CASE REPORT

Intrascleral haptic needle fixation of 20+-year-old dislocated intraocular lenses using trailing-haptic-first modification

Kim, Madeleine E.; Kim, Dooho B. MD

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doi: 10.1097/j.jcro.0000000000000083
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Abstract

Yamane intrascleral haptic needle fixation is an attractive technique because it is a minimally invasive way to secure the intraocular lens (IOL) in the absence of adequate capsular support.1

We describe 2 cases of IOL dislocation in which the original cataract surgeries were performed 20+ years ago. Using the trailing-haptic-first modification of the Yamane technique, the IOLs were repositioned and secured.2 To the authors' knowledge, these are the first cases described in the literature of successful intrascleral haptic needle fixation of 20+-year-old IOLs.

Patient Consent Statement

Both patients provided written informed consent.

CASE REPORTS

Case 1

A 52-year-old woman was referred with a 3-week history of sudden loss of vision in the left eye from a dislocated IOL. Uncorrected distance visual acuity (UDVA) was 20/20 in the right eye and 20/100 in the left eye, and uncorrected near visual acuity was J2 in the right eye and J3 in the left eye. Corrected distance visual acuity (CDVA) was 20/20 with −0.25 +0.25 ×129 in the right eye and 20/70 with −3.00 +3.00 × 159 in the left eye.

The original cataract surgery was performed in 2001 with Rezoom (Abbott Medical Optics, Inc.) multifocal IOLs in both eyes (no records). Slitlamp examination showed a dislocated IOL in the left eye with the inferior haptic displaced within the anterior chamber (Figure 1, A). The examination was otherwise normal, and her intraocular pressure (IOP) was 19 mm Hg in the left eye.

F1
Figure 1.:
A: Surgeon view of dislocated multifocal IOL with the inferior haptic in the anterior chamber. B: Iris retractors are used to facilitate visualization for scleral suture lasso of the haptics. There was surprisingly very little peripheral posterior capsule support seen with complete absence of the anterior capsule rim. C: The IOL is well centered with scleral suture fixation using Gore-Tex. D: The suture knots are buried within the sclerotomies, and the conjunctiva is reapproximated.

The patient insisted on keeping the Rezoom IOL in the left eye since it had given her such good vision. Urgent IOL repositioning was performed using CV-8 Gore-Tex scleral lasso suture technique. Hooks were used to retract the iris and assess the capsular bag. There was an approximately 10 mm, circumferential posterior capsule defect without significant peripheral support (Figure 1, B). The procedure was performed uneventfully; however, the next day, the patient presented with 2+ central corneal edema with the entire IOL optic and inferior haptic displaced within the anterior chamber (Figure 1, C and D). After extensive discussion, the decision was made to attempt refixation of the IOL using intrascleral haptic needle fixation. The patient was informed of the procedure's nature and wished to proceed. The procedure went uneventfully (Video 1, https://links.lww.com/JC9/A365), and at postoperative week 4, the patient had a well-centered posterior chamber (PC) IOL, with haptics positioned parallel to the sclera, indicating a solid shelf of support, and flanges buried within the sclera (Figure 2, A–C). UDVA was 20/60, uncorrected near visual acuity was J1+, and manifest refraction was −1.75 sphere for 20/20. The IOP was 17 mm Hg, and the examination, including dilated retinal examination, was unremarkable.

F2
Figure 2.:
A: Well-centered scleral fixated multifocal IOL in the posterior chamber. B, C: Right and left haptic flanges are visible under the conjunctiva and flush to the sclera. Observe the haptics positioned along the scleral wall, indicating good scleral shelf support.

Case 2

A 77-year-old woman was referred for progressive bilateral blurry vision from dislocated PC IOLs. The original cataract surgeries were performed in the mid-1990s (no records) with SI30 IOLs (Allergan, Inc.). CDVA was 20/30 with −1.50 +1.00 × 080 in the right eye and 20/25 with −1.00 +0.25 × 135 in the left eye. Slitlamp examination revealed sunsetting PC IOLs, with 40% dislocation in the right eye and 60% in the left eye. Similar to case 1, both IOLs seemed to have minimal peripheral capsule support. Her IOP was 18 mm Hg in the right eye and 19 mm Hg in the left eye, and the examination was otherwise unremarkable except for 1 disc diameter of retinal pigment epithelial atrophy in the macula of both eyes.

The left eye IOL was exchanged uneventfully with an AR40e (Johnson & Johnson Vision) IOL using the trailing-haptic-first technique. The explanted SI30 IOL haptics and optic–haptic junctions were inspected and found to be sturdy when pulled with forceps. With this realization, the decision was made to attempt scleral fixation of the SI30 IOL in the right eye. The procedure was performed uneventfully (Video 2, https://links.lww.com/JC9/A366). CDVA at postoperative week 2 was 20/20 with −0.75 +0.75 × 055. The examination was otherwise unchanged, and the IOP was 14 mm Hg.

DISCUSSION

The decision to retain or remove a dislocated IOL is complex. Problems with the IOL optic may arise, such as silicone IOL opacification from silicone oil exposure during vitreoretinal surgery, or the IOL itself can cause poor vision, such as with positive dysphotopsia or aberrations from multifocality.3–5 On the contrary, even when the IOL provides good vision, malpositioning can cause rubbing against adjacent uveal tissue resulting in chronic cystoid macular edema or uveitis–glaucoma–hyphema syndrome.6 In these situations, the decision to explant is clearer.

If the IOL itself is not the cause for complication, retaining and repositioning may be a better option to minimize time and risk; however, the zonules and capsular bag need to be sufficiently stable to assure long-term stability.

Time-related IOL changes are well-documented in the literature. IOL optic opacification can occur years after IOL implantation: hydrophilic optics can calcify with or without exposure to air or gas, and hydrophobic IOLs can opacity without reason over time.7,8 Scanning electron microscopy of hydrophobic IOLs have shown time-related structural changes to IOLs with microvacuole formation years after implantation.9 These findings are not seen in IOLs that have not been implanted.

Although there are not as many reports in the literature regarding haptic durability, polyimide haptics have been shown to become brittle years after initial implantation and crumble into pieces with manipulation. There are even reports of spontaneous shattering of the haptics within the capsular bag leading to late IOL dislocation.10

To further complicate matters, cannulation of the trailing haptic second, as originally described by Shin Yamane, is more challenging and may require more aggressive manipulation of the haptic.11 This overmanipulation of the haptics in an existing dislocated IOL can be a potential problem if it breaks or becomes damaged during scleral fixation.

The primary challenge in case 1 is the patient's desire to keep the IOL. Scleral suture lasso technique failed despite proper execution of the technique. This may be because the L-shaped haptic configuration of the Rezoom IOL could have allowed it to rotate and slip away from the suture lasso (Figure 3, A). A glued IOL technique was another viable alternative, but this requires conjunctival dissection, scleral flaps, and fibrin glue.12 The trailing-haptic-first technique enabled easy needle cannulation and gentle handling of the trailing haptic by externalizing the leading haptic (Figure 4, A).

F3
Figure 3.:
A: Diagram illustrating the L-shaped configuration of the haptics (eg, Sensar AR40 IOL, Tecnis Z9002 IOL and ZA9003 IOL, CT-Lucia 602 IOL), which is well-suited for intrascleral haptic needle fixation. B: Diagram illustrating the C-shaped configuration of the haptics (MA60AC), which is poorly suited for intrascleral haptic needle fixation.
F4
Figure 4.:
A: Trailing-haptic-first modification with the Rezoom IOL: the leading haptic is carefully externalized, which enables easier cannulation of the trailing haptic with the right-side needle and gentler handling of the delicate PMMA haptics. B: Trailing-haptic-first modification with the SI30 IOL: the leading haptic is carefully externalized in a similar fashion. The polypropylene haptics are relatively robust and are less likely to be damaged when cannulating the haptics within the needles.

Since the IOL was not tangled in vitreous, the procedure was performed in a closed system using ophthalmic viscosurgical device to keep the anterior chamber formed without the need for an anterior vitrectomy, which is usually necessary for an IOL exchange. Unfortunately, we did not have access to records to know the preoperative refractive status. Fortunately, despite a more myopic result of −1.75 diopter sphere, the patient was pleased. If the patient was not pleased, we would have offered laser vision correction for the residual refractive error.

The patient in case 2 had bilateral dislocated IOLs and underwent an IOL exchange in the left eye for a Sensar AR40e IOL and repositioning in the right eye with the existing SI30 IOL, both using the trailing-haptic-first technique (Figure 4, B). The SI30 IOL also has an L-shaped configuration, which is well-suited for intrascleral haptic needle fixation (Figure 3, A). The polypropylene haptics were found to be thicker and stronger than the poly(methyl methacrylate) haptics of the Rezoom or AR40e IOL, and they tolerated needle cannulation without damage.

Regarding refractive outcome, both eyes had comparable results. UDVA was 20/25 in the right eye and 20/40 in the left eye, and the CDVA was −0.75 +0.75 × 055 with 20/20 in the right eye and −1.50 +0.75 × 120 with 20/20 in the left eye.

In case 1, the IOL appeared to be within the ciliary sulcus, while in case 2, both IOLs appeared to be tenuously supported with minimal peripheral capsule support. We were perplexed as to how these IOLs remained in position after all these years despite such poor capsule support. Both cases were ideal to attempt the trailing-haptic-first technique with the existing IOL because they were relatively free of capsule or vitreous material and the IOLs were easily prolapsed into the anterior chamber to externalize the leading haptic. Externalizing the leading haptic also provided added security by preventing the IOL from falling into the vitreous space.

It is essential to know not only the haptic material but also the design before considering scleral fixation of an existing IOL. As stated, IOLs with an L-shaped haptic design, such as the AR40e and CT Lucia 602, are better for intrascleral haptic needle fixation, rather than a C-shaped design, such as the MA60AC IOL (Alcon Laboratories, Inc.) (Figure 3, A and B).

In summary, rather than defaulting to explantation of a dislocated IOL, one should consider repositioning the existing IOL with the trailing-haptic-first modification for intrascleral haptic needle fixation technique as a potentially safer and more efficient option. This is particularly useful when the IOL is in the ciliary sulcus or within the capsular bag but can be easily freed from the bag. Knowing the type of haptic material is critical to know whether the haptic will tolerate surgical manipulation, and knowing the type of IOL is critical to ensure the lens has an L-shaped haptic configuration, which is better suited for intrascleral haptic needle fixation.

WHAT WAS KNOWN

  • Dislocated IOLs are typically removed and replaced with a new IOL.
  • The Yamane technique is technically challenging, and overmanipulation of the trailing haptic can lead to kinking or breaking of the haptics.
  • PMMA haptics are easily damaged with overmanipulation.

WHAT THIS PAPER ADDS

  • To the authors' knowledge, these are the first reported cases of dislocated 3-piece IOLs being repositioned using intrascleral haptic needle fixation with the trailing-haptic-first modification of the Yamane technique.
  • The polypropylene haptics of the SI30 IOL seemed to be sufficiently sturdy to undergo intrascleral haptic needle fixation.
  • The trailing-haptic-first technique enables gentle handling of a 20+-year-old Rezoom IOL with delicate PMMA haptics for safe intrascleral haptic needle fixation.

REFERENCES

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2. Kim DB. Trailing-haptic-first modification of double-needle intrascleral haptic fixation technique. J Cataract Refract Surg 2018;44:424–428
3. Kusaka S, Kodama T, Ohashi Y. Condensation of silicone oil on the posterior surface of a silicone intraocular lens during vitrectomy. Am J Ophthalmol 1996;121:574–575
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9. Bhattacharjee H, Buragohain S, Javeri HJ, Das D. Scanning electron microscopic features of explanted degraded hydrophobic acrylic intraocular lenses which were in vivo for a prolonged period. Indian J Ophthalmol 2020;68:1086–1089
10. Stallings S, Werner L, Chayet A, Masket S, Camacho F, Peck CC, Mamalis N. Intraocular polyimide intraocular lens haptic breakage long-term postoperatively. J Cataract Refract Surg 2014;40:323–326
11. Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged intrascleral intraocular lens fixation with double-needle technique. Ophthalmology 2017;124:1136–1142
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