|Year : 2012 | Volume
| Issue : 2 | Page : 77-80
Visual and surgical outcomes in non sutured secondary posterior chamber intraocular lens implantation
KJN Siva Charan
Department of Ophthalmology, Maharajah's Institute of Medical Sciences, Nellimarla, Vijayanagaram, Andhra Pradesh, India
|Date of Web Publication||11-Jul-2012|
KJN Siva Charan
Assistant Professor of Ophthalmology, Maharajah's Institute of Medical Sciences, Nellimarla - 535 217, Vizianagaram District, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Aim: To study the visual and surgical outcomes in non-sutured secondary posterior chamber intraocular lens implantation (PC IOLS).
Materials and Methods: Retrospective analysis of 100 cases of non-sutured secondary PC IOLS done between June 2007 to June 2008 at tertiary eye hospital.
Results: 97% of patients had excellent visual and surgical results with non-sutured secondary PCIOL implantation.
Conclusion: Our study shows the importance of aborting primary IOL implantation in the event of intra-operative posterior capsular rupture with doubtful capsular support, followed by a postoperative assessment, and good surgical technique can give excellent results in secondary PC IOL Implantation. Long-term complications are similar to primary PC IOL implantation.
Keywords: Non-sutured, posterior chamber intra ocular lens, secondary
|How to cite this article:|
Charan KS. Visual and surgical outcomes in non sutured secondary posterior chamber intraocular lens implantation. J NTR Univ Health Sci 2012;1:77-80
|How to cite this URL:|
Charan KS. Visual and surgical outcomes in non sutured secondary posterior chamber intraocular lens implantation. J NTR Univ Health Sci [serial online] 2012 [cited 2021 Jul 30];1:77-80. Available from: https://www.jdrntruhs.org/text.asp?2012/1/2/77/98332
| Introduction|| |
After cataract surgery, patients without intraocular lens implantation cannot achieve functional visual acuity because of contact lens or spectacle intolerance. Intraocular lens implantation is the best method of correcting Aphakia.  There were lot of studies evaluating the outcome of secondary PCIOL's, which included both sutured and non-sutured PCIOL's, but in our study, we have restricted ourselves to evaluate the clinical results of secondary non-sutured posterior chamber IOLs done at tertiary eye hospital between June 2007 to June 2008. This was retrospective analysis of 100 cases.
| Materials and Methods|| |
100 patients who had attended the IOL clinic between June 2007 and June 2008 and who had been rendered aphakic during primary ocular surgery for any reason with significant posterior capsular support were considered for secondary intraocular lens implantation.
An informed consent was taken from all patients. Surgery was performed under local anesthesia using 2% xylocaine and 0.5% bupivacaine (peribulbar block). Secondary IOL implantation was performed by 2 surgeons. A superior or temporal sclerocorneal tunnel was performed depending on the surgeon's preference and preoperative astigmatism. In all cases, optimal and judicious use of viscoelastic hydroxypropyl methyl cellulose was exercised. Synechiolysis was performed using a cyclodialysis spatula or cut with vannas scissors to release synechiae, which were extensively adherent to anterior capsule or posterior capsule of the lens. In all cases, anterior and posterior capsular support was reassessed on table. If vitreous was present in the anterior chamber, adequate anterior vitrectomy was performed by an automated vitrectomy machine. A single piece or 3 piece PMMA lens was inserted, depending on support available for placing the IOL. Wound was closed with suture (9-o nylon) in most of cases.
Any patient who had been rendered aphakic for any reason during primary cataract extraction with adequate capsular support was planned for secondary intraocular lens implantation.
- Abnormal pupil (severe updrawn pupil and fixed and dilated pupil)
- Severe peripheral anterior synechiae
- Patient with recurrent uveitis
- Aphakic glaucoma
- Vitreo-retinal problem
- Any patient having less than 3 months follow-up period
Reasons for secondary iol implantation
Follow-up period: the follow-up period was taken as 6 months.
| Results|| |
Age Range- 8 to 80 years
Sex Ratio- 64 Male, 36 Female
Mean interval between cataract surgery and secondary pc iol implantation - 4 to 5 months.
The age range of patients who received secondary IOL implantation ranged from 8 to 80 years. The mean between initial surgery to secondary IOL implantation was 4-5 months. The most common indication for secondary IOL implantation was due to intolerance to spectacles or contact lens or contralateral eye being pseudophakic, young patients in whom IOL implantation was deferred at initial surgery in corneal tear repairs, and congenital cataract extraction.
There were more males as compared to females in our present study. About 85% of patient developed good visual acuity in immediate postoperative period (up to 6/24). Only 15% of patients has visual acuity less than 6/24 in immediate postoperative period, the most common reasons for decreased visual acuity was patients having preoperative corneal scar and post-operatively corneal edema, and fibrinous membrane and striate keratopathy.
Most common immediate post-operative complication [Table 1] was significant anterior chamber reaction, which was seen in 19 patients. 8 patient's developed corneal edema. Both iritis and corneal edema resolved at end of 1 month with appropriate medical therapy. Striate keartopathy was seen in 5 patients. 1 patient developed trace Hypopyon, which was subsequently diagnosed as toxic anterior segment syndrome, which resolved at 1 month postoperatively with adequate steroid therapy. 1 patient developed 360 degree choroidal detachment, which was treated medically and resolved by 4 months by post-operatively. 1 patient had a wrong IOL power inserted, which was later exchanged at 1 month postoperative period. 2 patients developed hyphema in immediate postoperative period, which resolved at end of 1 month by adequate medical therapy.
| Discussion|| |
Surgeons have 4 main options for treating aphakic patients.
Standard PCIOLs placed in ciliary sulcus or capsular bag are the standard of care. 
- Capsular bag fixated or sulcus fixated secondary IOLs
- Scleral fixated PCIOLs
- Iris fixated PCIOLs
Aphakic patients with residual capsule often have synechiae between anterior capsule and posterior surface of the iris or between anterior and posterior capsule. Surgeon has the option of the placing a PCIOL in ciliary sulcus after releasing adhesions or attempting capsular bag placement after reopening the bag. Slability and complications rates are similar to that primary PCIOL implantation in the sulcus.
Advantages non-sutured secondary PC IOLs
- Lower incidence of CME
- Lower incidence of pupillary block
- Lower incidence of UHG syndrome (uveitis glaucoma hyphema)
- Lower incidence of peripheral bullous keratopathy
- Less endothelial cell loss
- Mechanical barrier against vitreous movement and barrier against diffusion of vasoactive substances that could lead to CME or retinal detachment
- Positioned at nodal point of eye
- Distance from trabecular meshwork
Major indications for secondary PC IOLs
In patients with intact posterior capsule, a significant surgical obstacle is reopening the capsular bag.  In cases without expensive capsular fibrosis, the anterior and posterior capsule are separated. The key is locating one area in which the anterior capsules edge is not strongly adherent to posterior capsule. Using this entry point, viscoelastics are used to separate the capsules layers. If adhesions are very dense, blunt dissection with cannulas or other instruments can be attempted. In some cases, the adhesions can be left intact focally by creating an extension of anterior capsulotomy peripheral to adhesion using either capsulorhexis-like tearing techniques or scissors cutting the anterior capsule. A final alternative is sharp discussion between anterior and posterior capsules, but this carries a greater risk of penetrating the posterior capsule.
- Rupture of posterior capsule at time of cataract surgery
- Patient with threatened expulsive hemorrhage in whom cataract surgery was aborted without IOL placement
- Patients with closed loop AC IOLs who have been followed closely and have not yet developed generalized corneal edema, but have been found to have decreasing endothelial cell counts
- Increasing corneal thickness
- Cystoid macular edema
- Uveitis-glaucoma-hyphema syndrome
Ciliary sulcus fixation is another alternative for secondary PC IOL implantation.  This requires at least peripheral capsular support and intact zonular support. It is often necessary to lyse adhesions between capsular remnants posterior iris to reconstruct the ciliary sulcus for IOL placement.  It is important to visually confirm that the haptics are not inadvertently directed under the anterior capsule during insertion to ensure proper support and avoid vitreous entanglement.
Overall results of secondary IOL surgery are better if the initial cataract surgery has been uncomplicated. Eyes with previous cataract surgery complicated by vitreous loss have worse results, regardless of type of IOL used at second surgery. The most common postoperative complications of secondary PC IOL in whom the primary surgery is associated with significant surgical complication and vitreous loss is a persistent CME.  However, in our present study, most of CMEs resolved over a period of 6 weeks with adequate topical NSAIDs treatment [Table 2].
Second most common complication encountered was a secondary glaucoma, which can be due to blockage of trabcular meshwork by inflammatory cells released during postoperative inflammation since most of surgeries one associated with significant synechiolysis with concomitant involvement of iris.
Lens tilt / decantation can occur in few of those patients; therefore, IOLs with large optics are recommended so that a small degree of decentration is not usually clinically significant. 
Pseudophakic bullous keratopathy has not been a frequent reported complication of our study, perhaps because of relatively short follow-up of our present study. However, since our study was a retrospective analysis, we could not have details of preoperative secular microscopy and postoperative secular microscopy.
Bleeding in form of hyphema or vitreous hemorrhage would be anticipated to be a frequent problem with secondary PC IOLs as extensive surgical manipulation involving the iris to release iridocapsular adhesions and vitrectomy needed to clear vitreous in anterior chamber and close proximity of IOL haptics to the ciliary sulcus irritating the ciliary body.  Vitreous hemorrhage if it occurs is usually self-limited and spontaneously clears over a period of 6 weeks. Hyphema can also occur due to bleeding from section in any case of secondary PC IOL; therefore, it is always advisable to close the wound with sutures.
Retinal detachment, though infrequent, is a reported complication of secondary PC IOLs. Retinal detachment after secondary IOL implantation is primarily due to changes in the vitreous and the retina. There is a significant increase in the posterior vitreous detachment; anterior vitreous changes are dramatic because the extraction of the lens deprived the vitreous of its support at the level of patellar fossa.  An increase in sagittal diameter of vitreous cavity permits the vitreous to project partially into the anterior chamber, and therefore, increase the traction at the vitreous base or foci of vitreoretinal attachment. In young patients under 5 years of age, there is massive vitreous traction than older patients, resulting in retinal breaks and retinal detachment.
Uveitis is another complication seen in immediate postoperative period. It is usually associated with iris manipulation during synechiolysis and usually resolves with adequate steroid therapy in postoperative period given over a period of 6 weeks.
Choroidal detachment though rare, the risk of choroidal detachment increase with the length of ocular hypotony; most choroidal detachments subside within 3 weeks, and therefore, require no treatment. 
In our own series of patients, we had excellent results in secondary IOL implantation. Proper preoperative assessment and good surgical technique can give excellent results in secondary PC IOL implantation. The long term complications are almost similar to any primary IOL implantation.  Our study shows the importance of aborting the IOL implantation in primary surgical procedure if the surgeon has intraoperative complication and is not sure of adequate capsular support. The patient can be reassessed postoperatively, and IOL implantation can be done as a secondary procedure at end of 3 months when capsular fibrosis occurs, thus increasing the chances of IOL implantation and giving patients good quality vision. 
| References|| |
|1.||Hahn TW, Kim MS, Kim JH. Secondary intraocular lens implantation in aphakia. J Cataract Refract Surg 1992;18:174-9. |
|2.||Magli A, Forte R, Rombetto L. Long term outcome of primary verses secondary intraocular lens implantation after simultaneous removal of bilateral congenital cataract. - Graefes Arch Clin Exp Ophthalmol 2012 [Epub ahead of print]. |
|3.||Avetisov SÉ, AmbartSumian AR. Ultrasound biomicroscopy in evaluation of conditions for secondary intraocular lens implantation in aphakia. Vestn Oftalmol 2011;127:25-30. |
|4.||Chen YJ. Secondary in-the bag implantation of intraocular lenses in aphakia eyes after vitroretinal surgeries. Ophthalmologica 2012;227:80-4. doi: 10.1159/000333823. Epub 2011 Nov 22. |
|5.||Nihalani BR, Vanderveen DK. Secondary intraocular lens implantation after pediatric aphakia. JAAPOS 2011;15:435-40. |
|6.||Abdal-Hafez G, Trivedi RH, Wilson ME, Bandyopadhyay D. Comparison of aphakic refraction formula for secondary in the bag intraocular lens power estimation in children. JAAPOS 2011;15:432-4. |
|7.||Baranov lla, Khakimov AM, Effimov OA, Turavatova TV. Intraocular lens implantation into the anterior capsule in cases of posterior capsule rupture during phacoemulsification. Vestn Oftalmol 2011;127:37-40. |
|8.||Ma DJ, Choi HJ, Kim MK, Wee WR. Clinical comparison of ciliary sulcus and pars plana locations for posterior chamber intraocular lens transcleral fixation. J Cataract Refract Surg 2011;37:1439-46. Epub 2011 Jun 24. |
|9.||Choi HJ, Lee JH, Hwang JM. Secondary intraocular lens implantation in longstanding unilateral aphakia. Optom Vis Sci 2011;88:608-12. |
|10.||Chee SP, Jap A. Management of traumatic severely subluxated cataracts. Am J Ophthalmol 2011;15:866-71. e1. Epub 2011 Feb 18. |
|11.||Gimbel HV, Venkataraman A. Secondary in-the-bag intraocular lens implantation following removal of sommering ring contents. J Cataract Refract Surg 2008;34:1246-9. |
[Table 1], [Table 2]