Modified Technique for Sutured Intraocular Lens

Supplemental Digital Content is Available in the Text.

Abstract

Purpose:

To describe a novel scleral fixation technique for the Akreos AO60 intraocular lens using Gore-Tex sutures buried within the sclera to minimize long-term exposure-related complications and improve cosmetic outcomes.

Methods:

Four eyes of four patients underwent scleral fixation of the Akreos AO60 lens using the modified ab externo approach. Outcomes included best-corrected visual acuity, intraocular lens centration, and suture-related complications.

Results:

Preoperative best-corrected visual acuity ranged from 20/60 to 20/300. Postoperative best-corrected visual acuity ranged from 20/30 to 20/90 at final follow-up. All IOLs remained well-centered with no visible suture on external exam. One patient developed transient postoperative hypotony and a macula-off retinal detachment 1 month after lens fixation, which was successfully repaired with pars plana vitrectomy. No patients required additional surgery related to the intraocular lens or suture material.

Conclusion:

The described technique allows secure scleral fixation of the Akreos AO60 intraocular lens while minimizing the risk of Gore-Tex suture exposure. This modification may improve long-term outcomes and cosmesis.

Ab externo scleral fixation of a posterior chamber intraocular lens using suture was first described in 1991 and has become an effective management strategy in select patients with aphakia and poor capsular support.¹ Early techniques were associated with suture breakage, resulting in IOL dislocation, with reported rates ranging from 0.47% to 27.9%.^2–5 Polytetrafluoroethylene Gore-Tex (W.L. Gore & Associates, Newark, DE) sutures have gained popularity because of their high tensile strength and resistance to degradation. The four-point transscleral fixation of the Akreos AO60 lens (Bausch & Lomb, Rochester, NY) using Gore-Tex suture has emerged as a reliable method with a low complication profile.^6–11

The current technique described in the literature leaves the Gore-Tex suture under the conjunctiva. The long-term consequence of this technique remains uncertain, and studies have reported suture exposure in as high as 40% of cases.¹⁰ In addition, there are rare reports of infectious endophthalmitis and scleritis secondary to suture erosion, which all required IOL explantation.^9,12,13 Brown and others have attempted to mitigate these risks by burying the suture.¹¹

Herein, we describe a modified surgical technique of Akreos AO60 IOL fixation that uses parallel wound orientation and burial of Gore-Tex suture within the sclera to reduce exposure-related complications and improve cosmetic outcomes.

Technique

The key steps to this surgical procedure are outlined in the supplemental digital content (see Video, Supplemental Digital Content 1, http://links.lww.com/IAE/C748). A localized superior conjunctival peritomy is performed from seven to five o'clock. Wet field cautery is applied to achieve hemostasis if needed. A toric lens marker is then used to mark the corneal limbus at 2 points 180° apart. Marks are made 2.5 mm posterior to the limbus 5 mm apart and repeated 180° away. A 25-gauge trocar is placed in the inferotemporal mark for infusion. Paired 25-gauge sclerotomies are created in the superonasal and superotemporal marks. Finally, an additional incision is made with the trocar blade in the inferonasal mark. The incisions are not beveled and are oriented parallel to the limbus to minimize the chance of wound gape and leakage after suture passage (Figure 1A).

Fig. 1.

Schematic demonstrating key surgical steps of fixation technique (A–H).

A pars plana vitrectomy is performed as needed with removal of dislocated IOL. In this series, all surgeries were performed using the Constellation Vision System (Alcon Laboratories, Fort Worth, TX). Anterior chamber access is gained via a clear corneal incision or a 6-mm scleral tunnel when existing IOL retrieval is necessary. The needles of the CV-8 Gore-Tex sutures are kept intact, and the suture is cut into two halves. The trailing end is inserted into the inferior sclerotomy and externalized via the corneal or scleral tunnel using a handshake technique. The same step is repeated for the opposite side.

Each half-suture is threaded through adjacent eyelets of the Akreos AO60 lens in an anterior-to-posterior and posterior-to-anterior fashion to reduce iris chafing (Figure 1B). The trailing ends are reinserted into the eye and externalized via the superior sclerotomies (Figure 1C). The IOL is inserted, and suture tails are pulled gently to position the IOL in the posterior chamber (Figure 1D). The suture needle from the leading end of the Gore-Tex is grasped with a needle holder, and the needle is passed partial thickness within the scleral entering from the inferior sclerotomy and exiting from the superior sclerotomy. The same step is performed on the opposite side (Figure 1E). Passage of the suture within the sclera can be performed at the outset if the trocar cannulas are not required for vitrectomy and IOL retrieval. Tension is adjusted for IOL centration. A surgeon's knot (3-1-1) is used to increase friction and avoid overtightening with subsequent throws. Care is taken to make sure the knots are compact. Suture throws are alternated from side to side while continuously checking the lens position (Figure 1F). The sutures are then trimmed, and the knots are rotated and buried within the sclerotomy (Figure 1, G and H). The incisions do not typically require a suture for closure since the traction of the IOL suture is in line with their parallel orientation. However, if needed, the parallel orientation facilitates suture passage with less risk of damage to the IOL suture. The scleral tunnel wound is closed with 10-0 nylon suture as needed, and the overlying conjunctival peritomy is then closed.

Results

Four eyes of four patients underwent the described surgical technique for Akreos AO60 lens fixation. The preoperative best-corrected visual acuity (BCVA) ranged from 20/60 to 20/300, and the postoperative BCVA ranged from 20/30 to 20/90.

Patient 1, a 43-year-old woman with spontaneous crystalline lens dislocation, underwent removal of dislocated lens and AO60 fixation. The preoperative BCVA was 20/300, which improved to 20/30 at 4 months with no complications noted. External photos at follow-up demonstrate Gore-Tex sutures remain buried with good cosmetic outcome (Figure 2).

Fig. 2.

External photograph of left eye 4 months after surgery demonstrates buried sutures with intact conjunctiva.

Patient 2, a 78-year-old man with neovascularization of the iris refractory to anti-VEGF injections, presents with a subluxed IOL with iris-IOL touch on ultrasound biomicroscopy with downgaze. The patient underwent IOL removal and AO60 fixation. The preoperative BCVA was 20/100, and the postoperative BCVA was 20/90 at 4 months. The patient's iris maintained prominent mature iris vessels but demonstrated regression of neovascularization of the iris with no elevation in intraocular pressure.

Patient 3, a 65-year-old man with history of chronic panuveitis, presents with a dislocated IOL and underwent IOL removal and AO60 fixation. The preoperative BCVA was 20/100 and improved to 20/50. Despite the use of preoperative oral prednisone, the postoperative course was complicated by transient hypotony. He then developed a macula-off rhegmatogenous retinal detachment 1 month later that was repaired with pars plana vitrectomy (PPV) with gas tamponade. The patient's retina remains attached at 4 months with postoperative BCVA of 20/80 and continued good centration of the AO60 with no opacification.

Patient 4, a 72-year-old man with a dislocated IOL, underwent IOL removal and AO60 fixation. The preoperative BCVA was 20/150, and the postoperative BCVA was 20/60 at 2 months.

The IOLs remained well centered in all eyes. No suture was visible on the sclera of any eyes, and there were no suture-related complications.

Discussion

Various techniques for IOL scleral fixation in the setting of inadequate capsular support exist. The Akreos AO60 lens offers certain advantages given its design with two paired eyelets on either side of the optic. First, eyelets allow for four-point fixation for good centration and reduced risk of IOL tilt. Second, the Akreos AO60 IOL is easily folded thus allowing for a smaller incision and can be threaded with Gore-Tex sutures outside the eye. One limitation of the Akreos AO60 IOL is its hydrophilic acrylic material, which can unpredictably opacify after gas or air tamponade.¹⁴

This modified technique for fixation preserves the benefits of the Akreos AO60 lens while reducing suture-related risks. Our case series demonstrate both good visual and cosmetic outcomes with no incidence of suture exposure–related complications. The clinical course of patient 3 was complicated by hypotony and retinal detachment. In the absence of incision leakage, the etiology was presumed to be related to ciliary body shutdown in the setting of chronic panuveitis. After having a macula-off retinal detachment, he recovered postoperative BCVA of 20/80, which was an improvement from his preoperative BCVA.

Although few cases of Gore-Tex exposure-related complications exist in the literature, an infection related to suture issues requires IOL explantation. In addition, the fixation of AO60 IOL was popularized in 2014, but long-term outcomes remain to be seen. The potential harmful effects of chronic ultraviolet light exposure should also be considered. We believe that this modification to bury the Gore-Tex suture along with parallel wound orientation can minimize late term suture breakdown, erosion, and associated complications while also providing an improved cosmetic outcome. Ultimately, long-term evaluation will be needed to assess the potential advantages and disadvantages of this modified technique for sutured intraocular lenses.

Supplementary Material

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