Pars plana suture fixation for intraocular lenses dislocated into the vitreous cavity using a closed-eye cow-hitch technique

techniques Pars plana suture fixation for intraocular lenses dislocated into the vitreous cavity using a closed-eye cow-hitch technique Hiroyuki Nakashizuka, MD, Hiroyuki Shimada, MD, Yutaka Iwasaki, MD, Yoko Matsumoto, MD, Yukihiro Sato, MD We describe a modified intraocular cow-hitch technique for pars plana suture fixation of intraocular lenses (IOLs) that dislocated into the vitreous cavity in 3 patients who had a 3-port vitrectomy and IOL implantation because of retinal disease. To reposition the dislocated IOL after the residual vitreous was removed, 2 additional sclerotomies for suture fixation were made 3.0 mm posterior to the limbus. A loop (cow-hitch knot) was made with 10-0 polypropylene for suture fixation. After the neck of the cow-hitch loop was grasped with an intraocular forceps, the loop was used to lasso a haptic of the dislocated IOL, which was then pulled forward to the sclerotomy. The same procedure was used for the other haptic, and both sutures were secured to the sclera under scleral flaps. In all patients, the dislocated IOLs were repositioned without the need for extraction. The procedures were uneventful. Pars plana suture fixation with the intraocular cowhitch technique can be used to reposition an IOL that has dislocated into the vitreous cavity. J Cataract Refract Surg 2004; 30:302–306  2004 ASCRS and ESCRS

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ecent advances in cataract surgery with phacoemulsification and improvements to intraocular lenses (IOLs) have expanded the indications for IOL implantation. One indication is the treatment of zonular weakness, which may occur in the eyes of patients with pseudoexfoliative syndrome, high myopia, or atopic derAccepted for publication July 1, 2003. From the Department of Ophthalmology, Itabashi Hospital of Nihon University (Nakashizuka, Iwasaki, Sato), and the Department of Ophthalmology, Surugadai Hospital of Nihon University (Shimada, Matsumoto), Chiyoda-ku, Tokyo, Japan. Presented in part at the 55th Congress of Clinical Ophthalmology of Japan, Kyoto, Japan, October 2001.

matitis and after vitreoretinal surgery. In eyes with zonular weakness, dislocation of the IOL can occur. Extraction of the dislocated IOL involves the risk for vitreous prolapse, collapse of the ocular structures, intraocular bleeding, and the creation of severe surgical astigmatism. Repositioning the dislocated IOL with a closed-eye method is a desirable alternative to extraction. Although various methods for repositioning dislocated IOLs have been reported,1–15 they involve suture fixation to the ciliary sulcus. To improve the repositioning of dislocated IOLs, we developed a pars plana suture fixation method using a closed-eye technique. An intraocular cow-hitch suture of 10-0 polypropylene and a vitreous forceps are used to attach the suture to the IOL haptic.

None of the authors has a financial or proprietary interest in any material or method mentioned.

Case Reports

Professor Mitsuru Sawa provided assistance. Reprint requests to Hiroyuki Nakashizuka, MD, Department of Ophthalmology, Nihon University School of Medicine, 30-1 Oyaguchikamimachi, Itabashi-ku, Tokyo 173-8610, Japan.  2004 ASCRS and ESCRS Published by Elsevier Inc.

Case 1 In October 1998, a 51-year-old man had a vitrectomy, pars plana lensectomy, and implantation of a 1-piece poly0886-3350/04/$–see front matter doi:10.1016/S0886-3350(03)00663-1

TECHNIQUES: NAKASHIZUKA

Figure 1. (Nakashizuka) The cow-hitch technique. The neck of the loop (broken circle) is grasped with an intraocular forceps.

(methyl methacrylate) (PMMA) IOL in the right eye at Surugadai Hospital of Nihon University to treat vitreous opacity secondary to uveitis. The IOL was implanted in the capsular bag. Posterior capsule opacification subsequently developed, and a neodymium:YAG laser capsulotomy was performed in June 2000. After this, visual acuity was 20/20 with ⫺1.00 sphere and ⫺1.25 cylinder. However, the patient had blunt trauma to the right eye in November 2000 and presented with a complaint of suddenly decreased vision in this eye. Visual acuity in the right eye was 20/20 with ⫹11.50 sphere and ⫺0.50 cylinder. Slitlamp examination revealed several large tears in the periphery of the residual anterior capsule. Fundus examination showed that the IOL had fallen on the retinal surface.

Initially, sclerotomies for a 3-port closed vitrectomy were made at the pars plana 3.5 mm posterior to the limbus. Then, additional sclerotomies for fixation of the IOL under scleral flaps were placed 3.0 mm posterior to the limbus and 180 degrees apart to ensure optimal centering of the IOL in the pupillary zone. The residual vitreous was carefully excised by a conventional vitrectomy to prevent vitreous base avulsion or retinal detachment (RD). A single 10-0 polypropylene suture was used to stabilize the IOL and fix the haptic. A cow-hitch knot was first made under a surgical microscope (Figure 1). While the neck of the loop was held with an intraocular forceps, the loop was introduced into the vitreous cavity through the preformed sclerotomy at 9 o’clock. The loop was used to lasso 1 haptic of the dislocated IOL. While the IOL was gently supported with a light probe, the haptic was pulled to the sclerotomy site for suture fixation (Figure 2). A similar procedure was performed for the IOL haptic at 3 o’clock (Figure 3). Next, the tension of the sutures attached to the 2 haptics was adjusted to position the IOL optimally. Finally, the sutures were tied to the scleral bed under the scleral flaps and the sclerotomies were closed with an 8-0 polyglactin (Vicryl威) figure-8 suture. The patient’s postoperative visual acuity was 20/20 with ⫺0.75 cylinder, and there were no complications such as RD or tilting or decentration of the IOL (Figure 4).

Case 2 In 1991, a 23-year-old man had phacoaspiration and IOL implantation in the left eye at another hospital because of an atopic cataract. In March 2000, the patient presented at our hospital with an RD in the same eye. The detachment was caused by dialysis at the lateral aspect of the ora serrata.

Figure 2. (Nakashizuka) The IOL haptic is engaged with the cow-

Figure 3. (Nakashizuka) Similar procedures are performed with

hitch loop introduced via a sclerotomy.

the other haptic.

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cylinder. Complications such as RD or tilting or decentration of the IOL were not observed.

Discussion

Figure 4. (Nakashizuka) Postoperative slitlamp examination shows no IOL tilt or decentration.

A vitrectomy, encircling explants, fluid–air exchange, and silicone oil injection were performed. The silicone oil was removed in December 2000. In January 2001, the patient presented again with a complaint of suddenly decreased vision in the left eye. On examination, the left eye visual acuity was 20/200 with ⫺12.00 sphere and ⫺2.25 cylinder. Although the IOL was still inside the lens capsule supported by the residual zonules, the capsule itself had dislocated into the vitreous cavity. No recurrence of the RD was observed, but preexisting keratoconus showed progression. The dislocated IOL was fixated by the method described in Case 1. Postoperatively, the left eye visual acuity improved to 20/50 with ⫺12.00 sphere and ⫺1.75 cylinder. There were no complications such as RD or tilting or decentration of the IOL.

Case 3 In November 1999, a 35-year-old man developed an RD in the left eye from traumatic dialysis at the ora serrata. The patient had phacoaspiration, IOL implantation, a vitrectomy, encircling explants, fluid–air exchange, and a silicone oil injection in the left eye at our hospital. The silicone oil was removed in July 2000. The visual acuity in the left eye was 20/20 with ⫺7.50 sphere and ⫺0.50 cylinder, and in the right eye, 20/20 with ⫺8.00 sphere and ⫺0.25 cylinder. In November 2001, the patient had blunt trauma to the left eye and presented at our hospital the next day with complaints of decreased vision. On examination, the left eye visual acuity was 20/20 with ⫹7.50 sphere and ⫺1.00 cylinder. Slitlamp and fundus examination showed that the IOL had dislocated and was lying on the retinal surface, but there was no recurrence of the RD. After the same procedure as in Cases 1 and 2, the left eye visual acuity was 20/20 with ⫺6.00 sphere and ⫺0.50 304

Extracting an IOL that has dislocated into the vitreous cavity involves the risk for damage to intraocular tissues. Methods for repositioning a dislocated IOL by closed-eye surgery have been reported,1–15 and a procedure that can be done without extracting the IOL is considered desirable to minimize surgical damage. To fixate the IOL to the sclera in an eye without a capsular bag, ciliary suture fixation or pars plana suture fixation can be used. Pars plana suture fixation was originally described by Girard16 but is not as popular as the ciliary sulcus fixation method described by Stark and coauthors.17 Although ciliary sulcus suture fixation is now the most commonly performed method, it is associated with risks for intraocular hemorrhage, postoperative RD,18 and postoperative myopic shift of the refractive error from the predicted value.19 Reports indicate that pars plana suture fixation can reduce the incidence of these complications.20,21 However, it is unclear whether pars plana fixation is less stable than ciliary sulcus fixation. In previous studies, ciliary sulcus fixation was primarily a blind procedure and needle insertion and placement of haptics into the sulcus were often unsuccessful. In 1 report, only 1 of 4 haptics was successfully placed at the ciliary sulcus as intended.21 It is reported that the stability of an IOL depends primarily on reliable transscleral sutures and not on placement of the haptics at the ciliary sulcus or fibrous encapsulation.22 Furthermore, even if sulcus penetration is done precisely, the haptics cannot be guided into the sulcus and often remain at the pars plicata or the pars plana.23 Side-view analyses of IOLs in the capsular bag show that almost all the haptics are located posterior to the ciliary body.24 Therefore, if sulcus placement is not essential, we prefer fixation of the IOL to the pars plana rather than the ciliary sulcus to reduce the risk for the complications mentioned. In 1991, Maguire and coauthors25 reported a method of pars plicata suture fixation that used the same sclerotomies for vitrectomy and suture fixation. Using an intraocular forceps, a loop to lasso the IOL haptic was made with 10-0 polypropylene. This technique is simple and

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requires no intraocular handling of needles. However, the risk for intraocular hemorrhage and damage to the ciliary body when making sclerotomies at the pars plicata is still a problem. To achieve safer repositioning of dislocated IOLs, we placed our sclerotomies 3.0 mm posterior to the limbus and performed pars plana suture fixation to reduce complications such as intraocular hemorrhage during the sclerotomy. In our 3 patients, we made separate sclerotomies for suture fixation and vitrectomy and also constructed partial-thickness scleral flaps to prevent postoperative infection associated with exposure of the sutures on the conjunctiva. We applied the cow-hitch technique to lasso the haptics of the dislocated IOL with a 10-0 polypropylene loop. The cow-hitch technique has also been used for IOL fixation in the ciliary sulcus in an eye without a lens capsule.26 The advantage of the cow-hitch method is that the loop can be quickly tied and released,27 making it easy to adjust the position of the IOL in our cases. Additionally, we formed the cow-hitch knot in advance so intraocular manipulation was simplified. In our patients, the previously implanted IOLs were 1-piece PMMA lenses with an optic of 6.50 mm and a maximum outer diameter of 13.50 mm. Although our technique can also be applied to 3-piece IOLs, it is more suitable for 1-piece PMMA IOLs that have fairly rigid haptics because the stronger haptics facilitate easy and precise positioning of the IOL. Although the maximum outer diameter of 13.50 mm might be considered small for pars plana fixation, no complications such as decentration or tilting of the IOL were observed. Moving an IOL that was intended for capsular bag implantation to the pars plana may cause a hyperopic shift because the lens will be located farther back in the eye. However, the hyperopic shift was only about 1.00 diopter (D) in Case 1 and 1.50 D in Case 3. No significant change occurred in Case 2. Because the IOL haptics, which are angled forward at 5 degrees, were stretched axially, the optic may have moved forward. Case 2 was unusual in that the IOL dislocated into the vitreous cavity while remaining inside the capsular bag. After intraocular excision of the lens capsule, pars plana suture fixation using the same intraocular cowhitch technique was performed. In this patient, progression of keratoconus meant that the refractive error had increased before the IOL dislocation. Exchange of the

IOL was not performed because it was considered that keratoplasty would be needed in the near future. Trapping the haptic of a dislocated IOL with a 10-0 polypropylene loop held by an intraocular forceps requires delicate manipulation near the retina, involving advanced vitreoretinal techniques. Perfluorocarbon can be used to make a space between the retina and the IOL, which may be helpful. However, the surgeon should consider the possibility of retinal damage from the IOL; supporting the optic with a light probe may make it safer to move. In our method, sclerotomies for suture fixation were placed 3.0 mm from limbus. Postoperative slitlamp examination showed that the IOLs were in a position similar to that of IOLs implanted in the capsular bag. One study also showed that pars plana suture fixation 3.0 mm or 3.2 mm from the limbus might be preferable to reduce deviation of the postoperative refractive error from the predicted value.21 Although we have not observed postoperative complications, long-term follow-up and treatment of more cases are needed. In conclusion, the combination of a cow-hitch loop and pars plana suture fixation is useful for IOLs dislocated into the vitreous cavity. This technique allows repositioning of the IOL by closed-eye surgery.

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