Sutured IOL an alternative when capsular support is lacking

Jackson, MS-In eyes without capsular support, placement of a transscleral sutured, foldable IOL through a clear corneal incision is a reasonable option, said Hussein Wafapoor, MD.

His conclusion is based on a review of a series of 50 eyes operated on since August 2001 in which a one-piece, foldable, acry-lic IOL (AcrySof SA60AT, Alcon Laboratories) was implanted through a small, clear corneal incision and fixated with transscleral suturing. All of the surgeries were performed by two ophthalmologists at the University of Mississippi Medical Center and the Veterans Administration Medical Center, Jackson, MS, and in no case was sulcus fixation without suturing feasible since zonular support was lacking.

Those latter events included glaucoma (three eyes) and single cases of vitreous hemorrhage requiring pars plana vitrectomy, pupillary capture of the IOL, suture-wick endophthalmitis, and cystoid macular edema. Other common complications included transient increased IOP (six eyes) and pigment deposits on the IOL surface (five eyes), according to Dr. Wafapoor, assistant professor of ophthalmology, University of Mississippi Medical Center, Jackson.

Nevertheless, three-fourths of the eyes had visual acuity of 20/40 or better at last follow-up, including six of the seven eyes with a visually significant complication; two-thirds achieved at least one line of improvement from preoperative visual acuity; and more than half (57%) showed a >2-line improvement.

An informal review of the 20 eyes operated on more recently showed they achieved similar visual improvement. Mild pigmentary deposit occurred in six more eyes, but with 1 year of follow-up, none of those eyes has developed glaucoma.

"Scleral suturing of a posterior chamber IOL is not an innocuous procedure, and from a safety perspective, it is particularly distinguished from other approaches because it features a permanent, non-absorbable scleral suture that allows for the development of suture-wick endophthalmitis," Dr. Wafapoor said.

"However, we believe our efficacy and safety outcomes compare favorably with those reported in numerous studies evaluating other methods, and that our technique has the advantages of requiring only a small incision and using a one-piece acrylic IOL with a unique haptic design that enables secure IOL suture fixation," he continued.

Dr. Wafapoor noted that transscleral IOL suturing was first described in the 1980s and has been performed with acceptable results using a variety of surgical techniques and IOL models.

In the first 30-eye series, there were 30 patients ranging in age from 1 to 83 years. The population included two preverbal children (ages 1 and 2 years) and had a mean age of 51 years. Mean preoperative visual acuity excluding the preverbal children ranged from 20/25 to hand motion and was 20/40 or better in only eight (29%) eyes.