One complication after intraocular lens (IOL) implantation is dislocation of the IOL because of various causes. Depending on the IOL status and type, several treatment options exist for management.1–6 Dislocated IOL–capsular bag complexes or IOLs with closed-loop haptics can be reposited by suturing through the encapsulated haptics or the eyelets.7–9 The atypical intracapsular fixation technique uses 3 fixation haptics to secure a triple-looped haptic IOL. This method has the advantages of reducing the chances of IOL tilt and postoperative pupillary contact, improving IOL stability and centralization, and lowering the risk for pigment dispersion glaucoma and cystoid macular edema.10 To the authors' knowledge, no previous researchers have reported the reposition of a dislocated triple-looped haptic IOL. In this article we describe our experience using the single-string, closed-loop fixation technique to reposit dislocated triple-looped haptic IOL–capsular bag complexes. This technique requires less surgical skill and is minimally invasive because the surgeon does not need to separate the conjunctiva and create a scleral flap, pocket, or groove.
We performed a retrospective study on patients who underwent the single-string, closed-loop fixation procedure to reposit dislocated triple-looped haptic IOLs (CT ASPHINA 603P; Carl Zeiss Meditec AG) at Ningbo Eye Hospital (Ningbo, China) between June 2020 and March 2021. This study complied with the tenets of the Helsinki Declaration and was approved by the hospital's ethics committee. We enrolled patients by reviewing hospital medical records; patients with incomplete records were excluded. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
All procedures were performed by the same ophthalmologist (Q.-Y.Y.) with patients under retrobulbar anesthesia. The supplemental video (Video 1, https://links.lww.com/JRS/A597), as well as Figures 1 and 2 demonstrate the procedure. First, the patient underwent conventional 23-gauge 3-channel vitrectomy to remove the middle and peripheral portions of the vitreous. Under the guidance of an optical fiber, an intraocular forceps was used to place the triple-looped haptic IOL complex above the anterior chamber–iris to prevent it from falling back into the vitreous cavity. We used a marked disc with a scale to label the corneoscleral limbus at 2, 6, and 10 o'clock, corresponding to the 3 haptics of the IOL. Using either a double-curved needle or a needle with 1 straight end and 1 curved end with an 8-0/10-0 polypropylene suture (Ethicon; Johnson & Johnson Vision), we inserted at 2 mm posterior to the corneoscleral limbus at 2 o'clock and passed it through 1 eyelet of the IOL. A 27-gauge or 27/30-gauge needle was bent at the hub to serve as a guide needle. Next, we performed an ab externo penetration with the guide needle at the inferior fixation site 2 mm from the limbus at 10 o'clock, passing it through the other eyelet of the IOL. The tip of the long straight needle or the circular needle in the anterior chamber was then inserted into the guide needle using a needle-to-needle approach and then was guided out of the eye. The next step was to insert a long straight needle or circular needle into the exit point and 3 to 5 mm into the sclera at 2 mm posterior to the corneoscleral limbus. We then inserted the same needle into the eye again at the exit point. The eye was then punctured by a 27-gauge or 27/30-gauge guide needle that was inserted at 6 o'clock, 2 mm posterior to the temporal corneal limbus, and passed through the other eyelet of the IOL. The tip of the long straight needle or circular needle in the anterior chamber was inserted into the guide needle using a needle-to-needle approach and then was guided out of the eye. We inserted this needle at the exit point and passed it through the sclera parallel to the corneoscleral limbus several times before withdrawing it at the initial entry point. After adjusting the suture to center the IOL, we knotted the ends of the suture. Another overhand knot (anchor knot) was then created approximately 3 mm from the first. We used the same technique to bury the anchor knot as we did to insert the ends of the sutures into the scleral tunnel.11,12 At the end of the entire surgical procedure, we injected dexamethasone into the inferior subconjunctival space. Postoperatively, topical antibiotics and steroids were prescribed for 1 month.
We documented the following: (1) baseline characteristics; (2) preoperative measurements, including corrected distance visual acuity (CDVA), intraocular pressure (IOP), fundus examination, ocular ultrasound, fundus photography, and macular optical coherence tomography; (3) intraoperative measurements, including operative duration and complications; and (4) postoperative measurements at 1 week, 1 month, and 3 months, including CDVA, IOP, corneal endothelial cell counts, IOL position, fundus examination, ocular ultrasound, fundus photography, and macular optical coherence tomography.
Corneal endothelial cell density was assessed using a corneal endothelial microscope (SP3000P; Topcon Corp.). We evaluated the cornea in 5 areas: central-C, superior-S, temporal-T, nasal-N, and inferior-I. Each area was photographed and assessed according to the module in the system.
We included 4 patients in this study, 3 men and 1 woman. Their age range was 39 to 70 years (mean ± SD, 60 ± 10.3 years). The mean follow-up period was 12.7 (±1.8) months. Snellen visual acuity data were converted into logMAR. The preoperative uncorrected distance visual acuity and CDVA were 3.30 ± 3.95 and 4.7 ± 4.36, respectively; they were, respectively, 4.72 ± 4.3 and 4.79 ± 4.45 on examination at 1 month postoperatively. At the final follow-up visits, uncorrected distance visual acuity and CDVA were 4.72 ± 4.3 and 4.79 ± 4.45, respectively. No intraoperative complications were reported. The IOL remained centered throughout the follow-up period. We observed no erosion or exposure of the suture. No complications, such as low or high IOP, anterior chamber hemorrhage, vitreous hemorrhage, abnormal inflammation, cystoid macular edema, or retinal detachment, were reported during the postoperative follow-up period.
Dislocation of the IOL or IOL–capsular bag complex is a long-term complication after IOL implantation, commonly seen in patients with ocular contusion, high myopia, or Marfan syndrome.1–3 The treatment approach depends on the status and type of IOL.4 The conventional approach begins with removing the IOL or capsular bag complex, followed by the implantation of the IOL. Another approach is to simultaneously reposit and fix the IOL or IOL–capsular bag complex. Since the first report by Malbran et al., transscleral suture fixation of the posterior chamber IOL has become one of the most effective methods of scleral fixation.13 This technique requires exposure of the IOL haptics through the corneal/scleral incision for suture fixation and can also require conjunctival dissection, scleral groove incisions, and scleral flap creation.14,15 This refixation method is less invasive because it avoids a large corneal/scleral incision during IOL exchange. Recently, Silva et al. described a simple and practical surgical technique of intrascleral knotless zigzag suture fixation of the Akreos AO60 foldable IOL. IOLs do not need to be removed during the operation.16 To the authors' knowledge, no previous studies exist on the refixation of a dislocated triple-looped haptic IOL.
The triple-looped haptic IOL has ideal stability and less tilting risk because its 3 supporting haptics anchor the lens. It is often used in secondary IOL implantation after cataract extraction surgery.10 We designed a new surgical approach—the single-string, closed-loop fixation technique—to reposit a dislocated triple-looped haptic IOL or IOL–capsular bag complex. The outcomes in our patients were satisfactory.
The key points of this technique are as follows: (1) The 3 posterior scleral fixation points in the corneoscleral limbus must be accurately localized at equal distances before suturing, which stabilizes the IOL and helps avoid tilting. (2) As shown in Figure 2, A and C, the technique requires only 2 stitches, a guide needle, and a puncture needle (either long or circular). It has several advantages, including simplified surgical steps and easy manipulation. In addition, it does not require the surgeon to pull the haptics out of the eyeball and repeatedly penetrate the eyeball with a long needle. (3) The fixed anchoring points are the sutures passed within the sclera (Figure 2, B and D). There is no large conjunctival or scleral incision, which minimizes surgical trauma.17,18 (4) As shown in Figure 2, E, the suture is knotted at both ends, which allows the surgeon to adjust the tension at both ends to center the IOL before fixation. (5) The second knot is approximately 3 mm from the first, allowing the surgeon to anchor the suture ends within the sclera without creating a scleral flap, capsule, or groove. In Figure 2, F, the second knot is anchored within the scleral layers by friction to avoid its exposure and erosion.19 The procedure requires no large conjunctival incision, scleral flap, or scleral groove, nor any suture or knot exposed on the scleral surface. (6) This technique uses 3 anchoring points to secure a triple-looped haptic IOL, improving the stability of the IOL and preventing it from tilting.
Limitations of the current study included its retrospective design, a small sample size, and a single-center approach. Future prospective studies with large sample sizes are required to confirm our results.
In summary, we designed a new minimally invasive surgical approach, a single-string, closed-loop fixation technique, to reposit and secure a dislocated triple-looped haptic IOL or IOL–capsular bag complex. Our experience showed that this approach was safe and that it achieved satisfactory outcomes in affected patients.
WHAT WAS KNOWN
- Dislocated triple-looped haptic IOL–capsular bag complexes or IOLs are most often treated with 23-gauge vitrectomy combined with IOL extraction or 3 points of transscleral suture fixation of the IOL.
WHAT THIS PAPER ADDS
- Possible advantages of a single-string, closed-loop fixation technique for dislocated triple-looped haptic IOL–capsular bag complexes or IOLs were a shorter surgical duration and a simplified operation process. During all follow-up visits, the IOLs were well centered and stable. The technique is safe and that it achieved satisfactory outcomes in affected patients.
1. Mizuno Y, Sugimoto Y. A comparative study of transscleral suture fixated and scleral-fixated intraocular lens implantation. Int Ophthalmol 2018;1:1–7
2. Davis D, Brubaker J, Espandar L, Stringham J, Crandall A, Werner L, Mamalis N. Late in-the-bag spontaneous intraocular lens dislocation: evaluation of 86 consecutive cases. Ophthalmology 2009;116:664–670
3. Dabrowska-Kloda K, Kloda T, Boudiaf S, Jakobsson G, Stenevi U. Incidence and risk factors of late in-the-bag intraocular lens dislocation: evaluation of 140 eyes between 1992 and 2012. J Cataract Refract Surg 2015;41:1376–1382
4. Price MO, Price FW Jr, Werner L, Berlie C, Mamalis N. Late dislocation of scleral-sutured posterior chamber intraocular lenses. J Cataract Refract Surg 2005;31:1320–1326
5. Pueringer SL, Hodge DO, Erie JC. Risk of late intraocular lens dislocation after cataract surgery, 1980-2009: a population-based study. Am J Ophthalmol 2011;152:618–623
6. Sarrafizadeh R, Ruby AJ, Hassan TS, Williams GA, Garretson BR, Trese MT, Margherio RR. A comparison of visual results and complications in eyes with posterior chamber intraocular lens dislocation treated with pars plana vitrectomy and lens repositioning or lens exchange. Ophthalmology 2001;108:82–89
7. Chan CC, Crandall AS, Ahmed II. Ab externo scleral suture loop fixation for posterior chamber intraocular lens decentration: clinical results. J Cataract Refract Surg 2006;32:121–128
8. Hoffman RS, Fine IH, Packer M. Scleral fixation without conjunctival dissection. J Cataract Refract Surg 2006;32:1907–1912
9. Chung EJ, Kim CY, Koh HJ. Ab externo direct suture technique for dislocated intraocular lens. J Cataract Refract Surg 2007;33:955–958
10. Ni S, Wang W, Chen X, Wu X, He S, Ma Y, Xu W. Clinical observation of a novel technique: transscleral suture fixation of a foldable 3-looped haptics one-piece posterior chamber intraocular lens implantation through scleral pockets with intact conjunctiva. BMC Ophthalmol 2019;19:105
11. Hu X, Zhao B, Jin H. Intrascleral suture anchoring: a flapless/grooveless four-point intraocular lens fixation technique. J Ophthalmol 2020;2020:6642007
12. Zhang Q, Zhao P, Jin H. Intraocular suture looping and overhand friction knot: a flapless technique to refixate dislocated intraocular lenses. Retina 2019;39(suppl 1):S62–S67
13. Malbran ES, Malbran E Jr, Negri I. Lens guide suture for transport and fixation in secondary IOL implantation after intracapsular extraction. Int Ophthalmol 1986;9:151–160
14. Buckley EG. Safety of transscleral-sutured intraocular lenses in children. J AAPOS 2008;12:431–439
15. Long C, Wei Y, Yuan Z, Zhang Z, Lin X, Liu B. Modified technique for transscleral fixation of posterior chamber intraocular lenses. BMC Ophthalmol 2015;15:127
16. Nisa S, André F, Natália F, Bernardete P. Intrascleral knotless zigzag suture fixation of four-haptic hydrophilic acrylic foldable IOL: clinical outcomes. Clin Ophthalmol 2022;16:33–41
17. Huang L, Zhang Q, Jin HY. Intrascleral sewing-machine technique: a Grooveless/flapless cyclopexy technique for large traumatic cyclodialysis cleft repairs in pars plana vitrectomy. Retina 2020;00:1–6
18. Jin H, Zhang Q. Flapless intrascleral knotting technique for suture fixation of intraocular implants. Retina 2020. DOI: 10.1097/IAE.0000000000002895
19. Oskala P. Friction knot to fixate scleral sutures. J Cataract Refract Surg 2015;41:497–500