Dr. Madhu Kumar R, K16490, Dr.Pradeep Sagar, Dr. Kaustubh Balwant Harshey, Dr.Manish Saxena ,Dr Madhu Kumar R, Dr Pradeep Sagar, Dr Kausthubh B Harshey, Dr Manish Saxena
Introduction:
Purpose :
To evaluate safety and efficacy of internal fixation of posteriorly dislocated IOL in comparison with conventional technique.
Retrospective study of 45 eyes with dislocated IOL with Dialling holes. groupA(21) underwent pars plana vitrectomy + IOL removal followed by conventional SFIOL in the same sitting . Group 2(24) underwent vitrectomy+PFCL floatation of IOL and scleral fixation of the same IOL by passing 9-0 poly propelene suture through the dialling holes. All the manoeuvres are done with IOL in Vitreous cavity. Outcome measures included BCVA, astigmatism, duration of surgery and complications.
Mean operative time and induced astigmatism of group 2(39 ±5.37 min) &(-0.12±.06D) was significantly less than group 1( 58.87±5.21min) & (– 1.50 ±0.86D) respectively. Other parameters were comparable between the groups.
Conclusion :
The internal fixation technique obviates the reopening or making the fresh tunnel to explant the IOL and hence decreases the tunnel related complications.
Intraoperative dislocation of the intraocular lens (IOL) in routine cataract surgery is a rare but potentially dangerous complication. While dropped and retained crystalline lens fragments are commoner with phacoemulsification, dropped IOL is seen more frequently with extracapsular cataract extraction (ECCE) and small incision cataract surgery (SICS) especially in the hands of beginners, trainees and in the setting of a teaching institution. Numerous techniques have been described to handle this complication, most commonly being explantation of the IOL via a limbal incision and supplanting it with a secondary iris or scleral fixated lens. We describe a unique way of internally fixing a dropped rigid IOL with dialing holes using the pars plana approach.
Materials and Methods:
This is a Retrospective, comparative case series. All patients with posteriorly dislocated IOL following routine cataract surgery were included in the study. Cases with spontaneous dislocation due to zonulopathies such as pseudoexfoliation were also included. We excluded patients with foldable IOLs, rigid IOLs without dialing hole, post-traumatic dislocation, preexisting amblyopia, pediatric patients and concurrent posterior segment pathology precluding visual improvement. After applying the said criteria, 45 eyes of 45 patients were included in the study divided in to 2 groups. groupA (21) underwent pars plana vitrectomy + IOL removal followed by conventional SFIOL in the same sitting. Group 2 (24) underwent vitrectomy+PFCL floatation of IOL and scleral fixation of the same IOL by passing 9-0 poly propelene suture through the dialling holes.
The technique of internal fixation ( group 2 )
All patients underwent a complete ophthalmic examination with special emphasis on the presence or absence of capsular support, nature of primary surgical incision, anterior hyaloid status, nature of the dropped IOL, preoperative refraction BCVA ( Log MAR), keratometry, specular microscopy and detailed fundus evaluation. Eligible patients underwent a standard three port pars plana vitrectomy with 23 gauge system. Before creating the ports, two diagonally opposite sclera grooves were made 2mm from the limbus parallel to it depending on the location of the primary incision after conjunctival peritomy. After core vitrectomy, posterior vitreous detachment was induced. The vitreous around the IOL was trimmed freed of surrounding adherent vitreous with the cutter. The IOL was levitated using perfluorocarbon liquids (PFCL) and brought up to the anterior vitreous. Then, using a 26 gauge needle and double armed 9-0 polypropylene sutures with straight needles the IOL dialing hole was threaded through one edge of the sclerotomy and the suture externalized through the opposite 23 G port, using 26 G needle by Docking the suture needle. The suture path was reversed through the port in to the anterior vitreous cavity and externalized through the other edge of the sclerotomy by docking in to the 26 needle, thus completing the loop for sclera fixation through the dialing hole. Similarly, the other dialing hole was engaged. The polypropylene suture was tied with multiple throws in the sclera groove an IOL centration was confirmed. This was followed by fluid-PFCL exchange and the surgery was completed.
The patients were followed up on the first day, first week, one month, three months, six months and one year post surgery. The primary outcome measures were change in best corrected visual acuity (BCVA) and surgically induced astigmatism (SIA). The secondary outcome measures were the duration of surgery and incidence of any complications. Statistical analysis was done using “t” test.
Results:
Mean age group was comparable, average duration from the time primary of surgery was (15.34 ± 2.3) & (17.24±3.6) in groups 1 & 2 respectively (p > 0.5)
Mean presenting BCVA in group 1 was (0.4 ± 0.36) which improved to (0.17±0.42) in group 1 p<0.05
Mean presenting BCVA in group 2 was ( 0.42±0.29) which improved to ( 0.18±0.35) in group 2 p<0.05
Both groups achieved the pre operative BCVA at 4 weeks and further follow ups, there was no statistical significance.
Surgical induced astigmatism was avg (– 1.50 +/- 0.86D) range (-0.5 D to -7D) in group 1 as compared to avg (0.12D +/- 0.06D) range (0.00 – 0.50) less in group 2 which was Statistically significant.
Mean operative time in group 2 (39 ±5.37 min) was significantly less compared to that of group 1 ( 58.87±5.21min)
No significant IOL tilts were noted in either groups
Complications were divided into intra operative, immediate and delayed complications.
Intraoperative complications included iridodialysis (0/21 in group 1 and 1/24 in group 2), seeped in vitreous hemorrhage (1/21 in group 1 and 1/24 in group 2). Complication like ciliarybody dialysis was not encountered.
Immediate complications included corneal edema (2/21 in group 1 and 3/24 in group 2)
Delayed complications included pigment dispersion on IOL (1/21 in group 1 and 2/24 in group 2), CME (2/21 in group 1 and 3/24 in group 2) and was comparable in either groups.
Neither IOL dislocations/ decentrations nor any sight threatening complications like retinal detatchments or endophthalmitis were noted in either groups.
Discussion:
The conventional method of managing a posteriorly dislocated IOL is explantation with pars plana vitrectomy followed by either primary or secondary implantation of a sclera fixated IOL (SFIOL) or an iris supported IOL. This involves creation of a new incision or reopening of the primary incision to deliver out the IOL which is plagued by unstable intraocular pressure control, corneal trauma, postoperative astigmatism and related complications. It also means additional expenditure on the procurement of a new IOL for this purpose.
Because of the above reasons recent studies have tried to describe various ways of repositioning and internally fixing the dropped IOL without the risk of above mentioned complications. Lawrence et al described the use of lasso technique by anchoring the IOL haptic to the sclera sulcus by means of 9-0 polypropylene sutures.1 A modified technique of securing the haptics by cow-hitch sutures has also been reported.2 Temporary externalization of the IOL haptic through a small clear corneal incision and then suturing it to the sclera sulcus has been described by Nikeghbali et al.3 Controversial techniques such as heating the IOL haptic to form a knob have also been published.4 Recently, iris suture fixation of posteriorly dislocated IOL has been described by Soiberman et al.5 There is also a report mentioning refixation of the dropped IOL by sutureless glued IOL technique.6
Our technique, to the best of our knowledge hasn’t been previously reported. Majority of the refixation techniques involve anchoring the haptic with a 10-0 polypropylene suture.3 This provides a theoretically less stable and more often a two point fixation of the IOL. We used the dialing holes of the IOL optic to thread a 9-0 polypropylene suture and potentially achieved a four point fixation. Using the optic as a support also ensures lesser tilt which was evident from the lesser IOL induced astigmatism in our series as compared the conventional method. The 9-0 suture is sturdier and hence the chances of suture erosion and spontaneous suturolysis are reduced. In our longest follow up, we didn’t have a single case of suture related complications.
Our study was limited by its retrospective design and the limitation of only refixing the IOLs with dialing holes. In the future studies maybe planned to design a comparative analysis between various techniques of IOL re fixation in order to minimize tissue and IOL handling and maximize outcomes.
Conclusion : The novel technique described aims at minimal tissue handling, minimizes tunnel related complications and the induced astigmatism, in cases with dislocated IOL dialing holes.
References:
- Lawrence FC 2nd, Hubbard WA. “Lens lasso” repositioning of dislocated posterior chamber intraocular lenses. 1994;14(1):47-50
- Soiberman U, Gehlbach PL, Murakami P, Stark WJ. Pars plana vitrectomy and iris suture fixation ofposteriorly dislocated intraocular lenses. J Cataract Refract Surg. 2015 Jul;41(7):1454-60.
- Mensiz E, Aytuluner E, Ozerturk Y. Scleral fixation suture technique withoutlens removal for posteriorly dislocated intraocular lenses. Can J Ophthalmol. 2002 Aug;37(5):290-4.
- Nakashizuka H, Shimada H, Iwasaki Y, Matsumoto Y, Sato Y. Pars plana suture fixation forintraocular lenses dislocated into the vitreous cavity using a closed-eye cow-hitch J Cataract Refract Surg. 2004 Feb;30(2):302-6.
- Nikeghbali A,Falavarjani KG. Modified transscleral fixation technique for refixation of dislocated intraocular lenses. J Cataract Refract Surg. 2008 May;34(5):743-8.
- Agrawal A, Dhivya AK. Sutureless 20-gauge vitrectomy can be used to reposition dislocated IOL. Ocular Surgery News U.S. Edition, August 10, 2009