Eyeworld

EW RESIDENTS 120 March 2017 to IFIOLs or TSSIOLs, mirroring findings in the classic 2003 Wagoner et al. review. The current study's lim- itations stem from its retrospective nature and absence of detail regard- ing techniques used for sutured IOL procedures. This study begs us, as an ophthalmic community, to create a well-studied comparison between modern ACIOLs and techniques using foldable IOLs (such as the glued IOL technique or the Akreos small-incision technique 6,7 ). Our colleagues outside of the United States would certainly be interested in including iris clip IOLs in future comparison studies. As it stands, data demonstrate that the much maligned ACIOL serves as a good option for sec- ondary IOL placement in patients lacking capsular support. Brunin et al.'s study gives the ACIOL a nice little boost back into prime time. We appreciate the great effort of the authors to bring this data to our attention. EW References 1. Wagoner MD, et al. Intraocular lens implantation in the absence of capsular sup- port. Ophthalmology. 2003;110(4):840–859. 2. Collins JF, et al. A comparison of anterior chamber and posterior chamber intraocular lenses after vitreous presentation during cataract surgery: the Department of Veterans Affairs Cooperative Cataract Study. Am J Ophthalmol. 2003;136(1):1–9. 3. Millar ER, et al. Effect of anterior capsulor- hexis optic capture of a sulcus-fixated intra- ocular lens on refractive outcomes. J Cataract Refract Surg. 2013;39(6):841–844. 4. Chang DF, et al. Complications of sul- cus placement of single-piece acrylic intraocular lenses. J Cataract Refract Surg. 2009;35(8):1445–1458. 5. Kemp PS, et al. Stability and safety of MA50 intraocular lens placed in the sulcus. Eye. 2015;29(11):1438–1441. 6. Kumar DA, et al. Glued intraocular lens: a major review on surgical technique and results. Curr Opin Ophthalmol. 2013;24(1):21– 29. 7. Terveen DC, et al. Small-incision 4-point scleral suture fixation of a foldable hydro- philic acrylic intraocular lens in the absence of capsule support. J Cataract Refract Surg. 2016;42(2):211–216. 8. Donaldson KE, et al. Anterior chamber and sutured posterior chamber intraocular lenses in eyes with poor capsular support. J Cataract Refract Surg. 2005;31(5):903–909. 9. Chan TC, et al. Comparison of Outcomes of Primary Anterior Chamber Versus Secondary Scleral-Fixated Intraocular Lens Implantation in Complicated Cataract Surgeries. Am J Ophthalmol. 2015;159(2). Contact information Oetting: thomas-oetting@uiowa.edu committee's recommendation to avoid sulcus placement of sin- gle-piece acrylic lenses. Instead, they recommended a 3-piece IOL with a large optic, a smooth anterior surface, and long, thin angulated haptics (e.g. 14 mm). 4 One specific recommended lens was the STAAR Surgical AQ2010V (STAAR Surgical, Monrovia, California); unfortunate- ly, this IOL is no longer available. An alternative recommended IOL was the Alcon MA50 (Alcon, Fort Worth, Texas), which has some of the desired qualities for a sulcus IOL but has a shorter haptic length (13.0 mm). In 2015, Kemp et al. published a review of sulcus placement of the MA50, which warned that, without optic capture, sulcus-placed MA50s were not stable in eyes with axial length >25 mm. 5 Brunin et al.'s study did not describe the operative techniques used for suture fixation to the iris or sclera. While one can assume that the IFIOLs may have been foldable IOLs, it is less certain in the scler- al-sutured cases. This uncertainty makes the study less generalizable to present-day patients, as tech- niques have evolved to include the use of foldable IOLs (e.g., Agarwal's glued-IOL techniques or a recently described technique for Gore-Tex [Gore, Newark, Delaware] 4-point fixation of the Akreos AO60 IOL [Bausch + Lomb, Bridgewater, New Jersey] 6,7 ). Some authors have shown improved results with newer techniques; they argue that a small incision and simplified placement maneuvers obviate issues that arise with a large 6–7 mm incision re- quired to fixate lenses like the Alcon CZ70BD. In the current study, the mean follow-up for all patients was ap- proximately one year, which allows an adequate amount of time for visual acuity to stabilize. However, as the authors astutely noted, many of the complications associated with secondary IOL placement, such as corneal decompensation, suture failure, lens dislocation, and UGH syndrome, may take years to devel- op. To further determine long-term safety and equivalence, patients need to be followed for many years to identify late complications. Some subtle differences were noted between the three fixation groups in the study. Approximately 25% of patients in the IFIOL group lost at least 2 lines of CDVA, which was presumed to be due to high rates of postoperative CME. However, the time course for the decrease in vision is unknown, and this group also had the highest percentage of preoperative CME. Patients in the ACIOL group had the lowest num- ber of complications and were the only group out of the three to show a statistically significant improve- ment in vision from preop to postop. Hence, they recommended that an ACIOL be used in older patients with healthy corneal endothelium and normal anterior segment anatomy. Interestingly, ACIOLs remain controversial despite Wagoner et al.'s data and the data in the current pa- per. Many ophthalmologists believe that ACIOLs cause long-term corneal endothelial cell damage. This belief is partially based on outdated ACIOL data and surgical techniques. Recent studies show no difference in endo- thelial cell loss between ACIOLs and posterior chamber intraocular lenses (PCIOLs). 8,9 With this in mind, perhaps surgeons should have less apprehension to place an ACIOL, even in younger patients. The refractive analysis presented in this paper provided some unique and valuable information. In each study group, RPEs were quite low, and none were significantly different from zero. Additionally, many of the groups met or almost met refractive benchmarks, a testament to the importance of quality preoperative biometry and IOL power selection. An interesting secondary finding was the tendency for patients un- dergoing anterior vitrectomy to end up slightly myopic, echoing data in the pars plana vitrectomy literature. This study's refractive analysis could have important implications when choosing an IOL, with the caveat that the patient populations in the five study groups were heteroge- nous. Again, the authors did not comment on incision size or precise surgical technique. ACIOLs require a large incision whereas IFOLS are typ- ically done through a small incision. TSSIOLs can be done through either. The astigmatic data was unfortu- nately not included, but it would be interesting to analyze differences in surgically-induced astigmatism and final refractive error. Summary When capsular support is not avail- able, ACIOL use is at least equivalent Review continued from page 119 Secondary intraocular lenses: Complication rates, visual acuity, and refractive outcomes Greg Brunin, MD, Ahmar Sajjad, MD, Eric Kim, MD, Ildamaris Montes de Oca, MD, Mitchell Weikert, MD, Li Wang, MD, PhD, Douglas Koch, MD, Zaina Al-Mohtaseb, MD J Cataract Refract Surg. 2017;43(3). Article in press Purpose: To compare complication rates, visual acuity and refractive outcomes of secondary intraocular lenses (IOLs). Setting: Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston Design: Retrospective case series Methods: All secondary IOLs placed by the anterior segment service were reviewed. Preoperative data, operative reports, and data from each subsequent postoperative visit were evaluated. Patients were divided into five groups based on the final IOL position: 1) sulcus with optic capture (S+OC), 2) sulcus without optic capture (S-OC), 3) anterior chamber (ACIOL), 4) iris-fixated (IFIOL), and 5) transscleral- sutured (TSSIOL). Complication rates, visual acuity (VA), and refractive outcomes were compared for each group. Results: The sulcus with and without optic capture groups had the lowest complication rates and best VA outcomes. There was no difference in final corrected distance visual acuity (CDVA) among the TSSIOL, IFIOL, and ACIOL groups, although the ACIOL group had the lowest rates of early postoperative complications and a significant improvement in vision. The TSSIOL group had the highest complication rates, and patients in the IFIOL group had high rates of cystoid macular edema (23%), with 25% losing two or more lines of CDVA postoperatively. Conclusions: When a secondary IOL cannot be placed within the capsular bag, sulcus with optic capture is the best alternative, followed by sulcus without optic capture. We found no difference in VA outcomes among TSSIOLs, IFIOLs, and ACIOLs. ACIOLs resulted in fewer early complications and may be the best option for older patients with healthy corneal endothelium.

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