A new technique for suture fixation of posterior chamber intraocular lenses that eliminates intraocular knots

A New Technique for Suture Fixation of Posterior Chamber Intraocular Lenses that Eliminates Intraocular Knots Ruben Grigorian, MD,1 John Chang, MD,1 Marco Zarbin, MD, PhD,1 Lucian Del Priore, MD, PhD2 Purpose: The aim of this study was to describe a new technique for transscleral suturing of posterior chamber intraocular lenses (PCIOLs) without intraocular knots. Design: Retrospective noncomparative case series. Participants: Twenty-four eyes underwent implantation of PCIOLs with this new technique. Methods: Suture fixation of PCIOLs was performed in eyes without capsular support. Main Outcome Measures: The anatomic and functional outcome of surgery was determined during a follow-up of 2 to 40 months. Results: The PCIOL remained well centered without tilt in 22 of 24 (92%) eyes. The PCIOL was well centered in 16 of 17 (94%) eyes followed for ⱖ6 months. Complications related to lens suturing were minimal and resolved spontaneously. Final visual outcome depended almost entirely on the underlying health of the retina and optic nerve. Conclusion: This technique eliminates intraocular knots, minimizes operating time with an open globe, and provides excellent lens centration in the absence of capsular support. Ophthalmology 2003;110:1349 –1356 © 2003 by the American Academy of Ophthalmology.

In cases with little or no capsular support, anterior chamber intraocular lenses (ACIOLs) or sutured (iris-sutured or transsclerally sutured) posterior chamber intraocular lenses (PCIOLs) can be used for optical rehabilitation of aphakic eyes. Potential disadvantages of ACIOL implantation include corneal decompensation, secondary glaucoma, and cystoid macular edema (CME).1 As a result, many surgeons prefer PCIOL fixation in eyes lacking capsular support. Potential advantages of PCIOLs over ACIOLs include a reduction in the number of optical aberrations (e.g., magnification, aniseikonia, lens edge glare, flutter), a decreased incidence of secondary glaucoma, and free movement of the pupil to control the amount of light entering the eye. The risk of corneal decompensation, secondary glaucoma, and CME may be less with PCIOLs compared with ACIOLs.2 Several techniques for PCIOL fixation exist.3–7 Iris-sutured PCIOLs offer the advantages of reduced operative Originally received: April 3, 2002. Accepted: September 26, 2002.

Manuscript no. 220252.

1

Institute of Ophthalmology and Visual Science Ophthalmology, New Jersey Medical School, Newark, New Jersey.

time and no complications associated with transscleral sutures, such as ciliary body hemorrhage and suture exposure through the conjunctiva. Complications associated with this type of fixation include suture-induced iris chafing, iris atrophy, inflammation (uveitis, CME), pigment-dispersion syndrome, and limited pupillary motility.2,8 Transsclerally sutured PCIOLs, when placed properly, do not contact the iris and therefore reduce the risk of complications associated with iris-sutured lenses. However, this type of fixation often requires more surgical time and manipulation and may increase the risk of intraoperative hemorrhage and postoperative infection.9 –11 We present a new surgical technique for transscleral suture fixation of PCIOLs. The aim of this study was to assess intraoperative and postoperative complications and visual and anatomic outcomes after suturing PCIOLs by a technique that minimizes the amount of time the globe is open during surgery and eliminates intraocular suture knots. These advantages are realized by creating intraocular suture loops in preparation for PCIOL placement before creating a limbal incision.

2

Department of Ophthalmology, Columbia University, New York, New York, USA. Supported by grants from Research to Prevent Blindness, Inc., the Eye Institute of New Jersey (Newark, NJ) and the New Jersey Lions Eye Research Foundation (Princeton, NJ). The authors have no proprietary interest in any of the materials used in the study. Reprint requests to Marco Zarbin, MD, PhD, Institute of Ophthalmology and Visual Science, New Jersey Medical School, DOC bldg. 6-th floor, 90 Bergen Street, Newark, NJ, 07103-2499.

© 2003 by the American Academy of Ophthalmology Published by Elsevier Inc.

Methods This study is retrospective. We reviewed the medical records, from January 1995 to June 2002, of all cases of eyes with sutured PCIOLs. Review of the charts established a database, including factors such as age of the patient at the time of the surgery, ocular history, initial and final visual acuity, preoperative and postoperative intraocular pressure, and anatomic and functional outcome. The study was designed to identify clinical features, complicaISSN 0161-6420/03/$–see front matter doi:10.1016/S0161-6420(03)00467-6

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Figure 1. Ab externo insertion of a long 27-gauge needle (1.0 mm posterior to the limbus at the 3-o’clock position and exited at the 9:15o’clock position in a ciliary sulcus location).

tions, and outcomes associated with the new technique of PCIOL suturing.

Surgical Technique 1. The lens used is a Bausch & Lomb Model 6190B onepiece, polymethyl methacrylate with optic size 6.50 mm, biconvex, length 12.75 mm, displaying haptics with two mid-loop eyelets. 2. Either 50% thickness limbal-based triangular scleral flaps or circumferential 60% thickness scleral incisions are created, centered at the 3-o’clock and 9-o’clock positions. 3. Flexible iris retractors are placed at the 2, 4, 8, and 10o’clock positions; limbal incisions are created with a sharp blade, and the pupil is dilated widely. 4. If the eye has not previously undergone vitrectomy, a conventional three-port vitrectomy is done. Peripheral vitreous is dissected meticulously. 5. A long 27-gauge bent needle is inserted ab externo 1.0 mm posterior to the limbus at the 3-o’clock position and exited at the 9:15-o’clock position in a ciliary sulcus location (Fig 1). 6. A straight, 16-mm long needle, carrying Ethicon 10-0 polypropylene suture, is swaged, blunt end first, into the barrel of the 27-gauge needle and maximally advanced. 7. The entire assembly is withdrawn into the vitreous cavity (Fig 2). 8. The entire assembly is directed out of the eye, through the ciliary sulcus, at the 8:45-o’clock position (Fig 3). 9. The 27-gauge needle is withdrawn from the eye. This maneuver creates an intraocular loop of 10-0 polypropylene suture centered at the 9-o’clock position with two externalized sutures under the scleral flap (Fig 4). 10. A scleral tunnel or partial-thickness beveled limbal incision for PCIOL implantation is fashioned at the 12-o’clock

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Figure 2. A straight, 16-mm long needle, carrying Ethicon 10-0 polypropylene (Prolene) suture is swaged blunt end first into the barrel of the 27-gauge needle and maximally advanced. The entire assembly is withdrawn into the vitreous cavity.

position. If a limbal incision is made, the anterior chamber is entered with a sharp blade at the 12-o’clock position only (Fig 5). 11. The loop of 10-0 polypropylene is externalized through the scleral tunnel using a hook (Figs 6 and 7). 12. A long 27-gauge bent needle is inserted ab externo 1 mm posterior to the limbus at the 9 o’clock position (between the prolene sutures) and exited at the 3:15-o’clock position in a ciliary sulcus location. The same steps are followed in

Figure 3. Re-passage of the entire complex through the ciliary sulcus at the 8:45-o’clock position.

Grigorian et al 䡠 New Technique for Suture Fixation of PCIOLs

Figure 4. Withdrawing the 27-gauge needle from the eye. Blunt end of 16-mm long needle remains in the vitreous cavity.

the 3-o’clock position scleral bed to create the second externalized loop of 10-0 polypropylene. 13. The loop is twisted and passed through the eyelet attached to the haptic. The prolene suture is looped around the haptic without a knot (Fig 8). 14. The scleral tunnel is widened as needed, or the limbal incision is opened fully with a sharp blade to accommodate the IOL. 15. The PCIOL is introduced into the eye; the haptics are seated in the ciliary sulcus, and the lens is centered in the

Figure 6. Externalization of the loop of 10-0 Prolene through the scleral tunnel or limbal incision using a hook.

sulcus by pulling up on the externalized sutures (Fig 9). One can avoid intraocular suture tangles by pulling gently on the externalized sutures under the flaps so that the sutures are under mild tension. As the PCIOL is guided into the ciliary sulcus with one hand, the surgeon can use the other hand to pull up further on the free suture ends associated with the haptic that is entering the eye. 16. The externalized sutures are tied and trimmed slightly long so that they lie flat against the sclera. The knots are buried under the scleral flaps, which are sewn shut with 10-0 nylon suture (Fig 10). 17. The scleral tunnel is closed with 10-0 nylon suture; the sclerotomies are closed with 7-0 Vicryl, and the conjunctival incisions are closed with 6-0 plain gut.

Results

Figure 5. Fashioning of the scleral tunnel or partial-thickness beveled limbal incision for posterior chamber intraocular lens implantation at the 12-o’clock position. (If a limbal incision is made, the anterior chamber is entered with a sharp blade at the 12-o’clock position only.)

Twenty-four patients were operated on in the Ophthalmology Department at the New Jersey Medical School (13 men, 11 women). There were 8 whites, 8 blacks, 6 Hispanics, and 2 patients of other racial origin. The mean age was 50 years (range, 20 – 88 years). The duration of follow-up ranged from 2 to 40 months (mean, 15 months). Nineteen (79%) of 24 eyes had sustained trauma before PCIOL implantation. The interval between the trauma and PCIOL suturing ranged from 2 months to 4 years (mean ⫾ standard deviation, 13 months ⫾ 14.5 months). The preoperative diagnosis was aphakia in 9 eyes (status post traumatic cataract extraction in seven and status post routine cataract extraction in 2); traumatic cataract/subluxated crystalline lens in 9 eyes (after blunt trauma in seven and after penetrating

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Figure 8. Creation of the loop around the haptic. The looping of the suture through the eye-hook and around the haptic is shown in high magnification.

Figure 7. Externalization of the second loop through the scleral tunnel or limbal incision (created in similar fashion to the first loop).

trauma in two); and dislocated intraocular lens (ACIOL or PCIOL) in 6 cases. In the last group, the dislocated lens was an ACIOL in 3 eyes (in one case caused by trauma) and a PCIOL in 3 eyes (in two cases caused by trauma). Eighteen eyes were followed for ⱖ6 months. Four eyes (22%) achieved final visual acuity of 20/40 or better (logarithm of the minimum angle of resolution equivalent: ⬍ 0.3); 5 eyes (28%) achieved 20/50 to 20/100 (logarithm of the minimum angle of resolution equivalent: 0.4 – 0.7), and 9 eyes (50%) achieved final visual acuity less than 20/100 (logaritham of the minimum angle of resolution equivalent: ⬎ 0.7). Final visual acuity was improved in 9 eyes (50%), did not change in eight (44%) eyes, and worsened in 1 eye (6%) (Table 1). In the group with visual loss, one eye developed retinal detachment because of proliferative vitreoretinopathy (PVR). This patient underwent vitrectomy and PCIOL suturing after ACIOL dislocation after trauma. Subsequently, the patient underwent 4 penetrating keratoplasties in the same eye to manage rheumatoid melts. Two years after PCIOL suturing, the patient developed a traction-rhegmatogenous retinal detachment caused by PVR. She declined additional surgery. Final visual acuity was ⬍20/40 in 14 eyes and was limited by (1) previous retinal detachment with PVR in two eyes, (2) corneal edema in 2 eyes (one was related to trauma and one was related to recurrent erosion), (3) optic neuritis in 2 eyes (both cases diagnosed by neuroophthalmologists on our full-time faculty), (4) glaucoma in one eye, (5) epiretinal membrane in one eye (6) myopia in one eye, (7) macular degeneration in one eye, (8) clinically significant (nondiabetic) macular edema in 2 eyes, (9) macular scar in one eye, and (10) and irregular corneal astigmatism in one eye (Table 2).

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In all 24 eyes the PCIOL remained well centered and without tilt at 1 month of follow-up. The PCIOL remained centered and without tilt in 16 of 17 eyes (94%) that have a follow up ⱖ6 months and became slightly superiorly decentered in one eye (6%). In this case, there was no torquing of the lens. (In one eye with 6 months follow-up, we are uncertain of lens centration because of corneal opacification, but the lens was centered at the 1-month follow-up visit.) On postoperative day 1, intraocular pressure (IOP) ⬎ 21 mmHg was present in 9 eyes (39%) (range, 23–38 mmHg). All nine eyes with elevated IOP were treated medically (using Timoptic 0.5%, twice daily; Cosopt, twice daily; Alphagan, 2 to 3 times daily oral; and/or Diamox 500 mg twice daily). Of the 9 eyes with increased IOP after surgery, one subsequently developed a shallow anterior chamber with IOP of 38 mmHg. This patient had a history of primary angle-closure glaucoma. The pressure was elevated on the first day after surgery while the anterior chamber was formed. During the first 7 days after surgery, iridocorneal apposition developed from the 11-o’clock to the 1-o’clock positions because of iris displacement by the intraocular gas bubble, and the anterior chamber was reformed at the slit lamp to preserve as much functioning angle as possible. The IOP normalized subsequently. IOP ⬍ 8 mmHg was present in 6 eyes (26%) (range; 1 mmHg to 7 mmHg) immediately after surgery. All 6 eyes with low IOP were observed closely, and their IOP normalized spontaneously. Additional postoperative complications in our series are as follows. Mild vitreous hemorrhage, which we believe was due to bleeding from a sclerotomy site or a ciliary sulcus suture pass, occurred in a total of 3 eyes (12.5%). Vitreous hemorrhage resolved spontaneously in each case. Choroidal detachment developed in one eye (4.2%) and resolved spontaneously. Other complications that developed postoperatively were anterior uveitis in one eye (4.2%), hyphema in one eye (4.2%), bleeding from the

Grigorian et al 䡠 New Technique for Suture Fixation of PCIOLs

Figure 9. Positioned posterior chamber intraocular lens with externalized sutures. The looping of the suture through the eye-hook and around the haptic is shown in high magnification.

suture tract in one eye (4.2%), corneal edema in 2 eyes (8.3%), CME in one eye (4.2%), PVR with retinal detachment in 2 eyes (8.3%), and irregular corneal astigmatism in one eye (4.2%) (Table 3).

Discussion In the absence of sufficient capsular support, both ACIOLs and sutured PCIOLs (iris or transscleral) can be used to

Figure 10. Tying and trimming of the externalized sutures.

correct aphakia. Technically, ACIOLs are easier to implant and require less surgical manipulation. Nevertheless, ACIOLs may be more damaging to the corneal endothelium than PCIOLs.12 Iris-sutured PCIOLs offer several advantages over transsclerally sutured PCIOLs, including a more straightforward technique, reduced surgical time, and no complications associated with transscleral sutures. However, the structural and functional nature of the iris makes it a suboptimal structure for fixation. Moreover, iris-sutured PCIOLs have been associated with several complications.8 Transsclerally sutured PCIOLs reduce the rate of the complications associated with iris-sutured PCIOLs. Numerous transsclerally sutured PCIOL implantation techniques have been described.7,13–21 The essential modification of our technique is the creation of an intraocular suture loop that can be externalized, passed through the eyehooks of a haptic, and fixated to the haptic in a manner that eliminates intraocular knots. This technique also minimizes the time that the globe is open before insertion of the intraocular lens. Transscleral sutures might be expected to increase the risk of choroidal hemorrhage or effusion. Heidemann and Dunn22 found that 3.6% of sclera-sutured PCIOLs were associated with a choroidal detachment. Holland et al23 reported that when choroidal detachments occurred, often they were found in the meridian of a transscleral suture. We have experienced 2 suture-site–related complications: choroidal detachment in one eye (4.2%) and bleeding from the suture site in one eye (4.2%). After the case with choroidal detachment (the second in this series), we used sutured triangular flaps to cover the external suture sites. No subsequent cases of choroidal detachment developed. Initially, after the surgery, aqueous fluid can leak through the scleral incisions causing choroidal detachment. Scleral flaps prevent the leakage of the fluid and thus prevent choroidal detachment. In addition to reducing the likelihood of postoperative choroidal detachment (because aqueous can leak through the scleral incisions initially), we believe the scleral flaps may reduce the chance of endophthalmitis by covering the externalized sutures and preventing erosion through the conjunctiva.24 Erosion of the external polypropylene sutures placed under scleral flaps has been reported to occur in 5% to 17% of cases. External erosion through conjunctival flaps has been reported to occur in 5% to 50% of cases,25–27 (Lane SS et al. [Invest Ophthalmol Vis Sci 1990;31(Suppl): 573). It is important to minimize the incidence of external suture erosion because the suture tract may become an avenue by which microorganisms gain entry into the vitreous cavity. To decrease the incidence of external suture erosion, Lane et al8 and Lewis18 have suggested that one rotate external knots to an intraocular position. We do not believe that suture rotation would be easy or safe to achieve using the technique we describe, given the way in which the suture is swaged through the eyehook and looped around the haptic. If scleral flaps are used, we recommend leaving the suture ends slightly long, so they lie flat against the sclera, thus reducing the risk of conjunctival penetration. If a scleral groove is used instead, we recommend leaving the

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Ophthalmology Volume 110, Number 7, July 2003 Table 1. Postoperative Final Best-corrected Visual Acuity in Eyes with Follow-up ⱖ6 Months Best-corrected visual Acuity Preoperative Status

Improved

No change

Worse

20/20–20/40

20/50–20/100

⬍20/100

Aphakia Traumatic cataract, subluxated crystalline lens Dislocated ACIOL/PCIOL Total

4 3

3 3

0 0

1 1

1 2

5 3

2 9 (50%)

2 8 (44%)

1 1 (6%)

2 4 (22%)

2 5 (28%)

1 9 (50%)

ACIOL ⫽ anterior chamber intraocular lens; PCIOL ⫽ posterior chamber intraocular lens.

suture ends short to reduce protrusion external to the plane of the sclera. Precise PCIOL centration is important. Decentration or tilt of the IOL not only can cause decreased visual acuity or visual aberrations, but it also can cause secondary intraocular tissue effects. IOL decentration is related partially to IOL design, materials, and mechanical properties of the haptics.28,29 However, several studies demonstrate a direct correlation between decentration and asymmetric fixation of the PCIOL in the ciliary sulcus.30 –32 In an endoscopic comparison of PCIOL suture techniques, Althaus and Sundmacher33 showed that only 20% of the IOL haptics were placed correctly and sutured in the sulcus. Holland et al34 reported proper positioning of IOL haptics in 77% cases. Accurate ciliary sulcus fixation reduces the risk of dislocation of the IOL. Generally, the accuracy of the needle placement cannot be guaranteed, because the needle cannot be visualized behind the iris. Kora et al5 described two techniques to improve placement of the needle in the sulcus. In 12 of their cases, 2 iridectomies were made to permit a view of the ciliary sulcus. However, this method can result in monocular diplopia. In 3 other cases, they used an endoscope to ensure proper haptic position. No complications were associated with that device, which allowed visualization of the ciliary sulcus using the operating microscope. Eguchi and Araie35 described a method for direct visualization of the ciliary sulcus with videoendoscopy. A theoretical Table 2. Causes of Visual Acuity ⬍20/40 among Eyes with Follow-up ⱖ6 months (n ⫽ 18) Cause of Visual Loss

Ocular Condition

Traumatic Cataract, Dislocated Subluxated Intraocular Cause of Visual Loss Aphakia Crystalline Lens Lens PVR, RD Corneal edema Optic neuritis Glaucoma ERM Myopia Macular degeneration CSME Macular scar Astigmatism

1 1 1 1 1

1 1 1 1 1 1 1

1 1

Table 3. Postoperative Complications Total (%) 2 (11) 2 (11) 2 (11) 1 (5.5) 1 (5.5) 1 (5.5) 1 (5.5) 2 (11) 1 (5.5) 1 (5.5)

CSME ⫽ clinically significant macular edema; ERM ⫽ epiretinal membrane; PVR ⫽ proliferative vitreoretinopathy; RD ⫽ retinal detachment.

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disadvantage of videoendoscopy is loss of control of the field of observation of the operating microscope when the surgeon looks at the videomonitor. Sharkey and Murray36 suggested the method of transillumination. Before the sclerotomy, a light device is passed posterior to the globe, and illumination is created in the dark room to clearly demarcate the ciliary body and indicate the position of the ciliary sulcus. Roldan-Pallares and Manrique37 suggested placing a transilluminator in the inferonasal quadrant, 3 mm posterior to the limbus. Tilting of sutured IOLs also can be due to suture configuration and/or asymmetric placement of the haptics.28 –32,38,39 Lens tilt or decentration is found in 5% to 10% eyes after scleral-sutured PCIOL implantation.40 We observed no cases of lens tilt in this study, but we did have a single case of mild lens decentration that probably arose as a result of suture wrapping around a haptic during PCIOL placement. We used a flexible iris retractor to improve visualization of the ciliary sulcus and increase the accuracy of the needle placement in the sulcus. In our series, PCIOLs remained well centered and without tilt in 100% of cases at the 1-month follow-up visit and in 94% of cases with follow-up ⱖ6 months. The centration rate in published studies ranges from 48% to 100%.1,2,5–7,11,15–19,21,39,41– 48 The risk of expulsive choroidal hemorrhage is believed to increase with increased surgical time and manipulation.49 –51 Our technique minimizes the amount of time that the globe is open during the surgery, because the limbal incision or scleral tunnel is made only once the PCIOL is ready to be placed in the ciliary sulcus. Comparison of the results of this small series with those

Complication

Frequency (%)

Astigmatism Choroidal detachment Corneal edema Cystoid macular edema Flattening of anterior chamber Hyphema PVR, RD Bleeding from the suture site Uveitis Decentration Vitreous hemorrhage

1 (4.2) 1 (4.2) 2 (8.3) 1 (4.2) 1 (4.2) 1 (4.2) 2 (8.3) 1 (4.2) 1 (4.2) 1 (4.2) 3 (12.5)

PVR ⫽ proliferative vitreoretinopathy; RD ⫽ retinal detachment.

Grigorian et al 䡠 New Technique for Suture Fixation of PCIOLs Table 4. Results and Postoperative Complications after Sutured Posterior Chamber Intraocular Lenses—Review of the Literature Authors Agapitos, 1989 (19 eyes)43 Bergren, 1994 (8 eyes)21 Chen et al, 2001 (38 eyes)44 Cowden and Hu, 1988 (14 eyes)45 Durak et al, 2001 (56 eyes)39 Epley et al, 16 (20 eyes) Gabric et al., 1996 (109 eyes)1 Hannush, 2000 (208 eyes)2 Hu et al, 1988 (6 eyes)15 Imaim et al, 2001 (10 eyes)46 Kora et al, 1991 (23 eyes)5 Lewis, 1991 (over 80 eyes)7 Lewis, 1993 (100 eyes)18 Lindquist et al, 1989 (38 eyes)47 McCluskey, 1994 (32 eyes)48 Shapiro, Leen, 1991 (7 eyes)19 Schmidt, 2002 (17 eyes)17 Smiddy, 1990 (10 eyes)6 Solomon et al, 1993 (30 eyes)41 Spigelman, 1988 (22 eyes)42 Stark et al, 1989 (24 eyes)11

Well Centered (%)

Complications*

95 100 95 100 48 100 93 100 100 100 100 100 100 100 95 97.5 100 71 80 90 100 100

H-10.5%, VH-5.2%, SE-5.2%, IOP-10.5% None CE-27%, GS-21% U-7%, 1 IOP-7% No data VH-5%, I-5%, CME-15% A-17.4%, CME-16.5%, SE-9.2%, 1 IOP-4.6%, U-2.8%, AS-4.6%, HP-0.9% BH-⬍1%, CME-6%, 1 IOP-9% (flapless) None 1 IOP-40% VH-22%, 1 IOP-13% No data 60 eyes with flap; SE-20%, CME-15% 40 eyes flapless; SE-0%, CME-23% SE-8%, H-5.2%, VH-2.6%, 1 IOP-2.6% SE-12.5%, H-6.25%, CME-6.25%, VH-3.125%, RD-3.125% None None SE-10%, CME-10% SE-73%, OAG-17%, SCH-3% None SE-4.2%, CME-4.2%

A ⫽ astigmatism; AS ⫽ anterior synechia; BH ⫽ broken haptic; CE ⫽ corneal edema; CME ⫽ cystoid macular edema; GS ⫽ goniosynechia; H ⫽ hyphema; 1 IOP ⫽ elevated intraocular pressure; I ⫽ iritis; OAG ⫽ open-angle glaucoma; RD ⫽ retinal detachment; SCH ⫽ suprachoroidal hemorrhage; SE ⫽ suture erosion; U ⫽ uveitis; VH ⫽ vitreous hemorrhage.

in the reported literature (Table 4) indicates that this technique is relatively safe and effective. Some complications that we did not observe (e.g., suture erosion) may become evident as we acquire longer follow-up data on this cohort of patients. The limitations of this study include the retrospective nature of the study, the skewed patient population (most patients sustained previous trauma), and the limited duration of follow-up.

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