Transcript Sulcus-Placed Single-Piece Acrylic IOL After Posterior

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A.K. Junk, S. R. Wellik
Bascom Palmer Eye Institute, Miller School
of Medicine, University of Miami
Miami Veterans Health Care System
Sulcus-Placed Single-Piece Acrylic
IOL After Posterior Capsule Tear
The authors have no financial interest and no conflict of
interest in the subject matter to disclose.
CORE GRANT P30-EY14801
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Introduction
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With the advent of small incision cataract surgery foldable singlepiece acrylic (SPA) intraocular lenses (IOLs) have gained in
popularity and account for approximately one half of the IOLs
implanted in the U.S. Alcon estimates that worldwide more than 30
million AcrySof® IOLs have been implanted. With its square edge
SPA IOLs achieve better apposition to the lens capsule, thus
inhibiting lens epithelial migration. The “tacky” IOL surface
restricts lens epithelial cell access of aqueous and nutrients and
induces cell atrophy and apoptosis. The IOL material has excellent
biocompatibility, great stability in the capsular bag, and reduced
rates of posterior capsule opacification (PCO).
The manufacturer does not recommend sulcus placement of this
IOL style as the zero angulation of the haptic-optic junction may
induce iris chaffing.
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Introduction
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The peer reviewed literature is controversial on the question
whether SPA IOLs can be placed safely in the sulcus. Two reports in
in favor of sulcus placement are in contradiction with several case
reports of iris chafing, uveitis-glaucoma-hyphema (UGH) syndrome
or vitreous hemorrhage after sulcus placed SPA IOL.
Two articles from one center are in support of sulcus placed SPA
IOLs, reporting elevated IOP in 19% of patients, no need for IOL
exchange, and rare surgical revision[1, 2]. Prior reports of sulcus
placed SPA IOLs are case reports[3-7] or comprised of patients
referred to tertiary care centers for management of
complications[8, 9].
At the “Spotlight on Cataract Complications Symposium” during the
2008 AAO meeting the audience was surveyed on the issue of
sulcus placed SPA IOLs. Over 40% said a SPA IOL should be placed in
the sulcus “if capsular support was adequate”, 47% said “never”, 2%
said “yes”, if suture fixated, and 11% said “yes, if no other PC IOL
was available”.
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Patients and Methods
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E Y E I NS TI TU TE
This is a retrospective chart review of nine consecutive patients
who had cataract surgery complicated by posterior capsule tear or
anterior capsule rent and sulcus placed SPA IOL at one medical
center. Patient demographics are depicted in Table 1.
Table 1. Patient demographics at the time of surgery
Age at the time of surgery
Mean
79
Range
70 - 87
male
9
Female
0
2006
2
2007
3
2008
3
2009
1
Sex
Year of initial surgery
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Patients and Methods
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Please refer to Table 2. Surgical Complications and Outcomes, to
view details about the surgical cases.
Table 2 is available by clicking on the link “View additional
images/videos”
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Patients and Methods
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In 89% of surgeries a posterior capsule tear was noted after phacofragmentation and anterior vitrectomy was performed prior to
sulcus placement of SPA IOL.
An Acrysof® SA60WF implant was used in 67% of cases, three
patients had toric SPA IOLs, SN60T4 or SN50T5 respectively. Suture
fixation was not used.
One patient was lost of follow up after one month, two patients
expired six, respectively 14 month after cataract surgery. Three
patients required surgical intervention. The SPA IOLs were decentered in 66% of cases causing increased refractive astigmatism
compared to preoperative, spectacle correction yielded corrected
visual acuity of 20/40 or better.
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Results
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E Y E I NS TI TU TE
This case series demonstrates good final corrected visual acuity of 20/25
or better in 78% with SPA IOL in the sulcus (Table 3).
However, postoperative visits were more frequent and visual recovery was
prolonged, 33% needed additional surgery, seven patients (77%) require
distance spectacle correction, six patients (67%) had a final refractive
astigmatism of 1.50 D or more, 6 patients developed glaucoma and
continue to need ophthalmic therapy. Surprisingly, only 33% developed
CME. This resolved with medical treatment in all patients. Only one
patient had IOL exchange.
Table 3. Final corrected visual acuity at last follow up
IOL exchange and anterior
vitrectomy
Glaucoma drainage
implant
Repair of wound leak
1
MA60AC
20/25
1
Baerveldt 101-350
CF
1
n/a
20/20
Observation/medical
treatment
6
20/40 – 20/20
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Discussion
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SPA IOL rotation within the sulcus, even months after implantation, is
common in our patients and lead to monocular diplopia (22.%) and
unstable refractive error (44%).
The AcrySof® SPA IOL has a diameter of less than 13 mm from end to end
and is too short for most eyes. There is no accurate way to estimate the
ciliary sulcus diameter by external measurements. In addition, the
horizontal sulcus diameter is typically shorter than the vertical
diameter[10]. An initially well centered IOL may rotate into a wider sulcus
meridian and decenter.
SPA IOL decentration after initial excellent placement is particularly
undesirable in patients with high visual expectations after toric,
accommodative or multifocal IOL implantation. Given the likely resulting
higher manifest astigmatism and spherical aberration after sulcus
implantation of toric SPA IOL, it appears advisable to rather implant an
alternate three piece lens without astigmatism correction. This also holds
true if the patient has already paid out of pocket for the advanced optic
IOL.
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Discussion
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Further consideration should address the IOL power. Only with capsulorhexis
capture, the same IOL power calculated for capsular bag placement can generally
be used for sulcus placement. Placement of the optic behind the intact anterior
capsulorhexis will sequester the square edge of the optic away from the posterior
surface of the iris. Iris chafing and pigment dispersion may still ensue due to
contact of the SPA IOL haptics with the posterior iris. However, stable and centered
SPA IOL position can be achieved using capsulorhexis capture.
SPA IOLs have successfully been suture fixated onto the sclera[11]. It seems that
the “tacky” surface constitutes an advantage for suture fixation as the haptic will
not slip through the suture material. Scleral suture fixation has proven successful
even after spontaneous dislocation of a SPA IOL haptic into the anterior
chamber[12]. While scleral suture fixation can be considered intraoperatively to
securely place a SPA IOL into the sulcus, the surgeon must consider the additional
time needed in a soft, vitrectomized eye often under topical anesthesia. The more
anterior optic location in the sulcus requires that the lens power be reduced by 0.5
to 1.0 D when the entire PCIOL is placed in the sulcus. This eliminates the desirable
use of SPA IOL calculated for capsular bag placement in most cases with
insufficient capsular support or the final refraction cannot meet the set target.
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Discussion
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Placement of any posterior chamber IOL in the ciliary sulcus carries the potential
to cause complications such as pigment dispersion. However, a 3-piece posterior
chamber IOL with posterior angulation of the haptics will move the optic away
from the posterior pigment epithelium of the iris.
Additionally, a 3-piece IOL with a relatively thin optic edge and small, round
haptics will reduce potential problems when placed in the sulcus. Though none of
the patients in this series manifested heavy pigment deposition in the trabecular
meshwork of the operated eye or iris transillumination defects as evidence of iris
chafing, chronic secondary glaucoma developed in 66% of patients, necessitating
glaucoma drainage implant surgery in one individual. One patient developed
uveitic glaucoma, however the full picture of uveitis-glaucoma-hyphema (UGH)
syndrome was not observed.
A recent report on complications after SPA IOL implantation into the sulcus[8] and
the corresponding editorial[13] provide a comprehensive review and discussion of
associated risks, complications, and management of complications. Surgical
alternatives for SPA IOL placement in the sulcus are detailed and discussed.
Technological advancement in cataract surgery has raised today’s patients’ and
surgeons’ expectations for an elegant, fast surgery followed by a smoothe
postoperative course and rapid visual recovery to excellent uncorrected visual
acuity. There is no place for SPA IOLs in the sulcus.
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References
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