Innovative technique of scleral fixated intraocular lens in aphakic patients with inadequate capsular support.

Abstract

Methodology: Retrospective study of 43 cases of SFIOL implantation – 28 months, Complete history including details of cataract surgery and trauma. BCVA & IOP measurement: Slit lamp examination. * Presence of aphakia * Subluxated lens, traumatic cataract, decentred IOL. * Corneal scarring, vitreous in ac and wound. * Iridodialysis, iris defects, traumatic mydriasis. Status of anterior & posterior lens capsule: assessed, CTR with PCIOL implantation in minimally subluxated lens, excluded from our study. Eyes with intact CCC & inadequate posterior capsule: secondary PCIOL implantation done & excluded from study. Gonioscopy: in blunt trauma cases to rule out angle recession. Slit lamp biomicroscopy with 78 D: to rule out CME, macular oedema. Indirect Ophthalmoscopy- posteriorly dislocated lens/IOL, VH, RD, B-Scan, keratometry & biometry.

Results: 43 cases of SFIOL implantation were divided into 4 groups and all groups showed improvement in mean BCVA. Group 1: SURGICAL APHAKIA s/p complicated cataract Sx (n=16), Good visual outcome following SFIOL implantation, No significant postoperative (SFIOL) complication. Divided into 3 subgroups: A)  No IOL (n=10) * BCVA  ranged from 6/36 – 6/9. * CME in 2 cases, hence poor vision. B) Decentred IOL (n=4) * BCVA ranged from 5/60 – 6/12 * Cause of poor vision:  CME (n=1), corneal scar (n=1), NPDR with foveal exudates (n=1) C) Posteriorly dislocated IOL (n=2) * SFIOL done along with PPV (n=1) : VA- 6/12, * SFIOL done as second procedure (n=1), VA-6/24: chronic CME. Group 2: TRAUMATIC CASES (n=23): divided into 4 subgroups: A) Posteriorly dislocated lens (n=4) * BCVA ranged from CF1ft – 6/12, * SFIOL+PPV in 2 cases, SFIOL as second surgery in 2 cases, * 1 case had associated RD, poor final visual outcome despite, attached retina due to disc pallor. * CME (n=1) * Diffuse macular corneal opacity (n=1) * No complication related to SFIOL. B) Subluxated Traumatic Cataract (n=5) * SFIOL + ICCE + Anterior Vitrectomy * BCVA ranged from 6/36-6/12 * IOP was normal before as well as after cataract Sx * Cause of poor vision - chronic CME (n=1); 6/24 - corneal scar s/p repaired corneal tear (n=1); 6/36 * No complication due to SFIOL. C) Subluxated Traumatic Cataract with Secondary  Glaucoma (n=5) * Trabeculectomy + ICCE + SFIOL * BCVA ranged from 6/24-6/9 * Cause of poor vision :- corneal scar (n=1) *Complication (n=1): Raised IOP, repeat Trab+MMC done 25 days, after initial Sx, IOP subsequently controlled medically, final VA – 6/18. D) Surgical Aphakia with inadequate capsular support, s/p Traumatic cataract (TC) Sx  (n=9) * SFIOL implanted 1.5 months – 5years after primary Sx (TC Sx in 8, TPPM+PPV in 1 case) * BCVA ranged from CF1ft – 6/9 * SFIOL + PPV (n=2) due to VH – final VA: 6/24, 6/9 * SFIOL+ Optical Iridectomy (n=2) owing to diffuse corneal opacity, s/p corneal tear repair, final VA – CF1ft, 6/24 * This subgroup showed the maximum no. of complications (n=6):

• RD (n=2), noted at 1 & 6 months postoperatively: vitreous exudation was noted in 1 of these 2 cases for which I/V V+C was given, both patients were advised Sx (BB+PPV+SOI) but were lost to f/u.


• Raised IOP (n=3) on first f/u (1week): medically controlled (n=2) along with yag PI (n=1): 1 case required Trab+MMC done 10 days after Sx, IOP being subsequently controlled but had poor final VA due to macular scarring and exotropia.


• Decentration of SFIOL due to broken haptic(n=1) requiring SFIOL exchange

Group 3): Ectopia lentis in Marfan’s syndrome (n=3)

* SFIOL + ICCE (n=2), SFIOL + PPL (n=1)

* BCVA ranged from 6/24 – 6/12

* No complication was noted in this group

Group 4) : Optical PK + ACIOL explantation + SFIOL (n=1)

* VH noted postoperatively, resolved spontaneously

* Final VA : 6/36 with clear graft and well centred SFIOL

• All groups showed improvement in mean BCVA in the range

  * Group 1:  6/36 - 6/9

  * Group 2:  CF1ft – 6/9

  * Group 3:  6/24 – 6/12

  * Group 4:  6/36

• Complications included

   * Mild VH with spontaneous resolution (n=5)

   * RD (n=2)

   * Secondary Glaucoma (n=4)

   * Decentred IOL (n=1)

• Complications were mainly seen in Group 2-D


• Causes of poor vision

              * Corneal scar (n=6)

              * CME (n=6)

              * Macular scar (n=1)

              * Disc pallor (n=1)

              * CSMO in NPDR (n=1)

              * Traumatic mydriasis (n=6)

Conclusion:

1) The results indicate that SFIOL implantation is a safe and effective technique for aphakic correction with inadequate capsular support and gives good visual outcome.

2) It can be used even in presence of iris defects , diffuse corneal opacity and traumatic mydriasis.

3) SFIOL has advantage over ACIOL as it causes little / no corneal endothelial damage and carries reduced risk of secondary glaucoma.

4) There are more chances of decentration, uveitis and corneal decompensation with iris fixated IOLs.

Keywords: scleral fixated intraocular, aphakic patients, inadequate capsular support