Recurrent Iris Capture after Iris Suturing following Scleral-Sutured Intraocular Lens Fixation: A Case Report

Abstract

Introduction

Capture of the intraocular lens (IOL) optic by the iris or pupillary margin is defined as iris capture, and this postoperative complication occurs after scleral-sutured IOL fixation and sutureless intrascleral fixation. However, the optimal placement of iris sutures for preventing recurrence has yet to be adequately described.

Case Presentation

We report on the case of a 72-year-old man with ocular hypertension 1 year after scleral-sutured IOL fixation in the left eye who was referred for iris capture. Although topical medication was initially used to relieve the iris capture, it later became refractory. Iris suturing was initially performed at the 12 and 6 o’clock positions. However, at 1 month postoperatively, recurrent iris capture was subsequently observed. As a result, a second iris suturing procedure centered at the 8 o’clock position was performed at the documented capture site. In this second iris suturing procedure, which is shown in the online supplementary intraoperative video, an additional suture was placed at the documented 8 o’clock capture site. The clinical course has remained favorable and there has been no recurrence observed.

Conclusion

Current results suggest that iris suturing is an effective treatment option for recurrent iris capture after scleral-sutured IOL fixation. Moreover, further recurrence may be prevented by utilizing suture placement guided by the documented site of recurrence.

Introduction

Similar to postoperative events that have been described in the literature as optic capture or pupillary capture, this current report consistently uses the term “iris capture” to indicate intraocular lens (IOL) optic capture by the iris or pupillary margin. Iris capture is defined as a postoperative complication that occurs after scleral-sutured IOL fixation and sutureless intrascleral fixation. Depending on the fixation technique, IOL position, definition of capture, and the use of prophylactic iridotomy or iridectomy, reported incidence can vary widely. Previous studies and reports have described rates ranging from 3.6% to 38.9% after scleral-fixated or flanged intrascleral IOL fixation [1–4]. During this condition, despite the haptics remaining in their intended posterior position, part or all of the IOL optic will dislocate anterior to the iris and then become trapped. Off-axis needle passes, excessive anterior fixation of the IOL, insufficient suture tension, and IOL tilt are all intraoperative risk factors, while patient-related factors include iris atony, a history of vitrectomy, and reverse pupillary block [2, 5, 6].

Clinical initial management options include pharmacologic repositioning through the use of topical agents, in-office mechanical release, and laser peripheral iridotomy (PI) when there is suspected reverse pupillary block [1, 7, 8]. Nevertheless, when there are repeated episodes of iris capture, this can lead to chronic iris chafing and intraocular inflammation and result in secondary complications such as pigmentary glaucoma and cystoid macular edema, with a consequent visual decline. Although patients may experience glare due to impaired miosis and a decrease in their uncorrected visual acuity, some of these patients may remain minimally symptomatic. Therefore, when there is recurrent or refractory iris capture, this should be managed in accordance with the mechanism of capture, degree of IOL malposition, symptoms, intraocular pressure (IOP) elevation, and patient-specific risks.

Surgical options include the barrier or “block” suture techniques, IOL repositioning or exchange when marked malposition is present, and iris suturing or pupilloplasty [9–12]. When using barrier suture techniques, polypropylene sutures are passed between the iris and the IOL in order to prevent the optic from prolapsing anteriorly. Iris suturing is performed by passing sutures through the mid-peripheral iris. The former will mechanically block the IOL optic from prolapsing, whereas the latter will limit the pupillary dilation and thus prevent capture. However, it has yet to be clearly established as to what the optimal position of the iris sutures should be in eyes with localized, recurrent iris capture. Herein, we report a case in which iris capture recurred despite performing an initial iris suturing procedure and which was ultimately resolved by a second iris suturing procedure that was targeted to the actual capture site, with a net result of sustained resolution of the IOL capture.

Case Report

A 72-year-old man underwent cataract surgery at another hospital in September 2021, during which zonular dialysis was identified. Scleral-sutured IOL fixation was subsequently performed in April 2023. In September 2023, iris capture in the left eye was noted and was initially reduced pharmacologically through the use of mydriatic drops. However, recurrent capture occurred in April 2024, and as this was accompanied by an IOP of 23 mm Hg in the left eye, this led to a prompt referral to our clinic.

At patient presentation, the IOP measured 14 mm Hg in both eyes. Best-corrected visual acuity (BCVA) was 1.2 in both eyes. Axial length was 23.28 mm (right) and 22.95 mm (left). The ocular media were clear, and the fundus was unremarkable. Slit-lamp examination confirmed iris capture of the IOL optic in the left eye, predominantly at the 8 o’clock position (Fig. 1).

Fig. 1.

Slit-lamp photograph of the anterior segment at the initial presentation (April 2024). Image shows iris capture of the intraocular lens (IOL) optic predominantly at the 8 o’clock position.

In April 2024, iris suturing was scheduled for the week following the initial visit. Ports were created with a 20-gauge V-lance and the anterior chamber was reformed with a viscoelastic. Iris suturing was performed at the 12 and 6 o’clock positions using 10–0 polypropylene. Iris capture was released on postoperative day 1, and the BCVA was 1.2, while the IOP was 14 mm Hg. However, recurrent capture was observed at the 1-month follow-up (Fig. 2a). As the recurrent capture was again predominantly localized around the 8 o’clock region, this suggested that the first two sutures did not sufficiently restrict the actual capture arc. The BCVA remained at 1.2, while the IOP was 18 mm Hg. Since pharmacologic reduction using tropicamide/phenylephrine eye drops in the clinic was unsuccessful, a second surgery was planned.

Fig. 2.

a Slit-lamp photograph of the anterior segment after the first surgery. Image demonstrates recurrent iris capture of the IOL optic at 1 month postoperatively. Arrowheads (▼) indicate the area where the IOL optic was captured by the iris. b Slit-lamp photograph of the anterior segment after the second surgery. Arrows (→) indicate the iris suturing sites for the first surgery at the 12 and 6 o’clock positions, while the triangle (▼) indicates the documented 8 o’clock capture site, where the additional iris suture was placed during the second surgery. No recurrence of iris capture was observed after the second surgery.

Ports were created with a 20-gauge V-lance and the anterior chamber was reformed with a viscoelastic. After repositioning the IOL, iris suturing was performed at the 8 o’clock position using 10–0 polypropylene (online suppl. Video 1; for all online suppl. material, see https://doi.org/10.1159/000553616). The 8 o’clock position was selected as both the preoperative and recurrent slit-lamp findings determined this region to be the center of the capture arc. On postoperative day 1, BCVA was 1.2, the IOP was within the normal range, and the patient was asymptomatic. The iris capture remained resolved. Administration of 2% pilocarpine twice daily for 1 month in the patient served as a temporary postoperative adjunct for maintaining miosis during the early healing and minimizing pupillary movement across the IOL optic, thereby reducing the risk of any recurrent iris capture. There was no recurrence observed after cessation of the drops (Fig. 2b). The completed CARE checklist for this case report is provided as online supplementary material.

Discussion

Approaches used to manage iris capture after scleral fixation of an IOL include pharmacologic repositioning, in-office mechanical release, laser PI, IOL repositioning or exchange, barrier or block suture techniques, and iris suturing or pupilloplasty [1, 7–12]. After a first episode without marked inflammation or IOP elevation, a conservative or office-based treatment may be suitable. However, definitive surgical management is usually recommended after recurrent episodes, failed pharmacologic reduction, or suspected mechanical predisposition. Pharmacologic reduction was initially attempted in our current case, but recurrent capture ensued, thereby resulting in a prompt referral. In the literature, it has been suggested that an alternative office-based approach utilizing a mechanical release at the slit lamp via a 30-gauge needle be undertaken. However, recurrence can occur even when using adjunctive pilocarpine [1]. In addition, barrier or block suture techniques can be used to mechanically separate the iris from the IOL optic, and IOL repositioning or exchange may be appropriate when it is suspected there might be marked IOL tilt, decentration, or excessive anterior fixation. As the patient in our current case had good visual acuity, there was no obvious need for IOL exchange, and there was a localized recurrent capture site, we decided to utilize iris suturing as a relatively simple and mechanism-directed intervention.

At the time of patient presentation, the primary capture site was centered at the 8 o’clock position. The initial iris suturing procedure was performed using a conventional two-point strategy at 6 and 12 o’clock, which is generally intended to reduce pupillary enlargement. However, recurrent capture occurred in the patient at 1 month. As a result, a second procedure added a suture at 8 o’clock (Fig. 3; online suppl. Video 1). The video demonstrates the key decision-making point. That is, after repositioning the IOL optic posterior to the iris, the additional suture was placed not simply at a symmetric meridian but rather at the repeatedly documented capture site. Thus, by using the three-point iris suturing, pupillary dilation was effectively restricted and there was no further recurrence observed.

Fig. 3.

Schematic illustration of the iris capture site and iris suturing sites. Arrows (→) indicate the iris suturing sites for the first surgery at the 12 and 6 o’clock positions, while the triangle (▼) indicates the additional iris suturing site at the second surgery.

The reason for early recurrence after the first operation was likely due to a mismatch between the suture placement and the actual capture locus. Although the capture line involved the 8 o’clock meridian, the sutures were placed at positions that were relatively remote from the recurrent capture site, at the 6 and 12 o’clock positions. This may have preferentially allowed recurrent prolapse at the original 8 o’clock arc. Thus, had the initial iris suturing prioritized the documented capture site, it is possible that this recurrence might have been avoided. While two-point iris suturing can restrict pupillary dilation, in eyes with localized, repetitive capture, tailoring the suture placement to the documented capture arc may be more effective in reducing postoperative recurrence. This concept may be particularly useful when the IOL is otherwise stable and the capture pattern is reproducible as opposed to being diffuse.

We did not perform a PI in the current case, and whether an office-based laser PI should have been added remains a matter of discussion. Several studies have suggested that performing iridotomy or iridectomy may reduce the risk of pupillary capture or reverse pupillary block following scleral-fixated or intrascleral IOL fixation [7, 8]. Furthermore, PI may also mitigate reverse pupillary block, thereby helping to prevent capture [8, 13]. However, PI can also induce photophobia or dysphotopsia and, in some patients, actually reduce the quality of vision. Thus, its indication should be individualized [14]. In our present case, PI was reserved as a secondary option due to the fact that the fellow eye had developed bothersome photophobia after peripheral iridectomy.

Postoperative pilocarpine was used for 1 month after the second surgery in order to reduce the pupillary excursion during the early postoperative period. This duration was chosen as a short-term adjunct rather than long-term therapy as prolonged miotic use can cause visual discomfort, headache, or brow ache, reduced night vision, and difficulty with fundus examination. The absence of recurrence after this discontinuation suggested that the surgical configuration, rather than the continued pharmacologic miosis alone, was responsible for sustained resolution.

In summary, iris suturing represents an effective surgical option for recurrent iris capture that occurs after scleral-sutured IOL fixation. In our current case, an initial two-point suture at the 6 and 12 o’clock likely failed due to the fact that it did not address the primary capture site at 8 o’clock. Thus, careful identification of the capture site using slit-lamp photographs and intraoperative confirmation, followed by capture-site-guided suturing, may be the key to preventing recurrence.

Acknowledgments

The authors thank Dr. Sugimoto for her involvement in the patient’s clinical care and for helpful discussions regarding the management of this case.

Statement of Ethics

Ethical approval was not required for this case report as per the decision of the Institutional Review Board of Nippon Medical School Foundation. The report was prepared in accordance with the tenets of the Declaration of Helsinki. Written informed consent was obtained from the patient for publication of the details of this medical case and any accompanying images. All potentially identifying information has been anonymized to protect the patient’s privacy.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This case report was not supported by any sponsor or funder.

Author Contributions

Conceptualization and clinical management: T.K. and K.S.; surgery, writing – review and editing, and supervision: T.K.; data curation, investigation/clinical examinations and assessment, and writing – original draft: K.S.; and writing – critical revision: F.O. All authors read and approved the final manuscript.

Funding Statement

This case report was not supported by any sponsor or funder.

Data Availability Statement

The data supporting the findings of this case report are not publicly available due to privacy and ethical restrictions. Further information may be obtained from the corresponding author upon reasonable request.