Abstract
Purpose:
We report the longest follow-up to our knowledge of stable scleral fixation of a posterior chamber intraocular lens (PC IOL) with 10-0 polypropylene sutures.
Methods:
A retrospective review is presented of a case with more than 30 years’ follow-up after performing sutured scleral fixation with 10-0 polypropylene suture using 2 sutures tied together under a scleral flap. One suture was a cow-hitch looped around the haptic, and the other suture was passed through the sclera to create the scleral fixation.
Results:
The scleral fixation with 10-0 polypropylene suture knots for both haptics of the PC IOL allowed central optic positioning with excellent vision for more than 30 years without suture breakage.
Conclusions:
Polypropylene sutures for scleral fixation of PC IOLs remained stable for more than 30 years with central positioning of the PC IOL, without exposure of the fixation suture knots through the conjunctiva, and without suture breakage.
Keywords: 10-0 polypropylene suture, dislocated intraocular lens, intraocular lens repositioning, posterior chamber intraocular lens, scleral fixation, vitrectomy
Introduction
A sutured scleral-fixated posterior chamber intraocular lens (PC IOL) was the first procedure described for scleral fixation of a PC IOL without capsular support in 1988. 1 The first suture described for use was a polypropylene suture, and this was the most common suture used for this indication for decades. In 2006 Vote et al reported a high incidence of redislocation of sutured scleral-fixated PC IOLs with polypropylene sutures at 26.2%, which they theorized was related to breakage of the polypropylene sutures. 2 However, this high breakage rate has not been confirmed in any subsequent study since 2006. 3 -5 This case report documents a remarkable case with the longest reported follow-up to our knowledge of a polypropylene-sutured scleral-fixated PC IOL of more than 30 years, demonstrating the long-term stability of 10-0 polypropylene as a fixation suture for PC IOLs.
Methods
Case
A 58-year-old Asian woman had severe blunt trauma to her right eye due to a head-on collision in a motor vehicle accident. She developed a subluxated secondary cataract with 3+ pigment in the anterior vitreous 16 months later. This case was referred from the anterior segment surgeon, as a posterior segment approach was felt to be safer and a scleral-fixated PC IOL was indicated. The patient’s best-corrected visual acuity (BCVA) was 20/200. Slitlamp examination showed a significant cataract with laxity of zonular support. Fundus examination showed a choroidal nevus 3 disc diameters in size in the superotemporal periphery. In 1990, she underwent pars plana vitrectomy, pars plana lensectomy, and PC IOL implantation with sutured scleral fixation with 10-0 polypropylene. The fixation knot used 2 sutures, with 1 suture looped around the haptic as a cow-hitch and 1 suture fixated to the sclera, and both were tied together in 1 knot as previously described at the 2 and 8 o’clock positions with overlying scleral flaps. 6
Results
One year postoperatively, the patient’s BCVA in the right eye was 20/20 (–1.25 +0.75 ×024) with a centered and stably fixated PC IOL. In 2020, more than 30 years after sutured scleral fixation of the PC IOL with 10-0 polypropylene, the PC IOL was in excellent position with 20/30 uncorrected vision and 20/20 BCVA. There was no evidence of exposure of the scleral fixation suture knots through the conjunctiva.
Conclusions
For sutured scleral fixation of a PC IOL, significant attention has been given to the 26.2% breakage rate published in a series of 61 eyes with polypropylene-sutured fixation of PC IOLs by Vote et al. 2 That article was a multiple-surgeon study with a single loop of suture fixating the PC IOL to the sclera. The mean follow-up was 5.8 years, the minimum follow-up was 1 year, and the maximum follow-up was 127 months (10.6 years). The 10.6 years is approximately one-third of the follow-up of the present case.
Polypropylene suture is a slippery suture with memory, so if knots are not securely tied by surgeons inexperienced in tying fixation sutures, then a high redislocation rate can be encountered owing to slippage of knots. A subsequent report of the largest series of sutured scleral-fixated PC IOLs with 10-0 polypropylene recently published by Kokame and colleagues 6 included 118 eyes of 111 patients with a mean follow-up of 6 years and a minimum follow-up of 2 years. This article showed a redislocation rate related to polypropylene suture breakage of only 0.8%. The rate of suture breakage for all 214 scleral fixation sutures was 0.5%. This study differed from the Vote study that reported a high redislocation rate, 2 as this study had a single surgeon, longer follow-up, and the suture knot was different from the single loop of suture tied together with 1 knot. The suture knot in this study involved 2 sutures tied together under a scleral flap. One suture was a cow-hitch suture around the haptic (Figure 1A). (Note the bulb at the end of the haptic created by cautery to prevent slippage of the fixation suture and decrease the risk of suture knot exposure through the conjunctiva.) The second separate suture was fixated to the sclera. Both sutures were tied together in 1 knot underneath a scleral flap (Figure 1B). 6 This previous study strongly supports the long-term stability of 10-0 polypropylene sutures for sutured scleral fixation of a PC IOL with securely tied knots. The present reported case of a stable, sutured PC IOL with 10-0 polypropylene of more than 30 years is long-term proof of the stability of this type of suture for PC IOL scleral fixation.
Figure 1.
(A) Schematic diagram of cow-hitch suture around the haptic, which in this particular case was performed by externalization of the haptic through a clear corneal incision. Externalization can also be performed directly through the fixation sclerotomy through the pars plana. Note the bulb on the edge of the haptic created by cautery to the end of the haptic to prevent slippage and exposure of the knot through the conjunctiva. (B) Schematic drawing showing the 2 different 10-0 polypropylene sutures, which are then tied together in 1 knot underneath the scleral flap. The blue suture is the cow-hitch suture around the haptic and extending from the fixation sclerotomy. The red suture is through the sclera and closes the fixation sclerotomy. Both sutures are tied together in 1 knot, thus creating the scleral fixation. Inferior-based scleral flaps are used to minimize interference of the scleral flaps during suture-tying.
A study by Bading et al 4 of 63 procedures of sutured scleral-fixated PC IOLs with 10-0 polypropylene resulted in a 94% success rate with a minimum follow-up of 1 year and a mean follow-up of 3.6 years. The reoperation rate due to suture breakage was noted in only 3.2% of cases. A recent large study of sutured scleral-fixated PC IOLs by Portabella and colleagues 5 included 345 consecutive cases with a mean follow-up of 3.74 years, a minimum of 6 months, and a maximum of 10 years. This study involved multiple surgeons and sometimes involved a 10-0 polyester suture (Mersilene) for one haptic and a 10-0 polypropylene suture (Proline) for the other haptic. With multiple surgeons and different sutures, this much larger series showed a high success rate of sutured scleral-fixated PC IOLs with only a 7.2% reoperation rate (25 of 345 cases). The highest risk of redislocation (18.8%) was noted in cases with combined suture fixation with polypropylene for one fixation suture and polyester for the other fixation suture. This series included a group of younger patients from age 18 to 39 years, who had a higher risk of suture breakage. In patients older than 60 years, the risk of reoperation was only 3%.
The study by Kokame et al 3 included older patients with an average age of 67 years (range, 27-92 years), which could have contributed to the very low suture breakage of 0.8%. The Bading study 4 also had older patients with a mean age of 67.8 years (range, 34-89 years) and a suture breakage rate of 3.2%. The true breakage rate for polypropylene sutures in older patients thus ranged from 0.8% in the Kokame study, 3 to 3.2% in the Bading study, 4 to 3% in the Portabella study, 5 all of which were much lower than the 26.2% redislocation rate reported by the Vote study. 2 In addition, electron microscopic evaluation of implanted 10-0 polypropylene sutures have shown only superficial surface wrinkling and cracking but have not shown evidence of any changes that would be predisposed to suture breakage, 7 which again provides evidence for the long-term stability of polypropylene sutures.
Because of concern regarding breakage of polypropylene sutures initially suggested by the Vote study, 2 polytetrafluoroethylene (Gore-Tex) has been considered as an alternative suture. Gore-Tex is a potential long-term fixation suture because it is a soft, microporous, monofilament suture that is flexible and compressible. These characteristics could allow improved and more secure suture knots by ophthalmic surgeons, but the follow-up of Gore-Tex PC IOL fixation sutures is much shorter than that of 10-0 polypropylene sutures. This suture is also bulkier, is not US Food and Drug Administration–approved for use in ophthalmic surgery, and has been associated with granulation tissue around the Gore-Tex sutures. 8
The scleral tunnel technique for scleral fixation of a PC IOL initially described by Yamane et al is a promising technique, but the long-term follow-up is limited at this point in its clinical use, and there is a risk of endophthalmitis if the haptic becomes exposed through the conjunctiva. 9,10 Polypropylene sutures remain an important suture for long-term use for scleral fixation of PC IOLs without capsular support, and the present case with, to our knowledge, the longest follow-up ever reported illustrates the stability of 10-0 polypropylene scleral fixation sutures for more than 30 years. Multiple series after the initial high breakage rate reported by Vote and colleagues 2 have supported the long-term stability of 10-0 polypropylene with low suture breakage rates between 0.8% and 7.2%. Presently, the polypropylene fixation sutures for PC IOLs have much longer follow-up than the more recently used Gore-Tex scleral fixation sutures, although knot-tying must be secure for successful scleral fixation of PC IOLs with polypropylene.
Acknowledgments
The authors acknowledge Maria Won, research coordinator, Hawaii Macula and Retina Institute.
Footnotes
Ethical Approval: Ethics approval for this study was not obtained because of the singular, deidentified nature of the case reported.
Statement of Informed Consent: Informed consent was not sought for the present study because of the deidentification of the patient’s characteristics and maintenance of anonymity.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Gregg T. Kokame, MD, MMM 
https://orcid.org/0000-0001-7487-2205
References
- 1. Hu BV, Shin DH, Gibbs KA, Hong YJ. Implantation of posterior chamber lens in the absence of zonular and capsular support. Arch Ophthalmol. 1988;106(3):416–420. doi:10.1001/archopht.1988.01060130442039 [DOI] [PubMed] [Google Scholar]
- 2. Vote BJ, Tranos P, Bunce C, Charteris DG, Da Cruz L. Long-term outcome of combined pars plana vitrectomy and scleral fixated sutured posterior chamber intraocular lens implantation. Am J Ophthalmol. 2006;141(2):308–312. doi:10.1016/j.ajo.2005.09.012 [DOI] [PubMed] [Google Scholar]
- 3. Kokame GT, Yanagihara RT, Shantha JG, Kaneko KN. Long-term outcome of pars plana vitrectomy and sutured scleral-fixated posterior chamber intraocular lens implantation or repositioning. Am J Ophthalmol. 2018;189:10–16. doi:10.1016/j.ajo.2018.01.034 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Bading G, Hillenkamp J, Sachs HG, Gabel VP, Framme C. Long-term safety of combined pars plana vitrectomy and scleral fixated posterior chamber intraocular lens implantation. Am J Ophthalmol. 2007;144(3):371–377. doi:10.1016/j.ajo.2007.05.014 [DOI] [PubMed] [Google Scholar]
- 5. Portabella M, Nadal J, Alarex de Toledo J, Barraquer RI. Long-term outcome of scleral-sutured posterior chamber intraocular lens: a case series. Br J Ophthalmol. 2020;104(5):712–717. doi:10.1136/brjophthalmol-2019-314054 [DOI] [PubMed] [Google Scholar]
- 6. Kokame GT, Yamamoto I, Mandel H. Scleral fixation of dislocated posterior chamber intraocular lens by temporary haptic externalization through a clear corneal incision. J Cataract Refract Surg. 2004;30:1049–1056. doi:10.1016/j.ophtha.2006.10.037 [DOI] [PubMed] [Google Scholar]
- 7. Parekh P, Green WR, Stark WJ, Akpek EK. Subluxation of suture-fixated posterior chamber intraocular lenses a clinicopathologic study. Ophthalmology. 2007;114(2):232–237. doi:10.1016/j.ophtha.2006.10.037 [DOI] [PubMed] [Google Scholar]
- 8. Gregori NZ, Echegaray JJ, Flynn HW, Jr. Opacification of Akreos hydrophilic acrylic lens after retinal detachment repair with silicone oil tamponade: a case report. Ophthalmol Ther. 2019;8(2):341–345. doi:10.1007/s40123-019-0183-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Prenner JL, Feiner L, Wheatley HM, Connors D. A novel approach for posterior chamber intraocular lens placement or rescue via a sutureless scleral fixation technique. Retina. 2012;32(4):853–855. doi:10.1097/IAE.0b013e3182479b61 [DOI] [PubMed] [Google Scholar]
- 10. Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged intrascleral intraocular lens fixation with double-needle technique. Ophthalmology. 2017;124(8):1136–1142. doi:10.1016/j.ophtha.2017.03.036 [DOI] [PubMed] [Google Scholar]