In the absence of posterior capsule support, there are 3 methods to secure an intraocular lens (IOL): a posterior chamber IOL (PC IOL) suture fixated to the iris; a PC IOL suture fixated to the sclera; an anterior chamber IOL (AC IOL) placed in the anterior chamber. Many studies have documented the effectiveness of these techniques; however, there is no consensus on which technique produces the optimal outcomes. Several studies report successful outcomes regarding visual acuity and rates of graft survival, cystoid macular edema (CME), and intraocular pressure (IOP) rise using 1 or more of these techniques of securing IOLs.1–4
In 567 eyes with pseudophakic or aphakic bullous keratopathy that had penetrating keratoplasty with suture fixation of a PC IOL to the iris, Price and coauthors4 report long-term graft survival of 98% and 92% at 2 years and 5 years, respectively. This is higher than that reported by Lois and coauthors3 in a study of eyes with open-looped AC IOLs (87% and 65% at 2 years and 6 years, respectively). In 102 patients with scleral-fixated PC IOLs, Holland et al.5 report a graft survival rate of 97% at approximately 2 years. However, Heidemann and Dunn,6 using a scleral-fixation method, report a lower rate of graft survival, 89%, in 56 patients at approximately 1 year.
In the only prospective randomized study comparing the 3 techniques, suture fixation of a PC IOL to the iris was shown to have a significantly lower risk for CME (P=.04) and a significantly lower complication index.7
One complication that can be especially problematic is intraoperative or postoperative hemorrhage. Although the rate of bleeding is usually relatively low with all 3 techniques, it can be significantly increased in anticoagulated patients. Spontaneous hyphemas resulting from warfarin sodium (Coumadin®) have been reported as well as Coumadin-related bleeding associated with iris-clip and sulcus-fixated IOLs.8,9 Furthermore, hyphema or vitreous hemorrhage can result in prolonged decreased vision, ghost cell glaucoma secondary to vitreous hemorrhage, and elevated IOP from a hyphema. Several studies show a significant incidence of anterior chamber or vitreous hemorrhage with transscleral suture-fixated PC IOLs.10–13 Hemorrhage with scleral fixation is usually caused by the blind pass of the needle behind the iris and presumably through the ciliary sulcus. Unfortunately, the lack of visualization can lead to accidental puncture of the highly vascular ciliary body.
This article describes a method of suture fixating silicone PC IOLs to the iris from a limbal approach and reports the outcomes in anticoagulated patients.
Patients and Methods
A retrospective review of all patients from 1 surgeon's practice (F.W.P.) was conducted to identify those who were anticoagulated with Coumadin while having suture fixation of a silicone PC IOL to the iris through a limbal incision. Seven eyes of 5 patients were identified.
Of the 7 eyes, 5 had a 3-port pars plana vitrectomy, intracapsular cataract extraction, and suture fixation of a 3-piece silicone IOL to the iris from a limbal approach. Of these 5 eyes, 3 had been diagnosed with phacodonesis and 2 had a subluxated lens resulting in decreased vision, distortion, and monocular diplopia. The sixth eye had pars plana vitrectomy and iris fixation of a silicone PC IOL from a limbal approach secondary to aphakia and contact lens intolerance. The seventh eye had the same procedure with removal of a dislocated PC IOL (Table 1).
The 3-piece silicone PC IOL has a 6.3 mm optic, 12.5 mm overall length, and 0-degree modified C-loop haptics (model AQ2003V, Staar Surgical Co.). With this lens, the positioning hole is formed by passing the needle through the soft silicone optic; therefore, no sharp edges or suture abrasions occur.
The iris-sutured IOL technique from a limbal approach has been described.14 In brief, a 7.0 to 9.0 mm incision is created 1.0 mm posterior to the limbus and a beveled incision is carried forward to form a 3-step wound. A 3-port pars plana vitrectomy is then performed, removing the vitreous. A 9-0 polypropylene (Prolene®) suture on a 4.0 mm straight taper needle (Ethicon D-9904) is passed through the midperipheral iris at the 9 o'clock position using a Sutherland microforceps (#612.91, Grieshaber & Co.). A second suture is similarly passed through the midperipheral iris at the 3 o'clock position. The sutures are pulled back through the iris as the needle is retrieved through the pupil (Figure 1, upper and middle). Each suture needle is passed down through the optic of the PC IOL, penetrating the soft silicone at the periphery and then back up through the optic about 0.5 mm away. A loose loop tie is placed in each suture, and the PC IOL is inserted through the limbal incision to a position posterior to the iris. The IOL is oriented so the haptics are at the 3 and 9 o'clock positions. The knots are tied between the iris and the anterior surface of the optic (Figure 1, lower).
All patients were examined 1 day and 1 week after surgery. They were then seen as required for routine postoperative care.
The mean follow-up of the 7 eyes was 10.7 months (range 6 to 25 months) (Table 1). The mean age of the patients was 47.8 years (range 28 to 74 years). The reasons for anticoagulation therapy were Marfan's syndrome with aortic valve replacement (n = 3), a history of venous thrombosis and pulmonary embolus (n = 1), and severe cardiac disease and chronic atrial fibrillation (n = 1).
Intraoperatively, there were no intraocular hemorrhages. At each successive postoperative examination, no blood was noted in the anterior chamber or posterior segment in 6 of 7 eyes.
In eye 2, a nonlayering hyphema and a new superior bleb were noted 6 weeks postoperatively. The hyphema resolved within 1 week and did not recur over a 23-month period. It was believed that the hyphema was not a result of the iris-fixated PC IOL but rather secondary to trauma to the limbal wound, resulting in light bleeding from episcleral vessels into the anterior chamber. This is supported by the fact that when the hyphema was present, a superior filtering bleb developed over the limbal wound. The filtering bleb eventually lead to hypotony maculopathy and subsequent wound revision.
Pseudophacodonesis or lens decentration did not occur at any time during the follow-up (Figure 2), and there was no significant difference between the mean preoperative IOP (14.4 mm Hg) and the mean postoperative IOP (12.9 mm Hg). Iris depigmentation secondary to midperipheral suture placement was minimal at 12 months (Figure 3).
The visual acuity was 20/40 or better in all eyes at the last follow-up.
There is considerable debate about which technique of IOL fixation in the absence of capsule support gives the most favorable outcomes. Many physicians, as we do, favor using a PC IOL for many reasons. Its location behind the iris is the natural plane of the lens, it is closer to the nodal point of the eye, and it is situated farthest from the corneal endothelium.
Many studies report comparable results in postoperative visual acuity, graft clarity, and IOP change with iris-fixated and scleral-fixated PC IOLs.1–7,11–13,15–19 However, when evaluating which technique is most appropriate, the anticoagulated patient deserves special consideration. Intraoperative and postoperative bleeding can be sight threatening, and the risk is maximized in patients who are anticoagulated. There have been several reports demonstrating increased intraocular bleeding in patients on Coumadin.8,9,20
When suture fixating a PC IOL to the sclera, a blind needle passed through the ciliary sulcus region can accidentally perforate the highly vascular ciliary body, resulting in intraoperative or postoperative hyphema or vitreous hemorrhage. Several studies report a relatively high incidence of intraocular bleeding from transscleral PC IOL fixation (Table 2). 10–13 The incidence of intraocular hemorrhage appears to be much less with suture fixation of a PC IOL to the iris; there is only 1 report describing a hyphema after suture fixation to the iris.21 Moreover, at our practice, approximately 2000 IOLs have been suture fixated to the iris. Postoperative hyphema has not been a problem.
In this study of anticoagulated patients, who are at greatest risk for surgically induced bleeding, no cases of intraoperative bleeding occurred and there was only 1 case of a late postoperative hyphema secondary to limbal wound trauma. The lack of bleeding encountered is partly the result of penetration through a relatively avascular midperipheral iris.
Furthermore, we believe that the lack of postoperative bleeding, even at 19 months, was the result of the 0-degree haptics and 12.5 mm diameter of the 3-piece silicone IOL. In a study of postmortem eyes with iris-sutured PC IOLs, Apple et al.22 found that in most cases, the only means of support for the lens was the fixation suture. In addition, they report that in almost all cases, the IOL haptics were suspended behind the iris and ciliary body and not located in the ciliary sulcus, minimizing uveal contact and ciliary body erosion from the haptics. Several studies describe recurrent hyphemas and microhyphemas secondary to sulcus-fixated haptics contacting the peripheral iris.23–25 That the haptics of the 3-piece silicone IOL are not angulated toward the posterior iris may minimize iris chafing and subsequent bleeding. Furthermore, the overall diameter of 12.5 mm conforms well with the reported ciliary ring diameter of 11.5 to 12.5 mm.22,26 Larger IOLs of 13.75 to 14.50 mm diameter have been reported to extend through the zonules onto the pars plana.27 In a series of 65 postmortem eyes, Champion and coauthors28 found ciliary body erosion in 54% and obliteration of the major arterial circle of the iris in 17%. Attempts to prevent these problems could be of significant benefit in reducing the chance of hemorrhage, especially in patients predisposed to enhanced bleeding.
We chose to suture fixate lenses with a silicone instead of poly(methyl methacrylate) (PMMA) optic to minimize the risk of long-term suture breakage. Previous studies report breakage of 9-0 Prolene fixation sutures on iris-fixated PMMA lenses, presumably as a result of the edge of the “positioning hole” rubbing against the suture.15,29 These suture breakages typically occur 8 to 10 years after implantation. With a silicone optic, the positioning hole is formed by passing the needle through the soft silicone; therefore, no sharp edges or abrasions of the suture occur. The technique could be performed with other IOLs with soft optics such as acrylic lenses. However, we recommend using lenses with rigid haptics and not 1-piece foldable IOLs as these lenses, at least the plate-haptic type, lead to significant pseudophacodonesis. In our experience, pseudophacodonesis does not routinely occur with 3-piece lenses that are suture fixated to the iris.
None of the 7 treated eyes in the anticoagulated patients developed CME, which is consistent with findings that suture fixation of a PC IOL to the iris incurs a significantly lower risk for CME and other complications than scleral fixation of a PC IOL or placement of an AC IOL.7
In conclusion, our study further supports the low incidence of intraocular hemorrhage with suture fixation of a PC IOL to the iris. We believe this is the technique of choice for anticoagulated patients lacking capsule support.
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