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Original Article
Primary and Secondary Implantation of Scleral‑Fixated
Posterior Chamber Intraocular Lenses in Adult Patients
Zuleyha Yalniz‑Akkaya, Ayse Burcu, Guner O. Uney, Iskan Abay, Umit Eksioglu, Mehmet Akif Acar, Firdevs Ornek
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ABSTRACT
Purpose: The purpose of this study is to evaluate and to compare the results of primary and
secondary scleral‑fixated posterior chamber intraocular lens (PCIOL) implantations in adult
patients.
Materials and Methods: A retrospective analysis of scleral‑fixated PCIOLs‑implanted
during (primary group) or after (secondary group) cataract surgery was performed. The
median follow‑up time of 96 patients was 6 months (minimum: 6; maximum: 35 months).
Outcome measures were indications, corrected distance visual acuity (CDVA), change in
visual acuity and complications.
Results: A total of 37 patients (38.5%) had primary implantations and 59 (61.5%) had
secondary implantations. Penetrating keratoplasty was combined with secondary
implantation in 13 cases. The median post‑operative CDVA was 0.5 in decimal notation
in both groups (P = 0.576). The CDVA improved by at least one Snellen line or remained
unchanged in 35 eyes (94.6%) in the primary group and in 52 eyes (88.1%) in the secondary
group (P = 0.263). Eyes with CDVA of 0.5 or higher were 62.2% (n = 23) in the primary group
and 67.8% (n = 40) in the secondary group post‑operatively (P = 0.066). The difference in early
and late complications were not statistically significant between groups (P = 0.637, P = 0.154,
respectively). Regarding late complications, 30 eyes (81%) in the primary group and 40
eyes (67.9%) in the secondary group had no complications (P = 0.154).
Conclusion: Both primary and secondary scleral‑fixated PCIOL implantations can provide
favorable visual outcomes with lower complication rates. An important consideration is the
appropriate timing for scleral fixation, taking into account the patient’s characteristics and
the course of the operation.
Website:
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DOI:
10.4103/0974-9233.124093
Quick Response Code:
Key words: Aphakia, Subluxated Crystalline Lens, Subluxated Intraocular Lens, Traumatic
Crystalline Lens Subluxation, Traumatic Intraocular Lens Subluxation
INTRODUCTION
I
n the absence of adequate lens capsular support during cataract
surgery, the decision should be made whether to perform a
primary implantation at the same session or a secondary
implantation after a period of time.1‑3 Implantation of an anterior
chamber intraocular lens (ACIOL) is associated with a relatively
high rate of complications.4‑7 Several reports concerning
scleral‑fixated posterior chamber intraocular lenses (PCIOL)
have been reported with mostly favorable results.4,8‑11 However,
the surgical technique of scleral‑fixated PCIOL insertion is
more technically demanding.11‑13 Histological studies of the
anterior segment showed that the best position in these eyes is
sulcus fixation.14,15 The purpose of this study was to compare
the outcomes of primary and secondary scleral‑fixated PCIOL
implantations in adult patients.
MATERIALS AND METHODS
This study was approved by the institutional board. A chart
Ophthalmology Department, Ankara Training and Research Hospital, Ankara, Turkey
Corresponding Author: Dr. Zuleyha Yalniz‑Akkaya, Yukariovecler Mah, 1238 Cad, 12/34, Cankaya, TR06520 Ankara,
Turkey. E‑mail: [email protected]
44
Middle East African Journal of Ophthalmology, Volume 21, Number 1, January - March 2014
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Yalniz‑Akkaya, et al.: Scleral‑Fixated Intraocular Lens Implantation
review was performed of the medical records of 96 patients
who underwent scleral‑fixated PCIOL implantation between
April 2004 and September 2009 with follow‑up for at least
6 months. A total of 32 patients (33.3%) were females
and 64 (66.7%) were men. The median age at the time of
implantation was 67 years (minimum [min]: 17 years; maximum
[max]: 86 years). The median follow‑up was 6 months (min:
6 months; max: 35 months).
The indications for scleral‑fixated intraocular lens (IOL)
implantation were extensive capsular deficiency precluding
safe and stable IOL implantation in the bag or in the sulcus,
corneal decompensation due to ACIOL, IOL subluxation,
crystalline lens subluxation or contact lens intolerance. Uveitis,
endothelial dysfunction corneal dystrophy, retinal hole, subretinal
fluid, extensive lattice degeneration or major retinal diseases
were contraindications for scleral‑fixated PCIOL insertion.
The decision for primary or secondary implantation was made
according to the type of anesthesia, patient comfort and general
medical stability of patient and preference of individual surgeon.
All patients were informed about complications of the procedure
and the possible need for future IOL removal or exchange and
written informed consent was obtained pre‑operatively.
IOL powers were calculated using the Sanders‑Retzlaff‑Kraff II
formula. In primary implantation, the IOL power was adjusted
according to the A‑constant of the scleral‑fixated IOL selected
for implantation. The surgical maneuvers used for each surgery
have been documented.16 In primary scleral‑fixated PCIOL
implantation, the corneal incision performed for cataract
extraction was used or the wound was enlarged to 8 mm
in phacoemulsification cases. In secondary scleral‑fixated
PCIOL implantation, the conjunctiva was opened and triangular,
partial thickness scleral flaps were created at the 8 O’clock
and 2 O’clock positions. A superior three‑laminar corneal
incision was performed and an ocular viscoelastic device was
injected into the anterior chamber. In phakic patients, cataract
surgery was performed by phacoemulsification, extracapsular or
intracapsular extraction. Subluxated IOL were explanted through
the anterior incision. Anterior vitrectomy was performed in all
cases during the primary scleral‑fixated IOL implantation
and as warranted, during the secondary implantation with a
vitrector. A 10‑0 polypropylene suture on curved needles (PC‑9;
Alcon Laboratories, Inc., Texas, USA) was tied to the eyelets
of the haptics of a polymethylmethacrylate lens (CZ 70 BD;
Alcon, Fort Worth, Texas, USA). A guide needle (27 gauges)
was inserted from the sclera to the ciliary sulcus 0.8‑1.0 mm
from the limbus while remaining under the flap, measured
by a caliper from the corneoscleral limbus and marked by
pressing the corresponding arm of the caliper to the sclera.
The tip of the fixation needle was engaged in the opening of
the guide needle and pulled from ciliary sulcus to exit the eye.
The same procedure was performed with the second fixation
needle. The IOL was introduced into the eye. By pulling
both of the sutures, the haptics were drawn into the ciliary
sulcus. The cornea was sutured using 10‑0 monofilament nylon
suture (Alcon Laboratories Inc., Texas, USA) in a continuous
fashion. The polypropylene sutures were tied and left long under
the triangular scleral flaps. The scleral flaps and conjunctival
incisions were closed using 10‑0 monofilament nylon sutures.
At the end of the surgery, subconjunctival corticosteroids and
antibiotics were injected.
Post‑operative examinations were performed at 1 day, 1 week,
4 weeks, 3 months, and 6 months post‑operatively. Thereafter,
examinations were scheduled at approximately 6‑month
intervals. Post‑operatively, topical antibiotics (four times/day)
were used for 2 weeks and corticosteroids (four times/day) were
used for 1 month and tapered thereafter. Anti‑glaucomatous
medications were used when required.
Main outcome measures were age, gender, follow‑up time,
pre‑operative and post‑operative corrected distance visual
acuity (CDVA), change in visual acuity and complications. Outcome
measures (unless noted otherwise) were those obtained at the
most recent follow‑up examination. Visual acuities were measured
and reported in decimal units. Visual acuities were converted
to the logarithm of the minimum angle of resolution (logMAR)
units for statistical analysis. Visual acuity of counting fingers was
converted to 2.00 logMAR and hand motion was converted to
3.00 logMAR.17 No patient had a perception of light with or
without projection.
Data analysis was performed using the statistical package for
social sciences for Windows software (SPSS version 16.0, SPSS
Inc., Chicago, USA). Normality distribution of continuous
variables (age, follow‑up time, pre‑operative and post‑operative
CDVA), was tested by Kolmogorov‑Smirnov test, histogram and
P‑P plots. As all continuous variables were distributed abnormally,
descriptive statistics were demonstrated as median (min‑max).
Mann‑Whitney U test was used to compare the continuous
variables between the groups. Categorical variables were
presented as frequency (%). Pearson Chi‑square test was used
to compare the categorical variables between the groups.
RESULTS
The scleral‑fixated PCIOL implantation was performed in
37 patients (38.5%) as primary implantation (primary group)
and in 59 patients (61.5%) as secondary implantation (secondary
group). Penetrating keratoplasty was combined with secondary
implantation in 13 cases.
The median age was 69 years (min: 24; max: 86 years) and
67 years (min: 17; max: 85 years) in the primary group and
Middle East African Journal of Ophthalmology, Volume 21, Number 1, January - March 2014
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Yalniz‑Akkaya, et al.: Scleral‑Fixated Intraocular Lens Implantation
secondary group, respectively (P = 0.89, Mann‑Whitney
U test). The median follow‑up was 6 months in both
groups (min: 6; max: 14 months in primar y group and
min: 6; max: 35 months in secondary group, P = 0.112,
Mann‑Whitney U test).
Indications for the scleral‑fixated PCIOL implantation (lens
status) are summarized in Table 1. In the primar y
group; scleral‑fixated PCIOL implantation was performed during
the cataract surgery because of posterior capsule complications
encountered during extracapsular cataract extraction in
8 eyes (21.6%), phacoemulsification in 15 eyes (40.6%) and
subluxation of the crystalline lens in 14 eyes (37.8%). In the
secondary group, a total of 39 eyes (66.1%) were aphakic at the
time of surgery, with a median aphakic period of 5 months (min:
1 month; max: 60 months). Thirty aphakic eyes (50.8%) had
previous complicated phacoemulsification related to posterior
capsule rupture or zonular dialyses, 4 aphakic (6.8%) eyes had
previous uncomplicated cataract surgery due to congenital
cataract and 5 eyes (8.5%) had previous reoperation due
to the penetrating ocular injury. Seven eyes (11.9%) had
ACIOL‑related complications and 13 eyes (22%) had IOL
dislocation.
T h e m e d i a n p r e ‑ o p e r a t i v e C DVA w a s 0 . 0 5
(min: Counting fingers; max: 0.6) in the primary group and
0.05 (min: Counting fingers; max: 1.0) in the secondary
group, which was statistically different between groups
(P < 0.001, Mann‑Whitney U test). The median post‑operative
CDVA was 0.5 (min: Counting fingers; max: 1.0) in the primary
group and 0.5 (min: Counting fingers; max: 1.0) in the secondary
group, with no statistically significant difference between
the groups (P = 0.576, Mann‑Whitney U test) [Table 2].
The CDVA improved at least one Snellen line or stayed unchanged
in 35 (94.6%) eyes in the primary group and in 52 (88.1%)
eyes in secondary group. The change in visual acuity was not
statistically significant between the groups (P = 0.263, Pearson
Chi‑square test). Visual loss of one or more Snellen lines
occurred in 2 (5.4%) eyes (cystoid macular edema sequelae,
n = 1; tilted IOL, n = 1) in the primary group and 7 (11.9%)
eyes (cystoid macular edema sequelae, n = 3; glaucoma, n = 1;
graft failure without rejection, n = 1; tilted IOL, n = 1; bullous
keratopathy, n = 1) in the secondary group.
The median (min‑max) spherical equivalent was 2.00 D (0‑6.00 D)
and 1.75 D (0-5.00 D) in the primary and secondary groups
respectively (P = 0.121). The median (min‑max) cylindrical
power was 2.00 D (0‑6.00 D) and 2.00 D (0‑6.00 D) in the
primary and secondary groups respectively (P = 0.885). Patients
were divided into three groups according to their CDVAs (0.1
or less, between 0.2‑0.4 and 0.5 or more). Regarding these
visual acuity categories, the groups were statistically different in
46
the pre‑operative period (P < 0.001, Pearson Chi‑square test)
and they were similar in the post‑operative period (P = 0.066,
Pearson Chi‑square test). Post‑operatively, 62.2% (n = 23)
of the eyes had CDVA of 0.5 or higher in the primary group
while 67.8% (n = 40) of the eyes in the secondary group had
CDVA of 0.5 or higher. Non‑surgery related causes of CDVA of
less than 0.2 were age‑related macular degeneration (n = 2),
traumatic foveal choroidopathy (n = 3), traumatic partial
leukoma (n = 5) and retinitis pigmentosa (n = 1) in the
primary group and age‑related macular degeneration (n = 4)
in the secondary group.
Early and late post‑operative complications are listed in Table 3.
Table 1: Indications for scleral‑fixated PCIOL (lens status)
Indications (lens status)
Phakic
Complicated ECCE
Complicated
phacoemulsification
Lens subluxation*
Aphakic
Congenital cataract surgery
Operated traumatic perforation
Complicated
phacoemulsification
Pseudophakic
Blunt‑trauma‑related IOL
dislocation
Spontaneous IOL dislocation
Complicated ACIOL
Primary group
(n=37) (%)
Secondary group
(n=59) (%)
8 (21.6)
15 (40.6)
‑
‑
14 (37.8)
‑
‑
‑
‑
4 (6.8)
5 (8.5)
30 (50.8)
‑
1 (1.7)
‑
‑
12 (20.3)
7 (11.9)
*13 trauma, 1 Marfan syndrome; ACIOL: Anterior chamber intraocular lens,
ECCE: Extracapsular cataract extraction, PCIOL: Posterior chamber intraocular
lens, IOL: Intraocular lens
Table 2: Pre-operative and post‑operative visual acuities
Visual acuity
(in decimal notation)
Pre-operative VA
Median (min-max)
≤0.1
0.2‑0.4
≥0.5
Post‑operative VA
Median (min‑max)
≤0.1
0.2‑0.4
≥0.5
Changes in CDVA
Improved≥1 snellen line
Unchanged
Decreased≥1 snellen line
Primary
group
(n=37) n (%)
Secondary
group
(n=59) n (%)
P value
0.05 (CF‑0.6)
28 (75.5)
8 (21.6)
1 (2.7)
0.05 (CF‑1.0)
20 (33.9)
15 (25.4)
24 (40.7)
<0.001a
<0.001b
0.5 (CF‑1.0)
13 (35.1)
1 (2.7)
23 (62.2)
0.5 (CF‑1.0)
11 (18.6)
8 (13.6)
40 (67.8)
0.576c
0.066d
26 (70.3)
9 (24.3)
2 (5.4)
32 (54.2)
20 (33.9)
7 (11.9)
0.263e
CDVA: Corrected distance visual acuity, CF: Counting finger, VA: Visual acuity.
a
Mann‑Whitney U‑test (statistical comparison of pre‑operative visual acuities
between the groups, bPierson Chi‑square test (statistical comparison of
pre‑operative visual acuity categories between the groups, cMann‑Whitney
U‑test (statistical comparison of post‑operative visual acuities between the
groups, dPierson Chi‑square test (statistical comparison of post‑operative
visual acuity categories between the group, ePierson Chi‑square test (statistical
comparison of visual acuity changes between the groups)
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Yalniz‑Akkaya, et al.: Scleral‑Fixated Intraocular Lens Implantation
In the early post‑operative period, adverse events occurred in
13 eyes (35.1%) in the primary group and in 17 eyes (28.8%)
in the secondary group (P = 0.637, Pearson Chi‑square test).
Most of these were mild and transient. Elevated intraocular
pressure (IOP) occurred in 3 (8.1%) eyes in the primary
group and in 11 (18.6%) eyes in the secondary group. Eight
eyes (three in the primary group, five in the secondary group)
had pre‑operative glaucoma. Elevated IOP was transient in six
eyes and was controlled by anti‑glaucomatous agents in eight
eyes (one in primary group, seven in secondary group). No eyes
required glaucoma surgery.
Regarding late complications (at least 1 month post‑operatively),
30 eyes (81.0%) in the primary group and 40 eyes (67.9%) in
the secondary group had no complications (P = 0.154, Pearson
Chi‑square test). Cystoid macular edema occurred in 2
eyes (5.4%) in the primary group and in 4 (6.8%) in the
secondary group; in four of these eyes (1 in the primary group;
3 in the secondary group), CDVA deteriorated in spite of
peri‑ocular and topical treatment with corticosteroids. The other
surgery‑related causes of visual acuity of less than 0.2 were tilted
IOL (n = 1) in the primary group; bullous keratopathy (n = 1),
glaucoma (n = 1), graft failure without rejection (n = 1) and
tilted IOL (n = 1) in the secondary group. No patient had
endophthalmitis, hypotony, retinal detachment or spontaneous
dislocation of the IOL caused by breakage of the polypropylene
sutures during follow‑up.
Table 3: Pre‑operative and post‑operative complications
Primary
Secondary P value
group
group
(n=37) n (%) (n=59) n (%)
Early post‑operative period
(within 1 month)
Complications
Anterior chamber hemorrhage
Transient vitreous hemorrhage
Pupil distortion
Leakage requiring resuturing
Elevated intraocular pressure
None
Late post‑operative period
(after 1 month)
Complications
Glaucoma
Irregular astigmatism
IOL tilt/decentration
Suture exposure
Cystoid macular edema
Bullous keratopathy
Allograft reaction (reversible)
Graft failure without rejection
None
5 (13.5)
1 (2.7)
4 (10.9)
‑
3 (8.1)
24 (64.8)
4 (6.8)
‑
‑
2 (3.4)
11 (18.6)
42 (71.2)
0.637†
1 (2.7)
1 (2.7)
1 (2.7)
‑
2 (5.4)
1 (2.7)
‑
‑
30 (81.0)
7 (11.9)
3 (5.0)
1 (1.7)
1 (1.7)
4 (6.8)
1 (1.7)
2 (3.4)
1 (1.7)
40 (67.9)
0.154††
Pearson Chi‑square test, (statistical comparison of early post‑operative
complications between the groups). ††Pearson Chi-square test; (statistical
comparison of late post‑operative complications between the groups).
IOL: Intraocular lens
†
Seven eyes (5.8%) required post‑operative surgical intervention.
One adult patient underwent grafting with processed human
pericardium for exposed polypropylene suture and two
penetrating keratoplasty patients underwent re‑suturing for a
leaking corneal wound. One patient was added to a keratoplasty
waiting list due to the bullous keratopathy. Three patients refused
further surgery for tilted IOL and graft failure.
All the penetrating keratoplasties were performed in
combination with secondary scleral‑fixation surgery. Two of
these eyes needed re‑suturing for leaking corneal wound, two
underwent graft rejection reaction and one graft failed without
rejection. All the penetrating keratoplasties were performed
in combination with secondary scleral‑fixation surgery. Two
of these eyes needed re‑suturing for leaking corneal wound,
two underwent graft rejection and one graft failed without
rejection. The median (min‑max) spherical equivalent was
1.75 D (0‑5.00 D) and 2.00 (0‑6.00 D) in patients without
keratoplasty and with keratoplasty respectively (P = 0.188). The
median (min‑max) cylindrical power was 2.00 D (0‑5.50 D)
and 2.50 D (0‑6.00 D) in patients without keratoplasty and with
keratoplasty respectively (P = 0.078). The median (min‑max)
post‑operative CDVA was 0.5 (counting fingers‑1.00) and
0.4 (counting fingers‑0.9) respectively, in patients without
keratoplasty and with keratoplasty (P = 0.01).
DISCUSSION
PCIOL are the standard of care in current cataract surgery. Ideally,
the lens is placed in the capsular bag, which affords stable fixation
at a position closest to the nodal point of the eye. However,
there will always be instances where in the bag implantation
isn’t possible, requiring that the IOL be sutured to the sclera;
weakness of the lens zonules in various conditions, trauma and
surgical complications during the cataract surgery are just some
examples.2 Lack of capsular support is common in aphakic eyes,
especially following removal of traumatic cataracts. Trans‑scleral
suturing of posterior chamber IOL is well‑established and a good
option in patients with insufficient capsular support or zonular
support, either as a primary or secondary implantation. A number
of reports on secondary scleral‑fixated PCIOL implantation exist
in the literature.12,18‑20 However, to the best of our knowledge,
primary and secondary scleral‑fixated PCIOL implantation has
been compared only in one study.21
Posterior capsular rupture with or without vitreous loss is
the most common intraoperative complication during the
cataract surgery.22,23 In the absence of adequate capsular support,
the surgeon has to decide whether to perform a primary or
secondary implantation. The type of anesthesia, the general
medical stability of the patient and compliance, the surgical time
spent to fix the complications and the surgeon’s experience are
factors affecting the decision‑making process.
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Yalniz‑Akkaya, et al.: Scleral‑Fixated Intraocular Lens Implantation
The surgical technique of scleral‑fixated PCIOL implantation
requires good surgical skills and meticulous intraocular
maneuvers, which cannot be performed under stressful
conditions and poor patient compliance. The procedure of
scleral‑fixated PCIOL implantation is associated with prolonged
operating times because of time spent for creating scleral flaps,
suturing the IOL haptics, vitrectomy and IOL implantation.
Additional time is added to the first part (complicated cataract
extraction), which can add higher risks for post‑operative
inflammation associated with cystoid macular edema in primary
implantations.21 Besides this, light‑induced retinal injury may
also be another disadvantage of primary implantation.24,25 On
the other hand, patients undergoing secondary scleral‑fixated
PCIOL implantation are presumably a healthier patient group
with better visual potential and without inflammation and any
ocular sequelae.
Lee et al. reported a statistically significantly higher complication
rate in the early post‑operative period and less favorable visual
outcome in the primary group.21 Contrary to Lee et al.’s study,
we found similar complication rates and visual outcomes in
primary and secondary groups. The possible causes of higher
early and late post‑operative complications in the secondary
group, although not statistically significant, can be the prolonged
operation time during the first surgery due to more challenging
intraoperative complications, which can also be the reason
for the secondary implantation, combination of penetrating
keratoplasty in 13 cases, complicated ACIOL in 7 cases and
traumatic background in 5 cases.
Cystoid macular edema was noted to be the most common
complication in some series that reported a rate of 5.5‑11% in
secondary implantations.18,21,26,27 In our study, the incidence of
cystoid macular edema sequelae was 5.4% in the primary group
and 6.8% in the secondary group.
Another important complication was elevated IOP. The groups
had similar ratios of pre‑operative elevated IOP. In the single
study comparing primary and secondary scleral‑fixated IOL
implantations, glaucoma was reported to be 16.7% and 12.0%
after primary and secondary implantations, respectively.21 Sufficient
anterior vitrectomy in the primary group could be the reason
for the simultaneous scleral‑fixated IOL implantation and could
prevent the post‑operative IOP rise. All patients with elevated IOP
were treated medically and glaucoma surgery was not required.
Anterior chamber and vitreous hemorrhages were transient and
pupillary distortion did not affect the final visual acuity in any
patient. Two patients with CDVA of less than 0.2 due to a tilted
IOL refused further surgical intervention to re‑center the IOL.
Only one patient developed suture exposure after 37 months
in the secondary group and the suture node was covered using
48
processed human pericardium to reduce the risk of “suture
wick” endophthalmitis. In this study, we used partial‑thickness
triangular scleral flaps to cover and protect the suture knots
and the polypropylene sutures were tied and left long under
the triangular scleral flaps. When the suture ends are left long
enough to lie parallel to the sclera, the sharp ends do not cause
erosion of the overlying conjunctiva. We think that the low suture
exposure rate in our study is related to the protective scleral
flaps and the long suture ends.
The groups were similar regarding the median CDVA (P = 0.576)
and the change in the CDVA (P = 0.263). These results
are comparable to previous studies.18,20,21,24,28 Surgery‑related
complications causing visual acuity of less than 0.2 were similar
between groups. The CDVA can deteriorate not only due to surgery,
but also due to non‑surgery‑related causes (e.g. pre‑operative
pathologies, history of trauma or previous complicated surgeries
and age‑related macular degeneration).
The limitations of this study are its single‑center and retrospective
nature, variable duration of follow‑up, small heterogeneous
pre‑operative indications. Prospective, randomized trials with
longer follow‑up are required to identify the safety and efficacy
of primary and secondary scleral‑fixated PCIOL implantations
in homogeneous patient populations.
CONCLUSION
Both primary and secondary scleral‑fixated PCIOL implantations
can provide favorable visual outcomes with less complication
rates in cases with inadequate capsular or zonular support
for PCIOL implantation. Poorer visual outcomes are often
related to ocular comorbidities associated with the underlying
pathology necessitating extracapsular fixation. The important
consideration is the appropriate time for scleral fixation while
accounting for the characteristics of each patient and the
course of each surgery. Although primary implantation has the
advantage of a single operation and the avoiding a period of
aphakia with poor vision after cataract extraction, secondary
implantation can be a logical option in incompatible patients
and in prolonged surgeries.
ACKNOWLEDGMENTS
This study was partially presented as a poster at the 45th National
Congress of the Turkish Ophthalmology Society in October 2011.
REFERENCES
1.
2.
Dick HB, Augustin AJ. Lens implant selection with absence of
capsular support. Curr Opin Ophthalmol 2001;12:47‑5.
Por YM, Lavin MJ. Techniques of intraocular lens suspension
in the absence of capsular/zonular support. Surv Ophthalmol
2005;50:429‑62.
Middle East African Journal of Ophthalmology, Volume 21, Number 1, January - March 2014
[Downloaded free from http://www.meajo.org on Wednesday, July 16, 2014, IP: 212.156.73.78] || Click here to download free Android application for this journal
Yalniz‑Akkaya, et al.: Scleral‑Fixated Intraocular Lens Implantation
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Michaeli A, Assia EI. Scleral and iris fixation of posterior
chamber lenses in the absence of capsular support. Curr Opin
Ophthalmol 2005;16:57‑60.
Wagoner MD, Cox TA, Ariyasu RG, Jacobs DS, Karp CL,
American Academy of Ophthalmology. Intraocular lens
implantation in the absence of capsular support: A report by
the American Academy of Ophthalmology. Ophthalmology
2003;110:840‑59.
Apple DJ, Mamalis N, Loftfield K, Googe JM, Novak LC,
Kavka‑Van Norman D, et al. Complications of intraocular lenses.
A historical and histopathological review. Surv Ophthalmol
1984;29:1‑54.
Smith PW, Wong SK, Stark WJ, Gottsch JD, Terry AC,
Bonham RD. Complications of semiflexible, closed‑loop
anterior chamber intraocular lenses. Arch Ophthalmol
1987;105:52‑7.
Apple DJ, Brems RN, Park RB, Norman DK, Hansen SO,
Tetz MR, et al. Anterior chamber lenses. Part I: Complications
and pathology and a review of designs. J Cataract Refract Surg
1987;13:157‑74.
McAllister AS, Hirst LW. Visual outcomes and complications of
scleral‑fixated posterior chamber intraocular lenses. J Cataract
Refract Surg 2011;37:1263‑9.
Krause L, Bechrakis NE, Heimann H, Salditt S, Foerster MH.
Implantation of scleral fixated sutured posterior chamber
lenses: A retrospective analysis of 119 cases. Int Ophthalmol
2009;29:207‑12.
Bading G, Hillenkamp J, Sachs HG, Gabel VP, Framme C.
Long‑term safety and functional outcome of combined pars
plana vitrectomy and scleral‑fixated sutured posterior chamber
lens implantation. Am J Ophthalmol 2007;144:371‑7.
Kjeka O, Bohnstedt J, Meberg K, Seland JH. Implantation of
scleral‑fixated posterior chamber intraocular lenses in adults.
Acta Ophthalmol 2008;86:537‑42.
Uthoff D, Teichmann KD. Secondary implantation of
scleral‑fixated intraocular lenses. J Cataract Refract Surg
1998;24:945‑50.
Yang YF, Bunce C, Dart JK, Johnston RL, Charteris DG.
Scleral‑fixated posterior chamber intraocular lenses in
non‑vitrectomized eyes. Eye (Lond) 2006;20:64‑70.
Lubniewski AJ, Holland EJ, Van Meter WS, Gussler D,
Parelman J, Smith ME. Histologic study of eyes with
transsclerally sutured posterior chamber intraocular lenses.
Am J Ophthalmol 1990;110:237‑43.
Küchle M, Seitz B, Hofmann‑Rummelt C, Naumann GO.
Histopathologic findings in a transsclerally sutured
posterior chamber intraocular lens. J Cataract Refract Surg
2001;27:1884‑8.
16. Lewis JS. Ab externo sulcus fixation. Ophthalmic Surg
1991;22:692‑5.
17. Holladay JT. Visual acuity measurements. J Cataract Refract
Surg 2004;30:287‑90.
18. Kershner RM. Simple method of transscleral fixation of a
posterior chamber intraocular lens in the absence of the lens
capsule. J Refract Corneal Surg 1994;10:647‑51.
19. McCluskey P, Harrisberg B. Long‑term results using
scleral‑fixated posterior chamber intraocular lenses. J Cataract
Refract Surg 1994;20:34‑9.
20. Hahn TW, Kim MS, Kim JH. Secondary intraocular lens
implantation in aphakia. J Cataract Refract Surg 1992;18:174‑9.
21. Lee VY, Yuen HK, Kwok AK. Comparison of outcomes of
primary and secondary implantation of scleral fixated posterior
chamber intraocular lens. Br J Ophthalmol 2003;87:1459‑62.
22. Desai P, Minassian DC, Reidy A. National cataract surgery
survey 1997‑8: A report of the results of the clinical outcomes.
Br J Ophthalmol 1999;83:1336‑40.
23. Zaidi FH, Corbett MC, Burton BJ, Bloom PA. Raising the
benchmark for the 21st century – The 1000 cataract operations
audit and survey: Outcomes, consultant‑supervised training
and sourcing NHS choice. Br J Ophthalmol 2007;91:731‑6.
24. Lanzetta P, Menchini U, Virgili G, Crovato S, Rapizzi E. Scleral
fixated intraocular lenses: An angiographic study. Retina
1998;18:515‑20.
25. Azzolini C, Brancato R, Venturi G, Bandello F, Pece A, Santoro P.
Updating on intraoperative light‑induced retinal injury. Int
Ophthalmol 1994;18:269‑76.
26. Lim ES, Apple DJ, Tsai JC, Morgan RC, Wasserman D,
Assia EI. An analysis of flexible anterior chamber lenses with
special reference to the normalized rate of lens explantation.
Ophthalmology 1991;98:243‑6.
27. Donaldson KE, Gorscak JJ, Budenz DL, Feuer WJ, Benz MS,
Forster RK. Anterior chamber and sutured posterior chamber
intraocular lenses in eyes with poor capsular support. J Cataract
Refract Surg 2005;31:903‑9.
28. Lanzetta P, Bandello FM, Virgili G, Crovato S, Menchini U.
Is scleral fixation a safe procedure for intraocular lens
implantation? Doc Ophthalmol 1999;97:317‑24.
Cite this article as: Yalniz-Akkaya Z, Burcu A, Uney GO, Abay I, Eksioglu U,
Acar MA, et al. Primary and secondary implantation of scleral-fixated posterior
chamber intraocular lenses in adult patients. Middle East Afr J Ophthalmol
2014;21:44-9.
Source of Support: Nil, Conflict of Interest: None declared.
Middle East African Journal of Ophthalmology, Volume 21, Number 1, January - March 2014
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