EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/618732
EW RESIDENTS 32 January 2016 by Deepak Mangla, MD, Allison Ramsey Soneru, MD, Caroline L. Minkus, MD, Anne Michael Langguth, MD, and Dmitry Pyatetsky, MD O pen-loop anterior cham- ber intraocular lenses (ACIOLs), sutured scleral fixated intraocular lenses (SFIOLs), and sutureless scleral fixated intraocular lenses are all options when implanting an IOL in eyes without adequate capsular support. The choice of which lens to implant has traditionally been based on surgeon preference as prospec- tive randomized controlled trials do not exist to provide comparisons between them. While the literature regarding primary ACIOLs is exten- sive, relatively few studies about SFIOLs exist. SFIOLs have been used for years as an option for patients requiring secondary lens implanta- tion and have been shown to be effective. 1 While literature exists indicating that both sutured 1–4 and sutureless IOLs 5–6 are viable techniques for treatment of aphakia in patients with inadequate capsu- lar support, Sindal et al set out to provide a direct comparison between sutured and sutureless SFIOLs. This is the first study to our knowledge to directly compare them. To perform this comparison, the medical records of all patients who underwent primary or second- ary SFIOL implantation by either sutured or sutureless technique (1/1/2010–3/31/2014) at Aravind Eye Hospital in Pondicherry, India were retrieved for retrospective anal- ysis. The setting for the study was appropriate, as it was a high-volume tertiary referral center with report- edly low complication rates, and performed a significant number of SFIOL implantations. For inclusion in the analysis, indications for sur- gery included post-traumatic apha- kia, as well as aphakia as a compli- cation of cataract surgery. Eyes that had undergone additional surgical procedures (e.g., retinal detachment repair or vitrectomy) prior to SFIOL implantation were included. The choice of sutured vs. sutureless tech- nique for SFIOL implantation was determined based on surgeon pref- erence alone. Postoperative compli- cations and the timeframe between the surgery and when the complica- tion developed were recorded. Final- ly, uncorrected distance visual acuity (UCDVA) and best corrected distance visual acuity (BCDVA) at a baseline visit prior to surgery and at 1 year or last follow-up visit (whichever was later) were documented. This study analyzed post-cata- ract surgery and post-trauma apha- kic patients. The inclusion criteria were clearly outlined (all eyes with minimum follow-up time of 1 year, post-trauma cases with dislocation of crystalline lens or aphakia follow- ing open globe repair, post-cataract cases with loss of capsular/zonular support), and eyes were not exclud- ed based on additional surgical pro- cedures performed at the same time. By openly and clearly stating which patients were included, the authors allow the reader to properly apply the study results in other settings. By combining patients with aphakia due to various causes, the sample population is greatly increased and the power of the study increases as well; however, combining these 2 distinct groups (post-cataract surgery and post-trauma) may be subopti- mal as there was likely significant anatomic variance between the pre-SFIOL implanted eyes of patients in the trauma group as compared to the cataract group. This variability further confounds the overall results comparing sutured and sutureless techniques. The authors conclude that SFIOLs are a safe and effective choice for lens replacement in aphakic eyes; however, the low complication rates reported in this paper are based on a mean follow-up time of only 18 months. In their review of SFIOLs, Vote et al reported suture breakage in 28% of patients with maximum suture breakage 4 years postopera- tively. 7 Only 3 patients in this study were followed for greater than 4 years, and the majority of patients analyzed had only 2 years of follow- up. The authors acknowledge the Vote group's paper, but state only that they are unable to comment on the previous findings. In light of the prior results, however, it may be that this study has insufficient follow-up. While the results presented herein are promising, further follow-up is needed to assess the long-term safety and efficacy of SFIOLs. Additionally, the study states that surgical method was not ran- domized, but rather based purely on surgeon preference, which allows selection bias. Four separate sur- geons were part of this study. It does not specify if particular surgeons preferred one method to another or how the surgeons decided which technique to use. It is therefore unclear if another factor, such as the state of the globe preoperatively, influenced this decision. Further clarification elsewhere in the paper would be helpful and might affect the results or help guide other sur- geons' choice of surgical method. In addition to the limita- tions posed by the relatively short follow-up and the retrospective non-randomized nature of the study Review of "Comparison of sutured vs. sutureless scleral fixated intraocular lens – Comparison of sutured vs. sutureless scleral fixated intraocular lens – A retrospective analysis Manavi D. Sindal, MS, Chinmay P. Nakhwa, MS, FRCS, Sabyasachi Sengupta, DO, DNB, FRCS J Cataract Refract Surg (Jan) 2015;42. Article in press Purpose: To compare the intermediate term anatomical and visual results of a scleral fixated intraocular lens (SFIOL) implanted using two techniques—the four-point suture fixation technique versus the transscleral sutureless fixation. Setting: Tertiary referral eye care center in South India Design: Retrospective case series Methods: Medical records of consecutive patients operated for SFIOL from January 1, 2010 to March 31, 2014, with more than 1 year of follow-up were retrospectively analyzed. Indication for SFIOL implantation was aphakia following cataract extraction or trauma. The surgical technique was based on individual surgeon preference. Uncorrected distance visual acuity (UCDVA), previous surgery, type of trauma, surgical technique, and complications were analyzed. Results: One hundred and nine cases were analyzed. The mean duration of follow-up was 18.9+8.7 months. Majority of eyes experienced an improvement in UCDVA following surgery, and 93 eyes (86%) had best corrected distance visual acuity of better than or equal to 6/12 Snellen equivalent. On comparison of sutured (n=52) versus sutureless SFIOL (n=59), the baseline characteristics and final visual outcome were comparable. Subjects experiencing previous trauma (n=52) were predominantly men and were significantly younger than the cataract group. Both post-trauma and post-cataract groups showed comparable visual and refractive outcomes. Transient cystoid macular edema was the most common complication (12%), while retinal detachment occurred in 5 cases (4.5%). Conclusions: SFIOLs are an excellent option for visual rehabilitation of aphakic eyes without capsular support. Sutured and sutureless techniques appear to be equally good, in both post-cataract and post-trauma aphakia. Do scleral fixated IOLs have better outcomes if they are sutured or sutureless? I asked the Northwestern residents to review this large retrospective series that is published in the January issue of JCRS. –David F. Chang, MD, EyeWorld journal club editor Dmitry Pyatetsky, MD, residency program director, Northwestern University Feinberg School of Medicine, Chicago EyeWorld journal club