European Journal of Cardiovascular Medicine

Implantation of a scleral fixated posterior chamber intraocular lens (SF-IOLs), sutured/ suture less, is often used in the surgical management of aphakia in the absence of capsular support. They have the advantage of better safety profile over anterior chamber intraocular lenses (AC-IOL) with regard to complications such as corneal endothelial compromise, peripheral anterior synechia and glaucoma. Sutured PC-IOLs are considered by many the procedure of choice in young patients with congenital or traumatic subluxation of lenses. However, others have reported similar incidence of glaucoma between open-loop AC-IOLs and sutured PC-IOLs¹.

eyes of 35 admitted patients in the Department of Ophthalmology at U.C.M. S & G.T.B.Hospital, after informed consent and institutional ethical clearance

INCLUSION CRITERIA:

Patients admitted for surgery having the following diagnosis were included.                            

1. Aphakia without posterior capsular support
2. Dislocated or subluxated lens or cataract
3. Dislocated or subluxated intraocular lens, with insufficient capsular support
4. Patients found to have Zonular dialysis (≥ 1800) or posterior capsular rent (with inefficient capsular support), during cataract surgery

EXCLUSION CRITERIA:

The following patients were excluded from the study

1. Significant corneal opacity interfering with visualization during surgery
2. Bullous keratopathy
3. Endothelial cell count<1000/mm3
4. Glaucoma
5. Uncontrolled anterior/ posterior segment inflammation
6. Any local / systemic contraindication to surgery like scleritis, episcleritis,

Rheumatoid arthritis, herpes zoster ophthalmicus

1. Unwilling patient

Indications of surgery

After detailed pre–operative work-up the patients were divided into 2 groups

GROUP A - SUTURED IOL - Scleral fixated IOL using 10.0 prolene suture (16 eyes)

GROUP B – SUTURELESS IOL - Suture less scleral fixation of IOL with or without fibrin glue (21 eyes).

The standard procedure for lens extraction / removal of subluxated / dislocated IOL / cataract was followed as per the diagnosis of the patient. Anterior or pars plana vitrectomy was done in all cases. Sutured SF-IOL implantation was done using modified ab externo technique originally described by Lewis (1991). While, suture less SF-IOLs were implanted using the technique described by Agarwal et al (2008). Same visco-elastic, 2% HPMC, was used in all cases, and was removed meticulously after surgery. A detailed intra-op and post-op work-up was done. IOP was measured by applanation tonometer, daily for one week,weekly for 6 weeks and then monthly. The patients were followed-up from 3 months to 1 year.

The age ranged from 11-86 years, mean age being 54.62+ 16.9 years. Sutured group had younger patients.  Indications for SF IOL included, primary subluxated lens (5), posterior capsular rent (14), nucleus drop (7), IOL drop (4), traumatic subluxation (1), aphakia (6). 2 patients in sutured group and 3 patients in suture less group undervent SF-IOL implantation during the primary surgery itself, all the rest had undergone atleast 2-3 surgeries.

Pre-op mean AC depth was 3.56 +0.35mm, there was no AC reaction at the time of surgery. IOP was within normal limits without any medication. There was no significant difference in the pre-op parameters like AC depth, corneal thickness, endothelial cell count, gonioscopy and posterior segment changes between the two groups.

Early post-op glaucoma during the first post-op week was seen in 14/37(37.8%) eyes, being 37.5%(6 eyes) in sutured group and 38%(8 eyes) in suture less group. It was controlled medically with topical and systemic medication. On comparing the pre and post –op IOP, in the two groups, the rise in IOP was marginally significant (p=0.049) in suture less group only.

 Glaucoma persisted for more than 2 weeks in 7 eyes (19%), one eye developing glaucoma after 1 month. It was comparable in sutured (3/16,18.8%) and sutureless (4/21, 19.5%) group. However, all 3 eyes in sutured group and one eye of sutureless group recovered completely within 2 months on medical management alone. One patient,with late onset glaucoma, required Trabeculectomy with MMC, followed by cyclocryo to control glaucoma. Second patient with pre-op pseudoexfoliation and post-op vitreous haemorrhage,was controlled on oral and topical therapy, later required trabeculectomy. The third patient having complicated SICS with nucleus drop, was controlled on topical therapy alone. 

Inspite of complicated, prolonged and multiple surgeries, 37.8% (14/37) eyes in both the groups had post operative best corrected visual acuity ≥6/18. Of these, the better results were seen in the sutured SF-IOL (50%) compared to the sutureless group (28.6%)(NS, p=0.830).

Our results  are contrary to the study by Kumar et al² (2010) who reported a visual acuity of 6/9 or better in 50.9% patients following sutureless scleral fixation of glued IOLs. This difference may partly be explained by a larger sample size of 53 patients in their study as compared to only 21 in our study. Also 3 of 21 patients in suture less group had poor post-operative visual recovery, 2 of whom developed pseudophakic bullous keratopathy and one had undergone pars plana vitrectomy with silicon oil injection for retained intra-ocular foreign body, prior to SF IOL implantation. However, he developed redetatchment following oil removal. Subsequently his retina settled after silicone oil re-injection, but vision improved only to 1/60.

 In first post-operative week, the rise in IOP was marginally significant in suture less group (p=0.049). In a similar study on glued IOLs, Kumar et al² did not find significant IOP change post-operatively (p=0.447).

In sutured group, even though there was no significant change in the pre and post op IOP, still the post-operative IOP was high in 37.5% patients in the first post op week. This was comparable to the study of Vote et al³ (2006) who reported an incidence of increased IOP in 25% patients postoperatively. Donaldson et al ⁴ in 2005 also found elevated IOP in both his groups of sutured SF IOLs and AC IOLs, which was similar. However a much higher incidence of 50% was reported by Kwong et al¹ (2007). This persisted even one month after surgery in their cases.

Scharioth et al⁵(2010) and Chakrabarti et al ⁶ (2011) did not report a single case of post-operative high IOP in their study on sutureless IOLs. Our findings are contrary to theirs as we found post-operatively increased IOPs in 38% patients in sutureless group.

A transient rise in IOP postoperatively has also been reported in multiple studies^(7-11), however it resolved after some time.

The high post-operative IOPs in our cases may be due to increased manipulation during surgery leading to increased inflammation, hyphema (1 eye/ 2.7%) and vitreous haemorrhage (2 eyes/5.2%) in some patients.

All these patients were managed medically by systemic and topical anti glaucoma drugs for 1-2 months. However, 2 patients required trabeculectomy and one patient required cyclo cryotherapy even after trabeculectomy for control of glaucoma.

A high incidence of persistent secondary glaucoma is seen after implanting SF IOLs, both sutured as well as sutureless, mainly because of complicated and multiple surgeries. These patients require longer follow-up than normal

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