcomes were analyzed. Results: The study comprised 208 eyes (185 patients). The mean followup was 16.7 months ± 10.2 (SD). The intraoperative complications were hyphema (0.4%), haptic breakage (0.4%), and deformed haptics (0.9%). Early complications occurred in 29 eyes (13.9%) and included corneal edema (5.7%), epithelial defect (1.9%), and grade 2 anterior chamber reaction (2.4%). Late complications occurred in 39 eyes (18.7%) and included optic capture (4.3%), IOL decentration (3.3%), haptic extrusion (1.9%), subconjunctival haptic (1.4%), macular edema (1.9%), and pigment dispersion (1.9%). Reoperation was required in 16 eyes (7.7%). Haptic position was altered in eyes with IOL decentration. Corrected distance visual acuity (CDVA) improved or remained unchanged in 84.6% of eyes. The postoperative CDVA was 20/40 or better and 20/60 or better in 38.9% and 48.5% of eyes, respectively. Conclusions: The foldable glued-IOL procedure showed satisfactory visual outcomes without serious complications. Intraocular lens decentration was due to haptic-related problems. Financial disclosure: Dr. Agarwal is a paid consultant to STAAR Surgical Co. No author has a financial or proprietary interest in any material or method mentioned. Agarwal and colleagues first reported the technique of glued sutureless posterior chamber IOL implantation in 2007, and published outcome data of patients receiving glued rigid IOLs at their hospital in 2008.2 In this technique, a threepiece nonfoldable IOL was introduced through a corneoscleral tunnel incision, and implanted using fibrin glue-assisted intrascleral haptic fixation. In the August issue of the Journal of Cataract & Refractive Surgery, Kumar et al. report the visual outcomes and operative complications of glued intrascleral-fixated foldable IOL implantation in 208 eyes with deficient capsular support. A foldable three-piece IOL was injected through a corneal incision and positioned in the posterior chamber after an anterior vitrectomy. The haptics were externalized through two diagonal sclerotomies, secured in intralamellar scleral tunnels, and the overlying scleral flaps were closed with reconstituted fibrin glue. Kumar et al. advocate that glued posterior chamber IOLs represent a significant surgical option for eyes with inadequate capsular support. Compared to other available procedures, this technique may reduce complications including cystoid macular edema, ocular hypertension, retinal detachments, and suture-related complications. Study summary Dr. Kumar and colleagues present a retrospective study evaluating 208 eyes from 185 patients who received glued intrascleral-fixated foldable intraocular lens implants from 2008 to 2012 for intraoperative posterior capsule rupture, aphakia, or a subluxated cataractous lens. Exclusion criteria included glaucoma, aniridia, macular scars, traumatic subluxation, and dislocated nuclei requiring pars plana vitrectomy. The study defined the primary outcome measures as final logMAR visual acuity, early postoperative complications (defined as within one month of the operative date), and late surgical complications (those occurring one month after surgery). The surgical technique is described in further detail in the Surgical Techniques section of the paper. Average follow-up was 16.7 months. Overall uncor- rected visual acuity significantly improved from 1.2 to 0.99 logMAR after surgery, and 84.6% of patients achieved a final corrected visual acuity better than or equal to the recorded preoperative acuity. Early complications were seen in 13.9% of subjects. The most common complications were corneal edema (5.7%), anterior chamber cells (4.7%), and epithelial defects (1.9%). Late complications were seen in 18.7% of patients. Those directly related to the IOL included optic capture (4.3%), decentered IOL (3.3%), haptic extrusion (1.9%), pigment dispersion (1.9%), subconjunctival haptic (1.4%), and scleral thinning (0.9%). The most common reason for decentration was unequal haptic tuck and non-diagonal scleral flaps. Seventeen percent of patients required a reoperation for IOL repositioning, haptic repositioning, or conjunctival suturing. Except for postoperative macular edema seen in four eyes, there were no serious late posterior segment complications, including endophthalmitis, retinal breaks, retinal detachments, choroidal effusions, vitreous hemorrhage, uveitisglaucoma-hyphema syndrome, or suture-related problems. Comment To our knowledge, this is the largest study evaluating the complications and visual outcomes of glued foldable scleral-fixated intraocular lens placement, and thus represents an important addition to the literature. Notably, the authors included both elective (aphakia and subluxation) and non-elective cases (intraoperative posterior capsule rupture). A limitation of the study is its uncontrolled design. The authors report that ocular hypertension was observed in only 0.4% of eyes in their study, compared to 30.5–50% as seen after scleral-sutured IOLs.3-5 However, it is challenging to compare postoperative IOP across different patient populations in an uncontrolled fashion. The rate of ocular hypertension varies widely depending on when it is reported; in one study5 cited in the paper, immediate postoperative ocular hypertension was 7.5%, whereas late postop ocular hypertension was 50%. Utilizing the fellow eye as a control would have been helpful in placing the