Outcomes and Complications of Concurrent Pars Plana Vitrectomy and Scleral-Fixated Intraocular Lens Placement Using Gore-Tex Suture

The paper by Day and colleagues ¹ reports on 27 eyes of 27 patients using Gore-Tex (W.L. Gore & Associates) suture placement for suture fixation of an intraocular lens (IOL) with limited follow-up. The mean duration of follow-up was 200 days, which is just over one-half of a year. This is extremely short follow-up. The maximum follow-up in that series was just over 1.5 years.

By comparison, the series using 10-0 polypropylene for suture fixation of an IOL by Kokame et al ² included 118 eyes of 111 patients with a mean follow-up of 6 years and a maximal follow-up of 24.75 years. Of the 214 scleral-fixation sutures in this series, there was only 1 suture breakage in this large series of IOL fixation using 10-0 polypropylene sutures, resulting in a suture-breakage frequency of 0.47%. Mean follow-up was 6 years in this polypropylene suture series, ² as opposed to the mean follow-up of 200 days for the Gore-Tex paper. ¹ The longer follow-up is extremely important, because most recurrent dislocations occur much later after sutured scleral fixation. In the only case of dislocation due to 10-0 Prolene (Ethicon, a Johnson & Johnson Company) suture breakage in the series by Kokame et al, ² the dislocation occurred about 5 years after initial sutured fixation surgery.

The authors unfortunately misquote the reference by Kokame and colleagues ² and by Bading et al. ³ The sole reference used over and over to support a high rate of polypropylene suture breakage was the study by Vote et al. ⁴ This paper reported a 27% risk of suture breakage with polypropylene sutures. However, the studies by Kokame et al ² and Bading et al ³ both showed that the risk of polypropylene suture breakage was much lower than the series by Vote and colleagues. ⁴ The largest number of cases of any series and the longest follow-up were in the series by Kokame et al, ² with more than double the number of cases of the series by Vote and colleagues. ⁴ Thus, polypropylene suture fixation is still a good suture to consider for fixation of IOLs. However, it is a suture that has a lot of memory and is slippery, which can make it difficult to tie secure knots. If properly tied with secure knots, the long-term results are excellent. In the series by Vote and colleagues, there were multiple surgeons; some may have been inexperienced in the use of polypropylene sutures, so inadequate knots may have been mistaken as suture breakage rather than slippage of knots.

There have not been any other large series of scleral fixation of IOLs by polypropylene suture fixation that have confirmed the high rate of reported suture breakage by Vote and colleagues. A recent large series of 345 cases of scleral-fixated IOLs was reported by Portabella and colleagues, ⁵ in which 7.2% required a second surgery. This series included a mixture of polypropylene and Mersilene (Ethicon, a Johnson & Johnson Company) sutures, and it showed a greater reoperation rate with a combination of Mersilene and polypropylene sutures. It also included multiple surgeons, and probably a single knot, which was rotated into the fixation site often without a scleral flap. Even with these factors in consideration, this reoperation rate is much less than the 27% risk of redislocation reported by Bading et al. ³

Gore-Tex does have promise as a suture fixation material for sutured scleral fixation of IOLs. The suture is somewhat bulky and is not Food and Drug Administration approved for this use, but it is also less slippery than polypropylene. However, as noted earlier, the follow-up is short compared with the long follow-up available with polypropylene-sutured scleral fixation of IOLs. An IOL can be stably fixated for almost 25 years following a polypropylene suture-fixation, which indicates that polypropylene is still an excellent, stable, and long-term suture material for scleral fixation of IOLs.

Another issue brought up by the paper by Day and colleagues is the use of the Bausch + Lomb Akreos lens. ¹ As the authors noted, there has been opacification of this lens, especially after use of silicone oil or fluid gas exchange in vitreoretinal surgery. ^6,7 In addition opacification has been reported after scleral fixation of the Akreos IOL, requiring removal, which was challenging because of the granulation of the Gore-Tex suture into the choroid and sclera. ⁷ Although the haptic shape makes placement of the scleral-fixation sutures secure and easy to place with 2 eyelets on each haptic of the Akreos lens, this creates the need to perform 2 sclerotomies, rather than 1, for the sutures looped through the 2 eyelets on each side.

In summary, polypropylene sutures remain an excellent choice for scleral fixation of IOLs with long-term follow-up. Suture breakage in the largest series of polypropylene-fixated IOLs was 0.47%, and polypropylene suture fixation has been documented to maintain stable IOL fixation for up to 25 years. Gore-Tex is a promising option for sutured scleral fixation but has much shorter follow-up than polypropylene suture fixation, and recent findings of granulation tissue at the site of Gore-Tex suture fixation require more research with longer follow-up.