SF in eyes with aphakia after cataract surgery

 SF IOL can be used for visual
rehabilitation for aphakia in both adults and children. There are different techniques
of performing SFIOL; suture fixation and
sutureless scleral fixation with a range of possible complications like lens
tilt, lens decentration and dislocation, suture exposure,
cystoids macular edema, glaucoma, and transient vitreous hemorrhage7,9.   Suture fixation may be 2 point or 4 point
but the two-point suture fixation carries a higher risk of axial IOL tilt. In
sutureless scleral fixation, IOL haptics are externalized and fixated within
the sclera without the use of sutures. In a study on “Comparison of sutured versus
sutureless scleral-fixated intraocular lenses”, Sindal et al have
concluded that the sutured technique and sutureless technique appear to be
equally good in eyes with aphakia after cataract surgery or trauma 10 .

With the reduced risk for corneal endothelial damage and secondary glaucoma, scleral-fixated IOL is a
preferred choice over other alternatives like iris-fixated IOL and AC IOL 11.

 In the present study, we have
shown the visual outcome and complications rates with a modified 4-point
fixation technique in postoperative and post-traumatic cases after more than 18
months of follow-up. In this study, out of 30 patients studied, when compared to
preoperative CDVA the post-operative CDVA improved in 24 patients (80%). This
is better compared to the study by Andrew et al,  where the CDVA was improved or unchanged in 59
eyes (71.9%).9 This is due to a large amount of cataract
surgery-related cases in our present study and trauma related cases being only
25%. The main advantages of this modified technique are the stability of the
IOL and non-exposure and non-erosion of the proline suture knot. The final
proline knot remains within the scleral tunnel without getting
exposed or causing any erosion. Covering the suture ends with a
triangular flap of sclera is a common technique. These triangular flaps atrophy
over a period and leave the suture ends exposed causing erosion. We did not see
a single case of suture exposure and suture erosion in the follow-up of our
cases. For the same reason, the risk of endophthalmitis is also reduced. In the
study by Andrew S. McAllister et al, there were 11% cases of polypropylene
suture exposure.9 The most common early complication that we have
seen in this series was ocular hypertension. All the 13 patients were managed
by anti-glaucoma medications with no case going into chronic glaucoma. Other
studies have also reported early complications. Long and colleagues in a study
of transscleral fixation in 48 patients, reported post-operative complications
like transient corneal edema in 37/48 eyes (77.1 %), temporary hypotony (6–10
mmHg) in 11/48 eyes (22.9 %), vitreous hemorrhage in 4/48 cases (8.3 %),
temporary intraocular pressure elevation in 8/48 eyes (16.7 %), and cystoid
macular edema in 5/48 cases (10.4 %).12 All these complications
resolved within 4 weeks. All the post-operative cases in our series were
managed by a secondary scleral-fixated IOL. When a posterior capsular rupture
occurs leaving an inadequate capsular support, the surgeon has to decide
whether to do a primary or a secondary implantation. The factors that affect
the decision-making process are the type of anesthesia, the general condition
of the patient and his compliance, the time spent in managing the complication.
The technique of scleral-fixated IOL requires
good surgical skills and meticulous maneuvering which are quite challenging in
a stressful situation of capsular rupture and poor patient compliance.
Scleral-fixated IOL is a prolonged procedure requiring some time in creating
scleral tunnels, tying the proline suture to the haptics and maneuvering and
positioning the IOL before tying the knot. Added to this; the time spent in
managing the cataract surgery and its complication makes it quite prolonged
increasing the possibilities of postoperative inflammation and cystoid macular
edema. Lee et al reported higher early postoperative complications and less
favorable visual outcome in primary scleral fixated IOLs.13 Suture
rupture is reported after many years of SF IOL implantation, particularly in
young individuals.3 We have not seen any case with this complication
in our follow-up of cases.

In the absence of an adequate capsular support, different IOL implantation
options are pursued. SF IOL, AC IOL, and iris-fixated IOLs have all been found
to be safe and effective in this setting.4

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Scleral-fixated PC IOL insertion can offer favorable visual outcomes, as
shown in this study using four-point fixation technique with proper case
selection, in cases of aphakia without adequate capsular support. Open-loop AC
IOLs or iris-claw lenses may also offer good visual outcome when there are no
contraindications to their use. This modified technique allows stable placement
of PC IOLs in a series of post-operative and post trauma aphakic eyes.
According to our data, parsplana anterior vitrectomy, four point fixation of
the IOL and placement of the knots inside the scleral pouches give a stable and
favourable outcome. The limitations of this study are its single surgeon,
heterogenous pre-operative indications and variable durations of follow-up. We
need a randomized study with a longer follow-up to show the safety and efficacy
of this procedure.