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Consultation Section
consultation section edited by Samuel Masket, M.D.
Q
A 90-year-old male with no significant or active medical disorders had secondary sewn-in posterior chamber intraocular lenses (lOLs) implanted two years before examination for contact lens intolerance many years after bilateral uncomplicated intracapsular cataract extraction (lCCE). Although the patient has no current ocular symptoms, routine slitlamp examination shows that one end of a 10-0 polypropylene suture is exposed on the nasal aspect of the left eye. The remaining lens-supporting scleral sutures for both eyes are buried and quiet. The exposed and unintentionally externalized suture end (Figure 1) is surrounded by a granuloma, although no discharge is noted and the anterior and posterior ocular segments are without signs of inflammation or infection. The cornea, pupil, and chamber angle are bilaterally normal, and no vitreous is present anterior to the IOLs. According to the surgeon's note, a single-armed suture was tied to each of the two loops of a singlepiece poly(methyl methacrylate) (PMMA) lens. Each suture was passed through the sclera and tied to itself after reflecting. a conjunctival flap; no scleral flaps were dissected. At the close of surgery, the conjunctiva was repositioned and sewn into place over the cut ends of the polypropylene sutures. Given the patient's age and ocular findings, what management would you suggest?
Fig. 1.
(Masket) One end of a 10-0 polypropylene suture is exposed on the nasal aspect of the patient's left eye.
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suture erosion is the most common complication of scleral-sutured posterior chamber IOLs. To manage this patient's exposed suture end, it would be useful to know the type of IOL implanted. If it was one of the lenses specifically designed for this purpose (i.e., a lens with a closed eyelet at the apex of the haptic), one can perhaps be more aggressive with cautery and trimming of the suture end. If in the course of manipulation the exposed suture breaks and the haptic is not fibrotic ally attached, the eyelet on the opposite haptic provides greater assurance that the lens will not completely dislocate into the vitreous cavity. Before initiating management, I discuss, at length, the risk of infection versus the risk of IOL dislocation from suture manipulation. Thus far, all of my patients have chosen to proceed with management of the suture. One could argue that in a 90-year-old patient, observation is the more prudent course. However, this patient could live for 10 or more years, and my preference, pending the patient's desires, would be to proceed with the appropriate steps to eliminate the suture exposure. This patient's suture is approximately 1.5 mm to 2.0 mm posterior to the limbus. It is therefore likely that this haptic is not positioned in the ciliary sulcus and not fibrotic ally attached to the ciliary body. In managing patients with this problem, I have found it useful to assess the tension of the fixation suture. If the suture is loose, the haptic has probably achieved fixation and the suture is no longer required. It is difficult to determine from Figure 1 how tight the suture is. Initially, I would attempt to trim the suture end with fine scissors. I would then see the patient for follow-up in two to three weeks. In the interim, I would prescribe a topical antibiotic drop four times a day. If the suture remained exposed, I would attempt to apply cautery over the suture to melt the exposed end. For this technique, I use a hand-held cautery. The full heat from the cautery is usually intolerable to topically anesthetized patients. I therefore heat the tip until it is red hot and wait one to two seconds before approaching the eye with the cautery. To achieve adequate melting, it usually is sufficient to hold the hot tip a millimeter or so away from the suture. There are three potential outcomes from suture melting: (1) the knot retracts sufficiently and becomes covered by conjunctiva within one to two weeks, (2) the knot remains exposed, or (3) the suture breaks. In the last instance, I apply additional antibiotic drops and remove the suture, fully informing the patient of the potential risk of dislocation of this lens haptic. If
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the haptic dislocates, I would refix ate it with an iris fixation suture. A final option would be to create a partial-thickness scleral flap medial to the exposed suture knot and fold this flap over the exposed knot. Fortunately, I have not had to do this. My patients have fallen into one of two categories: (1) the suture is tight, and careful trimming or heating results in sufficient retraction of the knot to achieve conjunctival coverage, or (2) the suture is loose and is no longer required to fixate the IOL. Finally, if the patient requests the suture be left exposed, I carefully inform him or her of the symptoms of endophthalmitis. I suspect that long-term antibiotic prophylaxis is not beneficial. If I manipulate the suture and it breaks and is removed, I advise the patient about the symptoms of dislocation and strongly advise against rubbing or bumping the eye at any time. Douglas D. Koch, M.D.
Stephen S. Lane, M.D.
Houston, Texas
[AI
Stillwater, Minnesota
Externalization of polypropylene suture barbs from a transsclerally fixated posterior chamber lens demands immediate attention from the operating surgeon or consultant. Because of the reports of endophthalmitis associated with exposed suture ends that have become externalized after transscleral fixation of posterior chamber lenses,l the problem cannot be ignored. The exposed suture shown here is in the intrapalpebral, nasal aspect of the left eye where the conjunctiva is often very thin. Initially, I would attempt to thermally cauterize the suture barbs at the slitlamp. After administering topical anesthesia with the addition of a pledget of bupivacaine hydrochloride (4% Marcaine®) or tetracaine hydrochloride over the exposed barb, I would place a lid speculum in the eye and apply a hand-held, portable, thermal cautery needle to the exposed suture barbs. Usually, the polypropylene will melt and retract and the thermal effect of the cautery on the conjunctiva will cause it to coagulate and heal over the retracted and now blunted suture barb ends. The patient is then placed on topical antibiotics for one to two weeks while the conjunctiva heals. If after this time the suture ends remain exposed, I would bring the patient to the operating room and with local or peribulbar anesthesia (depending on the patient's cooperativeness), carefully dissect the conjunctiva and granuloma from the polypropylene knot and barb. The surrounding conjunctiva should be undermined, and a small, round lamellar donor corneal patch can be placed over the exposed barb and sewn in place (Bucci button).2 The conjunctiva is then reopposed. This is an extremely safe procedure and 100% effective in my experience, with no recurrences of knot or barb erosion. Although there are case reports of the suture being cut and removed under circum116
stances like this without difficulty, I have seen several cases of spontaneous dislocation of the posterior chamber lens when attempting this. I would strongly discourage others from taking this chance because an intraocular procedure would be necessary to refixate the IOL, and a relatively minor external procedure as described can remedy the problem. Finally, a number of steps can be taken to avoid this problem. Use of IOLs with positioning eyelets on the haptics (Alcon CZ70BD, Storz P366UV) allow the surgeon to place a double-armed suture to fixate the lens while burying the knot within the sclera, leaving no potential for erosion. I would also recommend putting the IOL in an oblique or vertical meridian, where the conjunctiva tends to be thicker and more redundant, thus lessening the chance for erosion. In addition, the long posterior ciliary arteries and nerves can be avoided?
REFERENCES 1. Heilskov T, Joondeph BC, Olsen KR, Blankenship
GW. Late endophthalmitis after transsc1eral fixation of a posterior chamber intraocular lens (letter). Arch Ophthalmol 1989; 107:1427 2. Bucci FA Jr, Holland EJ, Lindstrom RL. Corneal autografts for external knots in transsc1erally sutured posterior chamber lenses (letter). Am J Ophthalmol 1991; 112:353-354 3. Lane SS, Lubniewski AJ, Holland EJ. Transsc1erally sutured posterior chamber lenses: improved lens designs and techniques to maximize lens stability and minimize suture erosion. Semin Ophthalmol 1992; 7:245-252
[AI
In a 90-year-old patient, one would want to intervene as little as possible. Yet an exposed fixation suture may lead to a major complication if endophthalmitis occurs. I would first try noninvasive approaches. Initially, I would cauterize the exposed area of the suture down to the suture knot. If done carefully, this can be performed successfully without breaking the suture and in this case, would probably allow the conjunctiva to heal over the surface and solve the problem. If, after cauterization, there is still difficulty with closure, I would incise the conjunctiva and slide a full-thickness conjunctival/Tenon's flap over the area. This is a simple, minor surgical procedure with minimal morbidity. I would be very surprised if these two maneuvers did not solve the problem. If erosion occurs again and the knot erodes through conjunctiva and is exposed, I would cover the area with a small, thin, free-hand lamellar graft. The tissue should be tucked into grooves cut in the sclera on each side of the knot and then covered with conjunctiva. Vascularization and
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healing should provide adequate protection without intraocular manipulation and without compromising suture integrity. Randall J. Olson, M.D. Salt Lake City, Utah
In my early experiences with scleral fixation technique, I did several cases in which I did not place the suture under a scleral flap, and similar suture erosion occurred. In most cases, I was able to correct this by using cautery to the suture at the slitlamp. My technique was to anesthetize the eye with proparacaine and then apply proparacaine with a Q-tip® to the area of the suture for deeper anesthesia. I would then place a drop of antibiotic in the eye and, with a disposable cautery, touch the suture end until it melted down flat. Usually, epithelialization and granulation over the knot solve the problem. In one or two patients, I had to repeat the cautery. To date, I have not had a case I could not correct by using this approach. Some of my colleagues have placed a small button of donor cornea over the eroding suture after trimming it. This is a useful technique, but it requires an operative approach. Finally, one should discuss the preventative techniques that can eliminate this problem. The one I currently favor is a mattress suture by which the knot can be buried. This technique allows transscleral fixation even when there has been previous conjunctival surgery or in cases with very thin conjunctiva, as in elderly patients. For several years I had placed the single-armed sutures under a scleral flap, but I have seen sutures erode through these flaps as well. I, therefore, currently favor the double-armed suture technique in which the suture knot is buried.
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Richard L. Lindstrom, M.D. Minneapolis, Minnesota
The appearance of an exposed suture end after transscleral suture fixation of a posterior chamber IOL in the absence of capsular support is not unusual. The key to managing this patient is to remember that he has "no current ocular symptoms" and that the "externalized suture end is surrounded by a granuloma ... no discharge is noted, and the anterior and posterior ocular segments are without signs of inflammation or infection." It would be advisable to follow this patient with serial slitlamp examinations and explain the findings to him so he can report any change in ocular comfort or vision; intervention is simply not necessary. The best treatment for this complication of suturefixated IOLs is to avoid the suture exposure in the first place. In 1992, I reported on a new method of vertical
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transscleral sulcus IOL fixation in the absence of a posterior capsule. 1 In this method, the IOL is fixated with two polypropylene suture arms, as in this case. The suture knots, however, are rotated into the scleral tract to prevent suture end exposure. I reviewed the results of suture fixation of posterior chamber IOLs without scleral flap dissection in 30 cases and found no case of suture exposure? Complications of suture-fixated IOLs have been reported. 1- 7 The risks of leaving the exposed suture as is include extrusion, granuloma breakdown with secondary infection, and the small but ever-present chance of the exposed suture acting as a conduit for intraocular infection. Given the clinical appearance from this photograph and the patient's age and history, the likelihood of serious complications from this suture granuloma is probably low and simple observation should be adequate. If, however, the fixation sutures have to be recut or removed, they can be without ill effects on intraocular IOL position. A single-snip conjunctival peritomy with light cautery application to the end of the suture arm or trimming the suture end may cause the suture to lay flat and prevent recurrence of the granuloma. If trimming the suture is not possible and the suture is clean and completely covered, simple rotation of the suture knot may be attempted. This, too, carries a risk. Depending on the lens design (which is not noted in this case), one-piece 13.5 mm PMMA lenses that are fixated by a single suture through each haptic islet and are carefully placed into the ciliary sulcus are the least likely to move after the suture is removed. In fact, in many of these cases, suture fixation acts as nothing more than a guide for haptic placement in the ciliary sulcus. Once the IOL is properly in place, the suture may not be necessary'to prevent dislocation. Ophthalmologists should perform careful funduscopic evaluation with scleral depression and review the surgical notes with the operating surgeon to determine how the IOL was positioned. This may help them make the appropriate choice for managing this complication if the clinical picture changes. Although the management of this complication need not be risky, the best treatment is usually no treatment at all. Robert M. Kershner, M.D. Tucson, Arizona
REFERENCES 1. Kershner RM. Vertical transscleral sulcus fixation of intraocular lenses in the absence of a posterior capsule. J Cataract Refract Surg 1992; 18:201-202 2. Kershner RM. Simple method of transscleral fixation of a posterior chamber intraocular lens in the absence of the lens capsule. J Refract Corneal Surg 1994; 10:647-
651
3. Leo RJ, Palmer DJ. Episcleritis and secondary glau-
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4. 5.
6.
coma after transsc1eral fixation of a posterior chamber intraocular lens. Arch Ophthalmol 1991; 109:617 Schechter RJ. Suture-wick endophthalmitis with sutured posterior chamber intraocular lenses. J Cataract Refract Surg 1990; 16:755-756 Heilskov T, Joondeph BC, Olsen KR, Blankenship GW. Late endophthalmitis after transsc1eral fixation of a posterior chamber intraocular lens (letter). Arch Ophthalmol 1989; 107:1427 Panton RW, Sulewski ME, Parker JS, et al. Surgical management of subluxed posterior-chamber intraocular lenses. Arch Ophthalmol 1993; 111:919-926 Smiddy WE, Flynn HW Jr. Management of dislocated posterior chamber intraocular lenses. Ophthalmology 1991; 98:889-894
with thermal cautery. If the knot ever became fully exposed, I would take down the conjunctiva and Tenon's capsule and suture a scleral patch graft over the polypropylene suture. Kevin M. Miller, M.D. Los Angeles, California
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The externalized suture is present in a 90year-old asymptomatic patient with presumably satisfactory visual function and without 7. signs of inflammation or infection. The main concern is the potential for endophthalmitis, with the externalized suture acting as a conduit for intraocular infection. The protruding suture end would have to be For visual rehabilitation of contact-lenstrimmed or redirected to allow conjunctival re-epitheintolerant, aphakic patients after ICCE, I prelialization. However, trimming the suture carries the fer suture fixation of a posterior chamber risk of disrupting the anchor to that haptic, requiring IOL. The many advantages of posterior chamber IOL further intraocular surgery for repair. implantation over spectacle correction of aphakia are I would treat the problem with an extraocular prowell known to all ophthalmologists. Advantages over cedure by excising the conjunctival granuloma. Then, anterior chamber IOL implantation include less endothrough the resultant conjunctival opening, I would thelial cell loss, a lower incidence of uveitis-glaucocover and flatten the suture end with a small piece of ma-hyphema syndrome and its consequences, and less autologous or banked sclera sewn into place with eye pain and tenderness. Potential disadvantages inburied interrupted sutures, probably 10-0 polyproclude a higher rate of retinal detachment, a risk of pylene (Prolene®) or polyester fiber (Mersilene®). suture breakage and IOL dislocation, and suture granuloma reaction or exposure, as this patient developed. Overlying conjunctiva and Tenon's would be closed For secondary posterior chamber IOL implantation, with 8-0 polyglactin 910 (Vicryl®) after some underI make a generous peritomy, dissecting two 2.5 mm X mining for mobilization. This procedure should allow 2.5 mm partial-thickness scleral flaps in the 3:30 to conjunctival re-epithelialization with consequent res9:30 or 2:30 to 8:30 meridians for left and right eyes, toration of a barrier to infection. Cosme sis is a potenrespectively, to avoid hitting the long posterior ciliary tial concern, although it is unlikely to occur since the neurovascular bundles. I then attach single-armed 9-0 patient did not notice the suture granuloma. Another option would be to do nothing (or to chronpolypropylene sutures to the fixation eyelets of a Cileo ically cover with topical antibiotics) and hope that CZ70BD IOL, securing the sutures to the sclera beendophthalmitis does not develop during the remainneath the flaps, and trim the ends 5 mm to 6 mm long der of this 90-year-old patient's life. Although this so that they lie flat beneath Tenon's capsule and conjunctiva. The problem in this case is that the rigid option should be presented to the patient, I would not recommend it. polypropylene suture on the nasal aspect of the eye was cut too close to the knot, allowing it to point Barry S. Seibel, M.D. away from the sclera and erode through the overlying Los Angeles, California conjunctiva. In an asymptomatic 90-year-old man, I would initially recommend periodic observation. I am conThiS is a very interesting case. The patient is cerned that with an exposed suture, microbes on the asymptomatic, so one has to decide whether external ocular surface have a portal of entry to the to recommend a procedure that could lead to inside of the eye. The granuloma may be a barrier to IOL dislocation. Basically, it comes down to whether microbe movement along the suture; nevertheless, the the surgeon and the patient feel lucky. patient is at some risk for endophthalmitis. I would If the patient develops significant conjunctivitis, he give the patient a prescription for a broad-spectrum would have a high risk of developing endophthalmitis topical antibiotic, explain the nature of the exposure as the infection could travel along the suture track into problem to him, and counsel him to use the drops if the eye. I would explain this possibility to the patient that part of the eye becomes noticeably inflamed or and let him decide if he would like to go ahead with irritated. any procedure. If the exposure worsened, I would trim the end of If the patient is willing to proceed with treatment, I the suture with scissors (although this might worsen would recommend elevating the conjunctiva and covthe irritation produced by the suture) or melt it shorter ering the suture with a thick portion of conjunctiva and
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Tenon's with or without a thin graft of donor cornea or sclera. If only conjunctiva and Tenon's are used, there is a possibility the polypropylene will extrude again. The best treatment is to avoid this type of complication by using different fixation methods. I routinely use double-armed 9-0 Prolene so the knot can be rotated into the sclera after tying. This completely averts the possibility of postoperative suture extrusion. It also eliminates the need for scleral flaps or grafts. 1 Francis W. Price, M.D. Indianapolis, Indiana
REFERENCE 1. Price FW, Wellemeyer M. Transscleral fixation of posterior chamber implants. In press, J Cataract Refract Surg
Erosion of a polypropylene suture for a scleral-sutured IOL can be a problem, especially if no scleral flap is used. It appears that the ends of the sutures were left too long, which can cause the sutures to erode through a scleral flap. I would recommend two methods for correcting the problem: (1) cutting the length of the suture using fine tying forceps and Vannas scissors, or (2) shrinking the ends of the polypropylene with an argon laser. Care must be taken not to be too aggressive with the laser as it can damage the knot. If the knot is damaged and the suture releases with subluxation of the IOL, the lens can be repositioned and suture fixated to the iris using pupillary capture of the IOL and modified McCannel suturing of the loop to the iris, as has been previously described. 1
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Walter J. Stark, M.D. Baltimore, Maryland
REFERENCE 1. Panton RW, Sulewski ME, Parker JS, et al. Surgical management of subluxed posterior-chamber intraocular lenses. Arch Ophthalmol 1993; 111:919-926
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There have been several case reports of endophthalmitis secondary to an externalized suture from a sclerally fixated posterior chamber IOL. Although the risk is present in this case, it is probably low. Most patients I have treated have not only had a visibly exposed suture, but also had pain or irritation. At least two patients had suture erosion through scleral flaps, while it appeared that an attempt to bury the scleral fixation sutures was never made on the other patients. Considering that this 90-year-old patient is not bothered by the eroding suture, I would probably do
nothing more than observe and warn him about seeking attention should his eye become red or irritated. If the eye develops irritation from a suture end sticking through the conjunctiva, one could try gently cauterizing the suture with a disposable cautery tip. The suture end will retract and melt into a smooth glob, which may prevent the knot from unraveling. When surgical correction is required, I usually create a limbal conjunctival-based flap and free the suture and knot with careful blunt dissection. Then, I create a scleral flap or a half-thickness-deep incision just posterior to the fixation suture knot. I tie a 9-0 Prolene or 10-0 nylon suture to the end of the exposed suture and bury it into the incision or into the deep sclera below the flap. I close the conjunctival flap with one or two Vicryl sutures. I have not seen further suture erosion through conjunctiva in cases in which I have used this technique. In retrospect, it is curious that a 90-year-old, bilateral, aphakic male who was contact lens intolerant could not have been fitted with aphakic spectacles. Edward Laurence Shaw, M.D. Phoenix, Arizona
I would open the conjunctiva carefully and touch the knot with cautery so that the suture end melts and becomes rounded. The conjunctiva would then re-cover the area. Instead of cautery, an argon laser could be used. In an 88-year-old patient, and in patients much younger, I would have used a Worst iris claw lens (Ophtech, Groningen, Holland) for secondary implantation after ICCE. Since the early 1980s, I have used this lens in such cases and have never regretted my choice. In the United States, where the iris claw lens is not available, a modern angle-supported, Kelman-type IOL would be a good alternative. A bilateral intraocular operation should be done only when absolutely necessary. Contact lens intolerance alone does not seem a sufficient reason. I would first try to correct the patient's vision with glasses. If that failed, I would ascertain that patient still wanted to proceed after I thoroughly explained the procedure and its risks. These risks are, however, small; none of my patients has had a complication related to secondary implantation of any type of IOL.
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P.U. Fechner, M.D. Hannover, Germany
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ThiS is not an uncommon problem when single-armed sutures are used in transscleral fixation of posterior chamber lenses without flaps. I have, however, seen many cases in which suture arms have eroded through thin scleral flaps as well.
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Based on the asymptomatic process-and the patient's age-one may choose to leave this small granuloma alone. However, light cauterization of the suture arms with a hand cautery (Optemp, Alcon) can be easily accomplished after a pledget of tetracaine is used to anesthetize the area. Flattening the tips of the
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stiff polypropylene sutures will make the reaction subside without compromising lens stability. Richard S. Koplin, M.D. New York, New York
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Q
A 90-year-old male with no significant or active medical disorders had secondary sewn-in posterior chamber intraocular lenses (lOLs) implanted two years before examination for contact lens intolerance many years after bilateral uncomplicated intracapsular cataract extraction (lCCE). Although the patient has no current ocular symptoms, routine slitlamp examination shows that one end of a 10-0 polypropylene suture is exposed on the nasal aspect of the left eye. The remaining lens-supporting scleral sutures for both eyes are buried and quiet. The exposed and unintentionally externalized suture end (Figure 1) is surrounded by a granuloma, although no discharge is noted and the anterior and posterior ocular segments are without signs of inflammation or infection. The cornea, pupil, and chamber angle are bilaterally normal, and no vitreous is present anterior to the IOLs. According to the surgeon's note, a single-armed suture was tied to each of the two loops of a singlepiece poly(methyl methacrylate) (PMMA) lens. Each suture was passed through the sclera and tied to itself after reflecting. a conjunctival flap; no scleral flaps were dissected. At the close of surgery, the conjunctiva was repositioned and sewn into place over the cut ends of the polypropylene sutures. Given the patient's age and ocular findings, what management would you suggest?
Fig. 1.
(Masket) One end of a 10-0 polypropylene suture is exposed on the nasal aspect of the patient's left eye.
[N
suture erosion is the most common complication of scleral-sutured posterior chamber IOLs. To manage this patient's exposed suture end, it would be useful to know the type of IOL implanted. If it was one of the lenses specifically designed for this purpose (i.e., a lens with a closed eyelet at the apex of the haptic), one can perhaps be more aggressive with cautery and trimming of the suture end. If in the course of manipulation the exposed suture breaks and the haptic is not fibrotic ally attached, the eyelet on the opposite haptic provides greater assurance that the lens will not completely dislocate into the vitreous cavity. Before initiating management, I discuss, at length, the risk of infection versus the risk of IOL dislocation from suture manipulation. Thus far, all of my patients have chosen to proceed with management of the suture. One could argue that in a 90-year-old patient, observation is the more prudent course. However, this patient could live for 10 or more years, and my preference, pending the patient's desires, would be to proceed with the appropriate steps to eliminate the suture exposure. This patient's suture is approximately 1.5 mm to 2.0 mm posterior to the limbus. It is therefore likely that this haptic is not positioned in the ciliary sulcus and not fibrotic ally attached to the ciliary body. In managing patients with this problem, I have found it useful to assess the tension of the fixation suture. If the suture is loose, the haptic has probably achieved fixation and the suture is no longer required. It is difficult to determine from Figure 1 how tight the suture is. Initially, I would attempt to trim the suture end with fine scissors. I would then see the patient for follow-up in two to three weeks. In the interim, I would prescribe a topical antibiotic drop four times a day. If the suture remained exposed, I would attempt to apply cautery over the suture to melt the exposed end. For this technique, I use a hand-held cautery. The full heat from the cautery is usually intolerable to topically anesthetized patients. I therefore heat the tip until it is red hot and wait one to two seconds before approaching the eye with the cautery. To achieve adequate melting, it usually is sufficient to hold the hot tip a millimeter or so away from the suture. There are three potential outcomes from suture melting: (1) the knot retracts sufficiently and becomes covered by conjunctiva within one to two weeks, (2) the knot remains exposed, or (3) the suture breaks. In the last instance, I apply additional antibiotic drops and remove the suture, fully informing the patient of the potential risk of dislocation of this lens haptic. If
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the haptic dislocates, I would refix ate it with an iris fixation suture. A final option would be to create a partial-thickness scleral flap medial to the exposed suture knot and fold this flap over the exposed knot. Fortunately, I have not had to do this. My patients have fallen into one of two categories: (1) the suture is tight, and careful trimming or heating results in sufficient retraction of the knot to achieve conjunctival coverage, or (2) the suture is loose and is no longer required to fixate the IOL. Finally, if the patient requests the suture be left exposed, I carefully inform him or her of the symptoms of endophthalmitis. I suspect that long-term antibiotic prophylaxis is not beneficial. If I manipulate the suture and it breaks and is removed, I advise the patient about the symptoms of dislocation and strongly advise against rubbing or bumping the eye at any time. Douglas D. Koch, M.D.
Stephen S. Lane, M.D.
Houston, Texas
[AI
Stillwater, Minnesota
Externalization of polypropylene suture barbs from a transsclerally fixated posterior chamber lens demands immediate attention from the operating surgeon or consultant. Because of the reports of endophthalmitis associated with exposed suture ends that have become externalized after transscleral fixation of posterior chamber lenses,l the problem cannot be ignored. The exposed suture shown here is in the intrapalpebral, nasal aspect of the left eye where the conjunctiva is often very thin. Initially, I would attempt to thermally cauterize the suture barbs at the slitlamp. After administering topical anesthesia with the addition of a pledget of bupivacaine hydrochloride (4% Marcaine®) or tetracaine hydrochloride over the exposed barb, I would place a lid speculum in the eye and apply a hand-held, portable, thermal cautery needle to the exposed suture barbs. Usually, the polypropylene will melt and retract and the thermal effect of the cautery on the conjunctiva will cause it to coagulate and heal over the retracted and now blunted suture barb ends. The patient is then placed on topical antibiotics for one to two weeks while the conjunctiva heals. If after this time the suture ends remain exposed, I would bring the patient to the operating room and with local or peribulbar anesthesia (depending on the patient's cooperativeness), carefully dissect the conjunctiva and granuloma from the polypropylene knot and barb. The surrounding conjunctiva should be undermined, and a small, round lamellar donor corneal patch can be placed over the exposed barb and sewn in place (Bucci button).2 The conjunctiva is then reopposed. This is an extremely safe procedure and 100% effective in my experience, with no recurrences of knot or barb erosion. Although there are case reports of the suture being cut and removed under circum116
stances like this without difficulty, I have seen several cases of spontaneous dislocation of the posterior chamber lens when attempting this. I would strongly discourage others from taking this chance because an intraocular procedure would be necessary to refixate the IOL, and a relatively minor external procedure as described can remedy the problem. Finally, a number of steps can be taken to avoid this problem. Use of IOLs with positioning eyelets on the haptics (Alcon CZ70BD, Storz P366UV) allow the surgeon to place a double-armed suture to fixate the lens while burying the knot within the sclera, leaving no potential for erosion. I would also recommend putting the IOL in an oblique or vertical meridian, where the conjunctiva tends to be thicker and more redundant, thus lessening the chance for erosion. In addition, the long posterior ciliary arteries and nerves can be avoided?
REFERENCES 1. Heilskov T, Joondeph BC, Olsen KR, Blankenship
GW. Late endophthalmitis after transsc1eral fixation of a posterior chamber intraocular lens (letter). Arch Ophthalmol 1989; 107:1427 2. Bucci FA Jr, Holland EJ, Lindstrom RL. Corneal autografts for external knots in transsc1erally sutured posterior chamber lenses (letter). Am J Ophthalmol 1991; 112:353-354 3. Lane SS, Lubniewski AJ, Holland EJ. Transsc1erally sutured posterior chamber lenses: improved lens designs and techniques to maximize lens stability and minimize suture erosion. Semin Ophthalmol 1992; 7:245-252
[AI
In a 90-year-old patient, one would want to intervene as little as possible. Yet an exposed fixation suture may lead to a major complication if endophthalmitis occurs. I would first try noninvasive approaches. Initially, I would cauterize the exposed area of the suture down to the suture knot. If done carefully, this can be performed successfully without breaking the suture and in this case, would probably allow the conjunctiva to heal over the surface and solve the problem. If, after cauterization, there is still difficulty with closure, I would incise the conjunctiva and slide a full-thickness conjunctival/Tenon's flap over the area. This is a simple, minor surgical procedure with minimal morbidity. I would be very surprised if these two maneuvers did not solve the problem. If erosion occurs again and the knot erodes through conjunctiva and is exposed, I would cover the area with a small, thin, free-hand lamellar graft. The tissue should be tucked into grooves cut in the sclera on each side of the knot and then covered with conjunctiva. Vascularization and
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healing should provide adequate protection without intraocular manipulation and without compromising suture integrity. Randall J. Olson, M.D. Salt Lake City, Utah
In my early experiences with scleral fixation technique, I did several cases in which I did not place the suture under a scleral flap, and similar suture erosion occurred. In most cases, I was able to correct this by using cautery to the suture at the slitlamp. My technique was to anesthetize the eye with proparacaine and then apply proparacaine with a Q-tip® to the area of the suture for deeper anesthesia. I would then place a drop of antibiotic in the eye and, with a disposable cautery, touch the suture end until it melted down flat. Usually, epithelialization and granulation over the knot solve the problem. In one or two patients, I had to repeat the cautery. To date, I have not had a case I could not correct by using this approach. Some of my colleagues have placed a small button of donor cornea over the eroding suture after trimming it. This is a useful technique, but it requires an operative approach. Finally, one should discuss the preventative techniques that can eliminate this problem. The one I currently favor is a mattress suture by which the knot can be buried. This technique allows transscleral fixation even when there has been previous conjunctival surgery or in cases with very thin conjunctiva, as in elderly patients. For several years I had placed the single-armed sutures under a scleral flap, but I have seen sutures erode through these flaps as well. I, therefore, currently favor the double-armed suture technique in which the suture knot is buried.
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Richard L. Lindstrom, M.D. Minneapolis, Minnesota
The appearance of an exposed suture end after transscleral suture fixation of a posterior chamber IOL in the absence of capsular support is not unusual. The key to managing this patient is to remember that he has "no current ocular symptoms" and that the "externalized suture end is surrounded by a granuloma ... no discharge is noted, and the anterior and posterior ocular segments are without signs of inflammation or infection." It would be advisable to follow this patient with serial slitlamp examinations and explain the findings to him so he can report any change in ocular comfort or vision; intervention is simply not necessary. The best treatment for this complication of suturefixated IOLs is to avoid the suture exposure in the first place. In 1992, I reported on a new method of vertical
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transscleral sulcus IOL fixation in the absence of a posterior capsule. 1 In this method, the IOL is fixated with two polypropylene suture arms, as in this case. The suture knots, however, are rotated into the scleral tract to prevent suture end exposure. I reviewed the results of suture fixation of posterior chamber IOLs without scleral flap dissection in 30 cases and found no case of suture exposure? Complications of suture-fixated IOLs have been reported. 1- 7 The risks of leaving the exposed suture as is include extrusion, granuloma breakdown with secondary infection, and the small but ever-present chance of the exposed suture acting as a conduit for intraocular infection. Given the clinical appearance from this photograph and the patient's age and history, the likelihood of serious complications from this suture granuloma is probably low and simple observation should be adequate. If, however, the fixation sutures have to be recut or removed, they can be without ill effects on intraocular IOL position. A single-snip conjunctival peritomy with light cautery application to the end of the suture arm or trimming the suture end may cause the suture to lay flat and prevent recurrence of the granuloma. If trimming the suture is not possible and the suture is clean and completely covered, simple rotation of the suture knot may be attempted. This, too, carries a risk. Depending on the lens design (which is not noted in this case), one-piece 13.5 mm PMMA lenses that are fixated by a single suture through each haptic islet and are carefully placed into the ciliary sulcus are the least likely to move after the suture is removed. In fact, in many of these cases, suture fixation acts as nothing more than a guide for haptic placement in the ciliary sulcus. Once the IOL is properly in place, the suture may not be necessary'to prevent dislocation. Ophthalmologists should perform careful funduscopic evaluation with scleral depression and review the surgical notes with the operating surgeon to determine how the IOL was positioned. This may help them make the appropriate choice for managing this complication if the clinical picture changes. Although the management of this complication need not be risky, the best treatment is usually no treatment at all. Robert M. Kershner, M.D. Tucson, Arizona
REFERENCES 1. Kershner RM. Vertical transscleral sulcus fixation of intraocular lenses in the absence of a posterior capsule. J Cataract Refract Surg 1992; 18:201-202 2. Kershner RM. Simple method of transscleral fixation of a posterior chamber intraocular lens in the absence of the lens capsule. J Refract Corneal Surg 1994; 10:647-
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3. Leo RJ, Palmer DJ. Episcleritis and secondary glau-
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4. 5.
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coma after transsc1eral fixation of a posterior chamber intraocular lens. Arch Ophthalmol 1991; 109:617 Schechter RJ. Suture-wick endophthalmitis with sutured posterior chamber intraocular lenses. J Cataract Refract Surg 1990; 16:755-756 Heilskov T, Joondeph BC, Olsen KR, Blankenship GW. Late endophthalmitis after transsc1eral fixation of a posterior chamber intraocular lens (letter). Arch Ophthalmol 1989; 107:1427 Panton RW, Sulewski ME, Parker JS, et al. Surgical management of subluxed posterior-chamber intraocular lenses. Arch Ophthalmol 1993; 111:919-926 Smiddy WE, Flynn HW Jr. Management of dislocated posterior chamber intraocular lenses. Ophthalmology 1991; 98:889-894
with thermal cautery. If the knot ever became fully exposed, I would take down the conjunctiva and Tenon's capsule and suture a scleral patch graft over the polypropylene suture. Kevin M. Miller, M.D. Los Angeles, California
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The externalized suture is present in a 90year-old asymptomatic patient with presumably satisfactory visual function and without 7. signs of inflammation or infection. The main concern is the potential for endophthalmitis, with the externalized suture acting as a conduit for intraocular infection. The protruding suture end would have to be For visual rehabilitation of contact-lenstrimmed or redirected to allow conjunctival re-epitheintolerant, aphakic patients after ICCE, I prelialization. However, trimming the suture carries the fer suture fixation of a posterior chamber risk of disrupting the anchor to that haptic, requiring IOL. The many advantages of posterior chamber IOL further intraocular surgery for repair. implantation over spectacle correction of aphakia are I would treat the problem with an extraocular prowell known to all ophthalmologists. Advantages over cedure by excising the conjunctival granuloma. Then, anterior chamber IOL implantation include less endothrough the resultant conjunctival opening, I would thelial cell loss, a lower incidence of uveitis-glaucocover and flatten the suture end with a small piece of ma-hyphema syndrome and its consequences, and less autologous or banked sclera sewn into place with eye pain and tenderness. Potential disadvantages inburied interrupted sutures, probably 10-0 polyproclude a higher rate of retinal detachment, a risk of pylene (Prolene®) or polyester fiber (Mersilene®). suture breakage and IOL dislocation, and suture granuloma reaction or exposure, as this patient developed. Overlying conjunctiva and Tenon's would be closed For secondary posterior chamber IOL implantation, with 8-0 polyglactin 910 (Vicryl®) after some underI make a generous peritomy, dissecting two 2.5 mm X mining for mobilization. This procedure should allow 2.5 mm partial-thickness scleral flaps in the 3:30 to conjunctival re-epithelialization with consequent res9:30 or 2:30 to 8:30 meridians for left and right eyes, toration of a barrier to infection. Cosme sis is a potenrespectively, to avoid hitting the long posterior ciliary tial concern, although it is unlikely to occur since the neurovascular bundles. I then attach single-armed 9-0 patient did not notice the suture granuloma. Another option would be to do nothing (or to chronpolypropylene sutures to the fixation eyelets of a Cileo ically cover with topical antibiotics) and hope that CZ70BD IOL, securing the sutures to the sclera beendophthalmitis does not develop during the remainneath the flaps, and trim the ends 5 mm to 6 mm long der of this 90-year-old patient's life. Although this so that they lie flat beneath Tenon's capsule and conjunctiva. The problem in this case is that the rigid option should be presented to the patient, I would not recommend it. polypropylene suture on the nasal aspect of the eye was cut too close to the knot, allowing it to point Barry S. Seibel, M.D. away from the sclera and erode through the overlying Los Angeles, California conjunctiva. In an asymptomatic 90-year-old man, I would initially recommend periodic observation. I am conThiS is a very interesting case. The patient is cerned that with an exposed suture, microbes on the asymptomatic, so one has to decide whether external ocular surface have a portal of entry to the to recommend a procedure that could lead to inside of the eye. The granuloma may be a barrier to IOL dislocation. Basically, it comes down to whether microbe movement along the suture; nevertheless, the the surgeon and the patient feel lucky. patient is at some risk for endophthalmitis. I would If the patient develops significant conjunctivitis, he give the patient a prescription for a broad-spectrum would have a high risk of developing endophthalmitis topical antibiotic, explain the nature of the exposure as the infection could travel along the suture track into problem to him, and counsel him to use the drops if the eye. I would explain this possibility to the patient that part of the eye becomes noticeably inflamed or and let him decide if he would like to go ahead with irritated. any procedure. If the exposure worsened, I would trim the end of If the patient is willing to proceed with treatment, I the suture with scissors (although this might worsen would recommend elevating the conjunctiva and covthe irritation produced by the suture) or melt it shorter ering the suture with a thick portion of conjunctiva and
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Tenon's with or without a thin graft of donor cornea or sclera. If only conjunctiva and Tenon's are used, there is a possibility the polypropylene will extrude again. The best treatment is to avoid this type of complication by using different fixation methods. I routinely use double-armed 9-0 Prolene so the knot can be rotated into the sclera after tying. This completely averts the possibility of postoperative suture extrusion. It also eliminates the need for scleral flaps or grafts. 1 Francis W. Price, M.D. Indianapolis, Indiana
REFERENCE 1. Price FW, Wellemeyer M. Transscleral fixation of posterior chamber implants. In press, J Cataract Refract Surg
Erosion of a polypropylene suture for a scleral-sutured IOL can be a problem, especially if no scleral flap is used. It appears that the ends of the sutures were left too long, which can cause the sutures to erode through a scleral flap. I would recommend two methods for correcting the problem: (1) cutting the length of the suture using fine tying forceps and Vannas scissors, or (2) shrinking the ends of the polypropylene with an argon laser. Care must be taken not to be too aggressive with the laser as it can damage the knot. If the knot is damaged and the suture releases with subluxation of the IOL, the lens can be repositioned and suture fixated to the iris using pupillary capture of the IOL and modified McCannel suturing of the loop to the iris, as has been previously described. 1
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Walter J. Stark, M.D. Baltimore, Maryland
REFERENCE 1. Panton RW, Sulewski ME, Parker JS, et al. Surgical management of subluxed posterior-chamber intraocular lenses. Arch Ophthalmol 1993; 111:919-926
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There have been several case reports of endophthalmitis secondary to an externalized suture from a sclerally fixated posterior chamber IOL. Although the risk is present in this case, it is probably low. Most patients I have treated have not only had a visibly exposed suture, but also had pain or irritation. At least two patients had suture erosion through scleral flaps, while it appeared that an attempt to bury the scleral fixation sutures was never made on the other patients. Considering that this 90-year-old patient is not bothered by the eroding suture, I would probably do
nothing more than observe and warn him about seeking attention should his eye become red or irritated. If the eye develops irritation from a suture end sticking through the conjunctiva, one could try gently cauterizing the suture with a disposable cautery tip. The suture end will retract and melt into a smooth glob, which may prevent the knot from unraveling. When surgical correction is required, I usually create a limbal conjunctival-based flap and free the suture and knot with careful blunt dissection. Then, I create a scleral flap or a half-thickness-deep incision just posterior to the fixation suture knot. I tie a 9-0 Prolene or 10-0 nylon suture to the end of the exposed suture and bury it into the incision or into the deep sclera below the flap. I close the conjunctival flap with one or two Vicryl sutures. I have not seen further suture erosion through conjunctiva in cases in which I have used this technique. In retrospect, it is curious that a 90-year-old, bilateral, aphakic male who was contact lens intolerant could not have been fitted with aphakic spectacles. Edward Laurence Shaw, M.D. Phoenix, Arizona
I would open the conjunctiva carefully and touch the knot with cautery so that the suture end melts and becomes rounded. The conjunctiva would then re-cover the area. Instead of cautery, an argon laser could be used. In an 88-year-old patient, and in patients much younger, I would have used a Worst iris claw lens (Ophtech, Groningen, Holland) for secondary implantation after ICCE. Since the early 1980s, I have used this lens in such cases and have never regretted my choice. In the United States, where the iris claw lens is not available, a modern angle-supported, Kelman-type IOL would be a good alternative. A bilateral intraocular operation should be done only when absolutely necessary. Contact lens intolerance alone does not seem a sufficient reason. I would first try to correct the patient's vision with glasses. If that failed, I would ascertain that patient still wanted to proceed after I thoroughly explained the procedure and its risks. These risks are, however, small; none of my patients has had a complication related to secondary implantation of any type of IOL.
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P.U. Fechner, M.D. Hannover, Germany
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ThiS is not an uncommon problem when single-armed sutures are used in transscleral fixation of posterior chamber lenses without flaps. I have, however, seen many cases in which suture arms have eroded through thin scleral flaps as well.
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Based on the asymptomatic process-and the patient's age-one may choose to leave this small granuloma alone. However, light cauterization of the suture arms with a hand cautery (Optemp, Alcon) can be easily accomplished after a pledget of tetracaine is used to anesthetize the area. Flattening the tips of the
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stiff polypropylene sutures will make the reaction subside without compromising lens stability. Richard S. Koplin, M.D. New York, New York
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