- Email: [email protected]
Management of subluxated capsular bag–fixated intraocular lenses using a capsular anchor
TECHNIQUE
Management of subluxated capsular bag–fixated intraocular lenses using a capsular anchor Yokrat Ton, MD, Modi Naftali, MD, Ruth Lapid Gortzak, MD, PhD, Ehud I. Assia, MD
We describe the use of the capsular anchor (AssiAnchor) to manage a subluxated intraocular lens (IOL) in the capsular bag. The anchor comprises 2 prongs that hold the anterior lens capsule and a central rod that is sutured to the scleral wall, enabling centration of the IOL–capsular bag complex. Six pseudophakic patients presenting with subluxated posterior chamber IOLs in the capsular bag were operated on using the device. The anchor was used successfully in all cases, although in 2 cases only 1 prong was placed under the capsulorhexis edge. In 1 eye, 2 anchors were used 1 month apart following repeated traumatic zonular injury. The capsular bag holding the IOL remained centered and stable throughout the follow-up period. The anchoring device, which was originally designed to preserve the lens capsule and stabilize subluxated crystalline lenses, can also be used to treat subluxation of a capsular bag–fixated IOL. Financial Disclosure: Dr. Assia is the inventor of the AssiAnchor, has a licensed patent of the anchor, and is consultant to Hanita Lenses. Dr. Lapid-Gortzak is a consultant to and speaker for Alcon Surgical, Inc., Hanita Lenses, Orca Surgical, and Sanoculis Ltd.; a speaker for Santen; and a consultant to Icon. Drs. Ton and Naftali have no financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2016; 42:653–658 Q 2016 ASCRS and ESCRS
In recent years, subluxation of the intraocular lens (IOL)–capsular bag complex has become more prevalent.1–3 This is probably because of the longer pseudophakia lifespan; ie, people live longer, cataract surgery is done at an early stage of clinical manifestation, and surgery is done in the most complicated and complex cases. Although IOL exchange is a common method to manage IOL malposition, it is associated with complex surgery, including a large corneal incision, cutting
Submitted: October 15, 2015. Final revision submitted: March 9, 2016. Accepted: March 11, 2016. From the Meir Medical Center (Ton, Assia), Kfar-Saba, affiliated with Sackler School of Medicine, Tel-Aviv University, Tel Aviv, and the Pade Medical Center (Naftali), Poria, affiliated with Faculty of Medicine in the Galilee Bar-Ilan University, Ramat-Gan, Israel; the Academic Medical Center, University of Amsterdam, Amsterdam, and the Retina Total Eye Care (Lapid-Gortzak), Driebergen, the Netherlands. Corresponding author: Yokrat Ton, MD, Ophthalmology Department, Meir Medical Center, 59 Tchernichovsky Street, Kfar-Saba, 4435757, Israel. E-mail: [email protected]. Q 2016 ASCRS and ESCRS Published by Elsevier Inc.
and removing the IOL, and reimplantation of an alternative IOL. Repositioning and fixation of the existing IOL is often less traumatic and can be achieved using minimally invasive closed-system techniques, with most intraocular manipulations conducted away from the corneal endothelium.3,4 Most surgical techniques include suturing the IOL haptics to the scleral wall or the iris or fixating the IOL loop in a scleral mini-tunnel. A capsular anchor (AssiAnchor, Hanita Lenses) was originally designed and used as an intraocular device for the management of subluxated crystalline lenses, enabling preservation of the lens capsule and implantation of an IOL in the capsular bag. The anchor acts as a capsular clip to hold and fixate the subluxated lens capsule to the scleral wall.5 The anchor was successfully used in numerous cases of crystalline lens subluxation, including Marfan syndrome, trauma, and pseudoexfoliation (PXF) syndrome.A,B We describe the use of the anchor in the treatment of subluxated IOLs within the capsular bag. SURGICAL TECHNIQUE The capsular anchor is a uniplanar poly(methyl methacrylate) device comprising a central rod placed in http://dx.doi.org/10.1016/j.jcrs.2016.04.002 0886-3350
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TECHNIQUE: CAPSULAR ANCHOR FOR POSTERIOR CHAMBER IOL FIXATION
Figure 1. Schematic illustration of the capsular anchor's structure. The anchor is clipped on the anterior capsule rim at the zonular dehiscence zone and sutured to the scleral wall.
front of the anterior capsule and 2 lateral prongs placed under the anterior capsulorhexis edge, resulting in a firm grasp of the anterior capsule rim. The
tips of the prongs extend to the capsule equator, providing localized equatorial support. A small pocket (approximately 2 clock hours) is created under the capsule to facilitate insertion of the prongs. A fixation suture, which can encircle the central rod or be threaded through the hole at the rod's base, is secured to the scleral wall (Figure 1). A 2.5 mm incision is required for anchor implantation, followed by gentle separation of the capsule adhesions to the IOL optic to insert the anchor's prongs under the anterior capsule rim (Figure 2, A, B, and C). Synechias between the fibrotic capsule and the IOL are separated using a spatula or a microvitreoretinal knife. Two passages of a scleral fixating suture are performed in an ab interno or ab externo approach, per the surgeon's preference, using a10-0 or, preferably, a 9-0 polypropylene (Prolene) suture or a polytetrafluoroethylene (Gore-Tex) suture. The central rod and base are pulled peripherally, repositioning the entire IOL–capsular bag complex in the center (Figure 2, D). A temporary safety suture is passed
Figure 2. Intraoperative steps and postoperative view of Case 1. Traumatic IOL subluxation managed by anchoring the capsular bag to the scleral wall. A: Extensive superior subluxation of the IOL in the capsular bag (surgeon's view). B: Capsule adhesions to the IOL optic are separated, creating a pocket for the lateral anchor's arms to be implanted under the capsule. C: The capsular anchor is placed over the capsule rim. D: The anchor is in place, clipped on the capsular bag.
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TECHNIQUE: CAPSULAR ANCHOR FOR POSTERIOR CHAMBER IOL FIXATION
Figure 3. Postoperative view of the posterior chamber IOL in Case 2. Severe inferior subluxation of a hydrophilic IOL in the capsular bag was managed with a superior anchor. Excessive pulling on the IOL–bag complex during surgery resulted in superior decentration of the optic.
through a positioning hole between the prongs in some cases to prevent posterior dislocation of the IOL during surgery through the large zonular defect. The fixating suture is buried under the conjunctiva or a scleral flap. Adjusting the suture tension is important to position the IOL centrally (Figure 3), especially with multifocal IOLs (Figure 4). Results The capsular anchor was implanted in 6 cases of subluxated IOLs within the capsular bag (Figure 2, A). In 2 cases, only 1 lateral prong was successfully placed under the capsule rim. Demographic and clinical data are shown in Table 1. DISCUSSION The capsular anchor, initially used for the treatment of subluxated crystalline lenses,5 had been successfully used in the management of subluxated in-the-bag IOLs by securing the IOL–capsular bag complex to the scleral wall. The anchor was designed for cases in which preservation of the lens capsule and implantation of the IOL in the capsular bag are desired and preferred to maintain the natural barrier between the anterior and posterior segments of the eye. Although the reported incidence of IOL decentration requiring repositioning is low, the rate of the complication increases with time after cataract surgery, ranging between 0.032% and 0.6% in the first 10 years and increasing to 1.7% at 25 years.6–8 In our series, the underlying etiology of the IOL subluxation included PXF syndrome, surgical trauma to the zonular fibers during the primary cataract surgery,
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Figure 4. Postoperative view of Case 3 at 1 day. A well-centered trifocal IOL in the capsular bag is stabilized with the anchor (arrows). The anchor holds the capsulorhexis edge firmly at 2 points (asterisk).
and postoperative trauma. In 1 case, a risk factor could not be identified. Gimbel et al.2 suggest 4 mechanisms that result in postoperative capsule dislocation: preoperatively weak zonular fibers, surgical trauma to the zonular fibers, capsule contraction syndrome, and postoperative trauma. Pseudoexfoliation syndrome is a leading cause of progressive zonular weakness9,10 and an underlying condition in 25% to 66% of IOL decentration cases.2,3,11–15 The progressive nature of PXF syndrome may warrant a second point of fixation because of the risk for further zonular weakness and recurrent subluxation. Zonular trauma during the primary cataract procedure and postoperative ocular trauma are common risk factors for late in-the-bag subluxation.2,11 Other predisposing factors for in-the-bag IOL dislocation are previous vitrectomy, retinitis pigmentosa, uveitis, axial myopia, connective tissue disorders, and older age,2,6,12,16–18 none of which were found in our Case 4. In 9.5% to 24.0% of reported IOL dislocation cases, an underlying cause could not be identified.2,14,17,18 One eye in this series (Case 6) had a capsular tension ring (CTR) in the bag; it had been implanted because PXF and zonular decompensation were noted during the initial cataract surgery. Capsular tension ring implantation is indicated in cases of mild zonular insufficiency or diffuse zonular laxity to support the bag, but the ring does not guarantee long-term zonular stability and central positioning of the IOL–capsular bag complex, particularly in cases of progressive zonular weakness such as PXF syndrome.2,3,16,19 Moreover, the insertion of a CTR early during cataract removal is stressful to the zonular fibers.20 The time-interval range between cataract extraction and IOL subluxation repair in our study is consistent
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Table 1. Demographic and clinical data of 6 patients with subluxated IOLs managed with the capsular anchor. Time from Age Cataract Surgery Case Sex Eye (Y) to Subluxation
Etiology
1
M
OS
62
NA
Trauma
2
M OD
70
5.5 y
PXF syndrome
3
M OD
55
7y
4
M OD
66
2y
Surgical trauma to zonule Unknown
5
F
OD
86
Intraoperative
OS
84
13 y
6
F
1 mo
UCVA
PXF syndrome
Ocular Comorbidity Defect Site
Anchor Location
Preop
Postop
Inferior 3 to 9
6 o’clock
20/36
20/400; ph 20/50
2 mo
RD
Superior
1 o’clock
20/200
20/40
9y
d
Nasal 8 to 11
9 o’clock
20/25
20/20
24 mo
1 arm of device inserted d
Macular geographic atrophy
Superior 10 to 4
7 mo
d
Monocular diplopia
Superior
2 mo
1 arm of device inserted d
Traumatic hyphema vitreous prolapse d
Primary CTR PXF syndrome implantation and trauma 2nd trauma d
20/50 2 o’clock C 20/200 accessory fixation to fibrotic capsule 2 o’clock cc 20/50 20/100; cc 20/50
Followup Complications
Superior
12 o’clock
20/200
20/50
1 mo
Inferior
5 o’clock
d
20/36
15 mo
CME, resolved
cc Z with correction; CME Z cystoid macular edema; CTR Z capsular tension ring; ph Z pinhole; PXF Z pseudoexfoliation; RD Z retinal detachment; UCVA Z uncorrected visual acuity
with that in previous reports of IOL dislocation, 6.7 to 8.5 years.10,15–17,21 Neither the IOL material nor the IOL model was found to be a risk factor for IOL subluxation or dislocation.6,15,17 In our small series, various IOL models and materials were identified, including hydrophobic and hydrophilic IOLs with looped and plate-haptic designs. Surgical management options for subluxated IOLs include IOL exchange or repositioning and fixation of the IOL–capsular bag complex to the sclera or, less frequently, to the iris.3–15,22 Intraocular lens exchange, frequently performed in IOL decentration cases,1,21 usually requires a large incision and intraocular manipulation including cutting the IOL; it is more traumatic to the corneal endothelium. Intraocular lens explantation is preferred over preservation in cases with damaged haptics, highly flexible haptics inappropriate for suturing, or coexisting pathology.15 Scleral fixation of the IOL haptics, first described by Oshika,4 is safely managed within a relatively closed chamber.23,24 However, the integrity of the capsule is disrupted in this procedure and haptic visualization is sometimes difficult. In the majority of cases of subluxated in-the-bag IOLs presenting to our center, the existing IOL could
be preserved and secured in the eye by suturing the haptics and the bag directly to the sclera or using the anchor to preserve the capsule and the existing IOL. The anchor was clipped on the strong fibrotic edge of the original capsulorhexis; therefore, a circumferential peripheral dissection of the equator was not required and the suture did not puncture the capsule. In Case 4, using the technique described by Gimbel et al.,25,26 the robust capsule edge was sutured to the sclera with an accessory fixation point to further stabilize the bag. Haptic visualization is important for closedchamber suturing and not always possible to achieve. The anchor implantation is done under direct visualization of the capsule opening even in small-pupil settings, as is often the case in PXF-syndrome patients. Sutureless intrascleral haptic fixation is an alternative technique for IOL fixation that reduces the risk for suture degradation and IOL tilt seen with 2-point suturing of IOLs, but it requires a 3-piece IOL.27 The flexible hemi-ring is a capsular bag–implanted device that is externalized from the eye and fixated in a scleral tunnel under a scleral fibrin-glued flap; it also prevents suturerelated problems.28,29 Capsular fixation using the anchor can be performed with any IOL model, although suture degradation is a concern in younger patients.
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TECHNIQUE: CAPSULAR ANCHOR FOR POSTERIOR CHAMBER IOL FIXATION
Polytetrafluoroethylene sutures or 9-0 polypropylene sutures, which have significantly higher tensile force and durability than 10-0 sutures, are preferable. Potential complications of repositioning and fixating IOLs are intraocular hemorrhage, excessive suture traction, cystoid macular edema (CME), and retinal detachment (RD).3,15,30 In our series, CME was successfully treated in 1 case and RD developed 1 month after repositioning the IOL in Case 1, in which major trauma had affected the eye. In 2 cases, only 1 lateral arm of the anchor was successfully placed under the capsule rim. This was attributable to the loose nature of the subluxated bag and the intensive fibrosis of the capsule on the IOL optic. However, in both cases the fibrosed capsule rim was firm enough to hold the anchor and the IOL was well centered and remained stable. The capsular anchor was originally designed for subluxated crystalline lenses, and thus the width of each arm was purposely wide to provide a large area of contact and stable fixation. Modified models of the capsular anchor currently being developed will have thinner prongs, with the central rod extruding from the device plane to facilitate insertion.
4.
5.
6.
7.
8.
9.
10.
11.
12.
WHAT WAS KNOWN Direct suturing of the haptics or IOL exchange are the main methods for treating subluxation of the IOL–capsular bag complex. The capsular anchor is effective in repositioning and fixating the lens capsule of subluxated crystalline lenses caused by a variety of etiologies with profound zonular fiber deficiency. Anchoring the capsule to the scleral wall preserves the lens capsule and enables IOL implantation in the capsular bag.
13.
14.
15. 16.
17.
WHAT THIS PAPER ADDS The capsular anchor can be used for scleral fixation of the lens capsule in cases of pseudophakic patients with a malpositioned in-the-bag IOL.
18.
19.
REFERENCES 1. Jones JJ, Jones YJ, Jin GJC. Indications and outcomes of intraocular lens exchange during a recent 5-year period. Am J Ophthalmol 2014; 157:154–162 2. Gimbel HV, Condon GP, Kohnen T, Olson RJ, Halkiadakis I. Late in-the-bag intraocular lens dislocation: incidence, prevention, and management. J Cataract Refract Surg 2005; 31:2193–2204 3. Lorente R, de Rojas V, Vazquez de Parga P, Moreno C, Landaluce ML, Domınguez R, Lorente B. Management of late spontaneous in-the-bag intraocular lens dislocation:
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retrospective analysis of 45 cases. J Cataract Refract Surg 2010; 36:1270–1282 Oshika T. Transscleral suture fixation of a subluxated posterior chamber lens within the capsular bag. J Cataract Refract Surg 1997; 23:1421–1424 Assia EI, Ton Y, Michaeli A. Capsule anchor to manage subluxated lenses: initial clinical experience. J Cataract Refract Surg 2009; 35:1372–1379 €m M, Stenevi U, Jakobsson G, Zetterberg M, Lundstro Grenmark R, Sundelin K. Late dislocation of in-the-bag and out-of-the bag intraocular lenses: Ocular and surgical characteristics and time to lens positioning. J Cataract Refract Surg 2010; 36:1637–1644 €nestam EI. Incidence of dislocation of intraocular lenses and Mo pseudophakodonesis 10 years after cataract surgery. Ophthalmology 2009; 116:2315–2320 Pueringer SL, Hodge DO, Erie JC. Risk of late intraocular lens dislocation after cataract surgery, 1980–2009: a populationbased study. Am J Ophthalmol 2011; 152:618–623 Masket S, Osher RH. Late complications with intraocular lens dislocation after capsulorhexis in pseudoexfoliation syndrome. J Cataract Refract Surg 2002; 28:1481–1484 Jehan FS, Mamalis N, Crandall AS. Spontaneous late dislocation of intraocular lens within the capsular bag in pseudoexfoliation patients. Ophthalmology 2001; 108:1727–1731 Lichtinger A, Kim P, Yeung SN, Amiran MD, Alangh M, Rootman DS. Secondary intraocular lens interventions: predisposing factors, indications and coincident procedures. Int Ophthalmol 2013; 33:111–115 Hayashi K, Hirata A, Hayashi H. Possible predisposing factors for in-the-bag and out-of-the-bag intraocular lens dislocation and outcomes of intraocular lens exchange surgery. Ophthalmology 2007; 114:969–975 Michaeli A, Soiberman U, Loewenstein A. Outcome of iris fixation of subluxated intraocular lenses. Graefes Arch Clin Exp Ophthalmol 2012; 250:1327–1332 Gross JG, Kokame GT, Weinberg DV, for the Dislocated In-TheBag Intraocular Lens Study Group. In-the-bag intraocular lens dislocation. Am J Ophthalmol 2004; 137:630–635 Kim SS, Smiddy WE, Feuer W, Shi W. Management of dislocated intraocular lenses. Ophthalmology 2008; 115:1699–1704 Werner L, Zaugg B, Neuhann T, Burrow M, Tetz M. In-the-bag capsular tension ring and intraocular lens subluxation or dislocation; a series of 23 cases. Ophthalmology 2012; 119:266–271 Davis D, Brubaker J, Espandar L, Stringham J, Crandall A, Werner L, Mamalis N. Late in-the-bag spontaneous intraocular lens dislocation; evaluation of 86 consecutive cases. Ophthalmology 2009; 116:664–670 Matsumoto M, Yamada K, Uematsu M, Fujikawa A, Tsuiki E, Kumagami T, Suzuma K, Kitaoka T. Spontaneous dislocation of in-the-bag intraocular lens primarily in cases with prior vitrectomy. Eur J Ophthalmol 2012; 22:363–367 Scherer M, Bertelmann E, Rieck P. Late spontaneous in-the-bag intraocular lens and capsular tension ring dislocation in pseudoexfoliation syndrome. J Cataract Refract Surg 2006; 32:672–675 Ahmed IIK, Cionni RJ, Kranemann C, Crandall AS. Optimal timing of capsular tension ring implantation: Miyake-Apple video analysis. J Cataract Refract Surg 2005; 31:1809–1813 ndez-Buenaga R, Alio JL, Pe rez-Ardoy AL, LarrosaFerna s L, Barraquer R, Alio JL II, Mun ~ozQuesada A, Pinilla-Corte Negrete FJ. Late in-the-bag intraocular lens dislocation requiring explantation: risk factors and outcomes. Eye 2013; 27:795–801; quiz 802 Available at: http://www.nature.com/eye/journal/v27/ n7/pdf/eye201395a.pdf. Accessed March 15, 2016
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22. Smiddy WE, Ibanez GV, Alfonso E, Flynn HW Jr. Surgical management of dislocated intraocular lenses. J Cataract Refract Surg 1995; 21:64–69 23. Chan CC, Crandall AS, Ahmed K II. Ab externo scleral suture loop fixation for posterior chamber intraocular lens decentration: clinical results. J Cataract Refract Surg 2006; 32:121–128 24. Gunenc U, Kocak N, Ozturk AT, Arikan G. Surgical management of spontaneous in-the-bag intraocular lens and capsular tension ring complex dislocation. Indian J Ophthalmol 2014; 62:876–878. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4185167/. Accessed March 15, 2016 25. Gimbel HV, Amritanand A. Suture refixation and recentration of a subluxated capsular tension ring–capsular bag–intraocular lens complex. J Cataract Refract Surg 2013; 39:1798–1802 26. Gimbel HV, Camoriano GD, Shah CR, Dardzhikova AA. Capsule membrane suture fixation of decentered sulcus intraocular lenses. Arch Ophthalmol 2012; 130:101–105. Available at: http://archopht. jamanetwork.com/article.aspx?articleidZ1106548. Accessed March 15, 2016 27. Scharioth GB, Prasad S, Georgalas I, Tataru C, Pavlidis M. Intermediate results of sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg 2010; 36:254–259 28. Jacob S, Agarwal A. Fibrin glue assisted trans-scleral fixation of an endocapsular device for sutureless trans-scleral capsular bag fixation in traumatic subluxations: the glued endocapsular ring/ segment. Med Hypothesis Discov Innov Ophthalmol 2013; 2:3– 7. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 3939766/pdf/mehdiophth-2-003.pdf. Accessed March 15, 2016 29. Jacob S, Agarwal A, Agarwal A, Sathish K, Prakash G, Kumar DA. Glued endocapsular hemi-ring segment for fibrin
glue–assisted sutureless transscleral fixation of the capsular bag in subluxated cataracts and intraocular lenses. J Cataract Refract Surg 2012; 38:193–201 30. Rutar T, Hwang DG, Stamper RL. Acute angle-closure glaucoma due to iris transfixation of a subluxated posterior chamber intraocular lens-capsular bag complex. J Cataract Refract Surg 2007; 33:1662–1663
OTHER CITED MATERIAL A. Assia EI, Ton Y, Michaeli A, “The Capsular Anchor in Complicated Cases,” poster presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Boston, Massachusetts, USA, April 2014. Abstract available at: https://ascrs.confex.com/ascrs/ 14am/webprogram/Paper2954.html. Accessed March 15, 2017 B. Lapid-Gortzak R, Nieuwendaal CP, van der Meulen IJ, “Use of a Novel Capsular Anchoring Device,” video presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Boston, Massachusetts, USA, April 2014. Abstract available at: https://ascrs.confex.com/ascrs/14am/webprogram/Paper7174. html. Film available at: http://ascrs2014.conferencefilms.com/ atables.wcs?entryidZ000066. Both accessed March 15, 2016
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First author: Yokrat Ton, MD Meir Medical Center, Kfar-Saba, affiliated with Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Management of subluxated capsular bag–fixated intraocular lenses using a capsular anchor Yokrat Ton, MD, Modi Naftali, MD, Ruth Lapid Gortzak, MD, PhD, Ehud I. Assia, MD
We describe the use of the capsular anchor (AssiAnchor) to manage a subluxated intraocular lens (IOL) in the capsular bag. The anchor comprises 2 prongs that hold the anterior lens capsule and a central rod that is sutured to the scleral wall, enabling centration of the IOL–capsular bag complex. Six pseudophakic patients presenting with subluxated posterior chamber IOLs in the capsular bag were operated on using the device. The anchor was used successfully in all cases, although in 2 cases only 1 prong was placed under the capsulorhexis edge. In 1 eye, 2 anchors were used 1 month apart following repeated traumatic zonular injury. The capsular bag holding the IOL remained centered and stable throughout the follow-up period. The anchoring device, which was originally designed to preserve the lens capsule and stabilize subluxated crystalline lenses, can also be used to treat subluxation of a capsular bag–fixated IOL. Financial Disclosure: Dr. Assia is the inventor of the AssiAnchor, has a licensed patent of the anchor, and is consultant to Hanita Lenses. Dr. Lapid-Gortzak is a consultant to and speaker for Alcon Surgical, Inc., Hanita Lenses, Orca Surgical, and Sanoculis Ltd.; a speaker for Santen; and a consultant to Icon. Drs. Ton and Naftali have no financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2016; 42:653–658 Q 2016 ASCRS and ESCRS
In recent years, subluxation of the intraocular lens (IOL)–capsular bag complex has become more prevalent.1–3 This is probably because of the longer pseudophakia lifespan; ie, people live longer, cataract surgery is done at an early stage of clinical manifestation, and surgery is done in the most complicated and complex cases. Although IOL exchange is a common method to manage IOL malposition, it is associated with complex surgery, including a large corneal incision, cutting
Submitted: October 15, 2015. Final revision submitted: March 9, 2016. Accepted: March 11, 2016. From the Meir Medical Center (Ton, Assia), Kfar-Saba, affiliated with Sackler School of Medicine, Tel-Aviv University, Tel Aviv, and the Pade Medical Center (Naftali), Poria, affiliated with Faculty of Medicine in the Galilee Bar-Ilan University, Ramat-Gan, Israel; the Academic Medical Center, University of Amsterdam, Amsterdam, and the Retina Total Eye Care (Lapid-Gortzak), Driebergen, the Netherlands. Corresponding author: Yokrat Ton, MD, Ophthalmology Department, Meir Medical Center, 59 Tchernichovsky Street, Kfar-Saba, 4435757, Israel. E-mail: [email protected]. Q 2016 ASCRS and ESCRS Published by Elsevier Inc.
and removing the IOL, and reimplantation of an alternative IOL. Repositioning and fixation of the existing IOL is often less traumatic and can be achieved using minimally invasive closed-system techniques, with most intraocular manipulations conducted away from the corneal endothelium.3,4 Most surgical techniques include suturing the IOL haptics to the scleral wall or the iris or fixating the IOL loop in a scleral mini-tunnel. A capsular anchor (AssiAnchor, Hanita Lenses) was originally designed and used as an intraocular device for the management of subluxated crystalline lenses, enabling preservation of the lens capsule and implantation of an IOL in the capsular bag. The anchor acts as a capsular clip to hold and fixate the subluxated lens capsule to the scleral wall.5 The anchor was successfully used in numerous cases of crystalline lens subluxation, including Marfan syndrome, trauma, and pseudoexfoliation (PXF) syndrome.A,B We describe the use of the anchor in the treatment of subluxated IOLs within the capsular bag. SURGICAL TECHNIQUE The capsular anchor is a uniplanar poly(methyl methacrylate) device comprising a central rod placed in http://dx.doi.org/10.1016/j.jcrs.2016.04.002 0886-3350
653
654
TECHNIQUE: CAPSULAR ANCHOR FOR POSTERIOR CHAMBER IOL FIXATION
Figure 1. Schematic illustration of the capsular anchor's structure. The anchor is clipped on the anterior capsule rim at the zonular dehiscence zone and sutured to the scleral wall.
front of the anterior capsule and 2 lateral prongs placed under the anterior capsulorhexis edge, resulting in a firm grasp of the anterior capsule rim. The
tips of the prongs extend to the capsule equator, providing localized equatorial support. A small pocket (approximately 2 clock hours) is created under the capsule to facilitate insertion of the prongs. A fixation suture, which can encircle the central rod or be threaded through the hole at the rod's base, is secured to the scleral wall (Figure 1). A 2.5 mm incision is required for anchor implantation, followed by gentle separation of the capsule adhesions to the IOL optic to insert the anchor's prongs under the anterior capsule rim (Figure 2, A, B, and C). Synechias between the fibrotic capsule and the IOL are separated using a spatula or a microvitreoretinal knife. Two passages of a scleral fixating suture are performed in an ab interno or ab externo approach, per the surgeon's preference, using a10-0 or, preferably, a 9-0 polypropylene (Prolene) suture or a polytetrafluoroethylene (Gore-Tex) suture. The central rod and base are pulled peripherally, repositioning the entire IOL–capsular bag complex in the center (Figure 2, D). A temporary safety suture is passed
Figure 2. Intraoperative steps and postoperative view of Case 1. Traumatic IOL subluxation managed by anchoring the capsular bag to the scleral wall. A: Extensive superior subluxation of the IOL in the capsular bag (surgeon's view). B: Capsule adhesions to the IOL optic are separated, creating a pocket for the lateral anchor's arms to be implanted under the capsule. C: The capsular anchor is placed over the capsule rim. D: The anchor is in place, clipped on the capsular bag.
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TECHNIQUE: CAPSULAR ANCHOR FOR POSTERIOR CHAMBER IOL FIXATION
Figure 3. Postoperative view of the posterior chamber IOL in Case 2. Severe inferior subluxation of a hydrophilic IOL in the capsular bag was managed with a superior anchor. Excessive pulling on the IOL–bag complex during surgery resulted in superior decentration of the optic.
through a positioning hole between the prongs in some cases to prevent posterior dislocation of the IOL during surgery through the large zonular defect. The fixating suture is buried under the conjunctiva or a scleral flap. Adjusting the suture tension is important to position the IOL centrally (Figure 3), especially with multifocal IOLs (Figure 4). Results The capsular anchor was implanted in 6 cases of subluxated IOLs within the capsular bag (Figure 2, A). In 2 cases, only 1 lateral prong was successfully placed under the capsule rim. Demographic and clinical data are shown in Table 1. DISCUSSION The capsular anchor, initially used for the treatment of subluxated crystalline lenses,5 had been successfully used in the management of subluxated in-the-bag IOLs by securing the IOL–capsular bag complex to the scleral wall. The anchor was designed for cases in which preservation of the lens capsule and implantation of the IOL in the capsular bag are desired and preferred to maintain the natural barrier between the anterior and posterior segments of the eye. Although the reported incidence of IOL decentration requiring repositioning is low, the rate of the complication increases with time after cataract surgery, ranging between 0.032% and 0.6% in the first 10 years and increasing to 1.7% at 25 years.6–8 In our series, the underlying etiology of the IOL subluxation included PXF syndrome, surgical trauma to the zonular fibers during the primary cataract surgery,
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Figure 4. Postoperative view of Case 3 at 1 day. A well-centered trifocal IOL in the capsular bag is stabilized with the anchor (arrows). The anchor holds the capsulorhexis edge firmly at 2 points (asterisk).
and postoperative trauma. In 1 case, a risk factor could not be identified. Gimbel et al.2 suggest 4 mechanisms that result in postoperative capsule dislocation: preoperatively weak zonular fibers, surgical trauma to the zonular fibers, capsule contraction syndrome, and postoperative trauma. Pseudoexfoliation syndrome is a leading cause of progressive zonular weakness9,10 and an underlying condition in 25% to 66% of IOL decentration cases.2,3,11–15 The progressive nature of PXF syndrome may warrant a second point of fixation because of the risk for further zonular weakness and recurrent subluxation. Zonular trauma during the primary cataract procedure and postoperative ocular trauma are common risk factors for late in-the-bag subluxation.2,11 Other predisposing factors for in-the-bag IOL dislocation are previous vitrectomy, retinitis pigmentosa, uveitis, axial myopia, connective tissue disorders, and older age,2,6,12,16–18 none of which were found in our Case 4. In 9.5% to 24.0% of reported IOL dislocation cases, an underlying cause could not be identified.2,14,17,18 One eye in this series (Case 6) had a capsular tension ring (CTR) in the bag; it had been implanted because PXF and zonular decompensation were noted during the initial cataract surgery. Capsular tension ring implantation is indicated in cases of mild zonular insufficiency or diffuse zonular laxity to support the bag, but the ring does not guarantee long-term zonular stability and central positioning of the IOL–capsular bag complex, particularly in cases of progressive zonular weakness such as PXF syndrome.2,3,16,19 Moreover, the insertion of a CTR early during cataract removal is stressful to the zonular fibers.20 The time-interval range between cataract extraction and IOL subluxation repair in our study is consistent
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TECHNIQUE: CAPSULAR ANCHOR FOR POSTERIOR CHAMBER IOL FIXATION
Table 1. Demographic and clinical data of 6 patients with subluxated IOLs managed with the capsular anchor. Time from Age Cataract Surgery Case Sex Eye (Y) to Subluxation
Etiology
1
M
OS
62
NA
Trauma
2
M OD
70
5.5 y
PXF syndrome
3
M OD
55
7y
4
M OD
66
2y
Surgical trauma to zonule Unknown
5
F
OD
86
Intraoperative
OS
84
13 y
6
F
1 mo
UCVA
PXF syndrome
Ocular Comorbidity Defect Site
Anchor Location
Preop
Postop
Inferior 3 to 9
6 o’clock
20/36
20/400; ph 20/50
2 mo
RD
Superior
1 o’clock
20/200
20/40
9y
d
Nasal 8 to 11
9 o’clock
20/25
20/20
24 mo
1 arm of device inserted d
Macular geographic atrophy
Superior 10 to 4
7 mo
d
Monocular diplopia
Superior
2 mo
1 arm of device inserted d
Traumatic hyphema vitreous prolapse d
Primary CTR PXF syndrome implantation and trauma 2nd trauma d
20/50 2 o’clock C 20/200 accessory fixation to fibrotic capsule 2 o’clock cc 20/50 20/100; cc 20/50
Followup Complications
Superior
12 o’clock
20/200
20/50
1 mo
Inferior
5 o’clock
d
20/36
15 mo
CME, resolved
cc Z with correction; CME Z cystoid macular edema; CTR Z capsular tension ring; ph Z pinhole; PXF Z pseudoexfoliation; RD Z retinal detachment; UCVA Z uncorrected visual acuity
with that in previous reports of IOL dislocation, 6.7 to 8.5 years.10,15–17,21 Neither the IOL material nor the IOL model was found to be a risk factor for IOL subluxation or dislocation.6,15,17 In our small series, various IOL models and materials were identified, including hydrophobic and hydrophilic IOLs with looped and plate-haptic designs. Surgical management options for subluxated IOLs include IOL exchange or repositioning and fixation of the IOL–capsular bag complex to the sclera or, less frequently, to the iris.3–15,22 Intraocular lens exchange, frequently performed in IOL decentration cases,1,21 usually requires a large incision and intraocular manipulation including cutting the IOL; it is more traumatic to the corneal endothelium. Intraocular lens explantation is preferred over preservation in cases with damaged haptics, highly flexible haptics inappropriate for suturing, or coexisting pathology.15 Scleral fixation of the IOL haptics, first described by Oshika,4 is safely managed within a relatively closed chamber.23,24 However, the integrity of the capsule is disrupted in this procedure and haptic visualization is sometimes difficult. In the majority of cases of subluxated in-the-bag IOLs presenting to our center, the existing IOL could
be preserved and secured in the eye by suturing the haptics and the bag directly to the sclera or using the anchor to preserve the capsule and the existing IOL. The anchor was clipped on the strong fibrotic edge of the original capsulorhexis; therefore, a circumferential peripheral dissection of the equator was not required and the suture did not puncture the capsule. In Case 4, using the technique described by Gimbel et al.,25,26 the robust capsule edge was sutured to the sclera with an accessory fixation point to further stabilize the bag. Haptic visualization is important for closedchamber suturing and not always possible to achieve. The anchor implantation is done under direct visualization of the capsule opening even in small-pupil settings, as is often the case in PXF-syndrome patients. Sutureless intrascleral haptic fixation is an alternative technique for IOL fixation that reduces the risk for suture degradation and IOL tilt seen with 2-point suturing of IOLs, but it requires a 3-piece IOL.27 The flexible hemi-ring is a capsular bag–implanted device that is externalized from the eye and fixated in a scleral tunnel under a scleral fibrin-glued flap; it also prevents suturerelated problems.28,29 Capsular fixation using the anchor can be performed with any IOL model, although suture degradation is a concern in younger patients.
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TECHNIQUE: CAPSULAR ANCHOR FOR POSTERIOR CHAMBER IOL FIXATION
Polytetrafluoroethylene sutures or 9-0 polypropylene sutures, which have significantly higher tensile force and durability than 10-0 sutures, are preferable. Potential complications of repositioning and fixating IOLs are intraocular hemorrhage, excessive suture traction, cystoid macular edema (CME), and retinal detachment (RD).3,15,30 In our series, CME was successfully treated in 1 case and RD developed 1 month after repositioning the IOL in Case 1, in which major trauma had affected the eye. In 2 cases, only 1 lateral arm of the anchor was successfully placed under the capsule rim. This was attributable to the loose nature of the subluxated bag and the intensive fibrosis of the capsule on the IOL optic. However, in both cases the fibrosed capsule rim was firm enough to hold the anchor and the IOL was well centered and remained stable. The capsular anchor was originally designed for subluxated crystalline lenses, and thus the width of each arm was purposely wide to provide a large area of contact and stable fixation. Modified models of the capsular anchor currently being developed will have thinner prongs, with the central rod extruding from the device plane to facilitate insertion.
4.
5.
6.
7.
8.
9.
10.
11.
12.
WHAT WAS KNOWN Direct suturing of the haptics or IOL exchange are the main methods for treating subluxation of the IOL–capsular bag complex. The capsular anchor is effective in repositioning and fixating the lens capsule of subluxated crystalline lenses caused by a variety of etiologies with profound zonular fiber deficiency. Anchoring the capsule to the scleral wall preserves the lens capsule and enables IOL implantation in the capsular bag.
13.
14.
15. 16.
17.
WHAT THIS PAPER ADDS The capsular anchor can be used for scleral fixation of the lens capsule in cases of pseudophakic patients with a malpositioned in-the-bag IOL.
18.
19.
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OTHER CITED MATERIAL A. Assia EI, Ton Y, Michaeli A, “The Capsular Anchor in Complicated Cases,” poster presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Boston, Massachusetts, USA, April 2014. Abstract available at: https://ascrs.confex.com/ascrs/ 14am/webprogram/Paper2954.html. Accessed March 15, 2017 B. Lapid-Gortzak R, Nieuwendaal CP, van der Meulen IJ, “Use of a Novel Capsular Anchoring Device,” video presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Boston, Massachusetts, USA, April 2014. Abstract available at: https://ascrs.confex.com/ascrs/14am/webprogram/Paper7174. html. Film available at: http://ascrs2014.conferencefilms.com/ atables.wcs?entryidZ000066. Both accessed March 15, 2016
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First author: Yokrat Ton, MD Meir Medical Center, Kfar-Saba, affiliated with Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel