- Email: [email protected]
Suture fixation of a posterior chamber intraocular lens in anticoagulated patients
Suture fixation of a posterior chamber intraocular lens in anticoagulated patients D. Shawn Parker, MD, Francis W. Price Jr., MD Purpose: To describe a technique of suture fixating posterior chamber silicone intraocular lenses (PC IOLs) to the iris through a limbal incision and to evaluate its effectiveness in preventing intraocular hemorrhages. Setting: Price Vision Group, Indianapolis, Indiana, USA. Methods: This retrospective single-center study comprised 7 eyes (5 patients) that had suture fixation of a silicone PC IOL from a limbal approach to the midperipheral iris using 9-0 polypropylene (Prolene姞) suture. All patients were taking warfarin sodium (Coumadin姞) preoperatively and postoperatively. At each follow-up examination, visual acuity and intraocular pressure were measured, the stability of the PC IOL was assessed, and the anterior chamber and posterior segment were evaluated for blood. Results: There was no incidence of intraocular hemorrhage during surgery in any eye. In 6 eyes, there was no blood in the anterior chamber or posterior segment at any postoperative examination. A nonlayering hyphema that resolved within 1 week without sequelae was noted in 1 patient 6 weeks postoperatively. The mean follow-up was 10.7 months (range 6 to 25 months). Conclusion: Suture fixating a PC IOL to the iris through a limbal approach was an effective means of placing an IOL in anticoagulated patients without capsule support. J Cataract Refract Surg 2003; 29:949 –954 © 2003 ASCRS and ESCRS
I
n the absence of posterior capsule support, there are 3 methods to secure an intraocular lens (IOL): a posterior chamber IOL (PC IOL) suture fixated to the iris; a PC IOL suture fixated to the sclera; an anterior chamber IOL (AC IOL) placed in the anterior chamber. Many studies have documented the effectiveness of these techniques; however, there is no consensus on which technique produces the optimal outcomes. Several studies report successful outcomes regarding visual acuity and rates of graft survival, cystoid mac-
Accepted for publication September 4, 2002. From Eye Care Specialists, Cape Girardeau, Missouri (Parker), and Price Vision Group, Inc., Indianapolis, Indiana (Price), USA. Neither author has a financial or proprietary interest in any material or method mentioned. Reprint requests to Francis W. Price Jr., MD, Price Vision Group, Inc., 9002 North Meridian Street, Suite 100, Indianapolis, Indiana 46260, USA. © 2003 ASCRS and ESCRS Published by Elsevier Inc.
ular edema (CME), and intraocular pressure (IOP) rise using 1 or more of these techniques of securing IOLs.1– 4 In 567 eyes with pseudophakic or aphakic bullous keratopathy that had penetrating keratoplasty with suture fixation of a PC IOL to the iris, Price and coauthors4 report long-term graft survival of 98% and 92% at 2 years and 5 years, respectively. This is higher than that reported by Lois and coauthors3 in a study of eyes with open-looped AC IOLs (87% and 65% at 2 years and 6 years, respectively). In 102 patients with scleralfixated PC IOLs, Holland et al.5 report a graft survival rate of 97% at approximately 2 years. However, Heidemann and Dunn,6 using a scleral-fixation method, report a lower rate of graft survival, 89%, in 56 patients at approximately 1 year. In the only prospective randomized study comparing the 3 techniques, suture fixation of a PC IOL to the iris was shown to have a significantly lower risk for 0886-3350/03/$–see front matter doi:10.1016/S0886-3350(02)01810-2
PC IOLS IN ANTICOAGULATED PATIENTS
CME (P⫽.04) and a significantly lower complication index.7 One complication that can be especially problematic is intraoperative or postoperative hemorrhage. Although the rate of bleeding is usually relatively low with all 3 techniques, it can be significantly increased in anticoagulated patients. Spontaneous hyphemas resulting from warfarin sodium (Coumadin威) have been reported as well as Coumadin-related bleeding associated with iris-clip and sulcus-fixated IOLs.8,9 Furthermore, hyphema or vitreous hemorrhage can result in prolonged decreased vision, ghost cell glaucoma secondary to vitreous hemorrhage, and elevated IOP from a hyphema. Several studies show a significant incidence of anterior chamber or vitreous hemorrhage with transscleral suture-fixated PC IOLs.10 –13 Hemorrhage with scleral fixation is usually caused by the blind pass of the needle behind the iris and presumably through the ciliary sulcus. Unfortunately, the lack of visualization can lead to accidental puncture of the highly vascular ciliary body. This article describes a method of suture fixating silicone PC IOLs to the iris from a limbal approach and reports the outcomes in anticoagulated patients.
Patients and Methods A retrospective review of all patients from 1 surgeon’s practice (F.W.P.) was conducted to identify those who were anticoagulated with Coumadin while having suture fixation of a silicone PC IOL to the iris through a limbal incision. Seven eyes of 5 patients were identified. Of the 7 eyes, 5 had a 3-port pars plana vitrectomy, intracapsular cataract extraction, and suture fixation of a
3-piece silicone IOL to the iris from a limbal approach. Of these 5 eyes, 3 had been diagnosed with phacodonesis and 2 had a subluxated lens resulting in decreased vision, distortion, and monocular diplopia. The sixth eye had pars plana vitrectomy and iris fixation of a silicone PC IOL from a limbal approach secondary to aphakia and contact lens intolerance. The seventh eye had the same procedure with removal of a dislocated PC IOL (Table 1). The 3-piece silicone PC IOL has a 6.3 mm optic, 12.5 mm overall length, and 0-degree modified C-loop haptics (model AQ2003V, Staar Surgical Co.). With this lens, the positioning hole is formed by passing the needle through the soft silicone optic; therefore, no sharp edges or suture abrasions occur. The iris-sutured IOL technique from a limbal approach has been described.14 In brief, a 7.0 to 9.0 mm incision is created 1.0 mm posterior to the limbus and a beveled incision is carried forward to form a 3-step wound. A 3-port pars plana vitrectomy is then performed, removing the vitreous. A 9-0 polypropylene (Prolene威) suture on a 4.0 mm straight taper needle (Ethicon D-9904) is passed through the midperipheral iris at the 9 o’clock position using a Sutherland microforceps (#612.91, Grieshaber & Co.). A second suture is similarly passed through the midperipheral iris at the 3 o’clock position. The sutures are pulled back through the iris as the needle is retrieved through the pupil (Figure 1, upper and middle). Each suture needle is passed down through the optic of the PC IOL, penetrating the soft silicone at the periphery and then back up through the optic about 0.5 mm away. A loose loop tie is placed in each suture, and the PC IOL is inserted through the limbal incision to a position posterior to the iris. The IOL is oriented so the haptics are at the 3 and 9 o’clock positions. The knots are tied between the iris and the anterior surface of the optic (Figure 1, lower). All patients were examined 1 day and 1 week after surgery. They were then seen as required for routine postoperative care.
Table 1. Characteristics of anticoagulated patients receiving iris-sutured silicone PC IOLs. BCVA Eye
Diagnosis
IOP (mm Hg)
Preop
Postop
Preop
Postop
Follow-up (Mo)
Complications
1
Phacodonesis OD
20/30
20/20
18
17
8
2
Phacodonesis OS
20/60
20/40
14
10
25
Hyphema X1, superior bleb
3
Subluxated lens OD
20/200
20/25
13
12
10
None
4
Subluxated lens OS
20/50
20/30
15
10
6
None
5
Phacodonesis OS, cataract OS
20/70
20/30
16
15
7
None
6
Aphakia OD (contact lens intolerance)
20/40
20/25
11
12
6
None
7
Dislocated PC IOL OD
20/50
20/30
14
14
13
None
950
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None
PC IOLS IN ANTICOAGULATED PATIENTS
patients was 47.8 years (range 28 to 74 years). The reasons for anticoagulation therapy were Marfan’s syndrome with aortic valve replacement (n ⫽ 3), a history of venous thrombosis and pulmonary embolus (n ⫽ 1), and severe cardiac disease and chronic atrial fibrillation (n ⫽ 1). Intraoperatively, there were no intraocular hemorrhages. At each successive postoperative examination, no blood was noted in the anterior chamber or posterior segment in 6 of 7 eyes. In eye 2, a nonlayering hyphema and a new superior bleb were noted 6 weeks postoperatively. The hyphema resolved within 1 week and did not recur over a 23-month period. It was believed that the hyphema was not a result of the iris-fixated PC IOL but rather secondary to trauma to the limbal wound, resulting in light bleeding from episcleral vessels into the anterior chamber. This is supported by the fact that when the hyphema was present, a superior filtering bleb developed over the limbal wound. The filtering bleb eventually lead to hypotony maculopathy and subsequent wound revision. Pseudophacodonesis or lens decentration did not occur at any time during the follow-up (Figure 2), and there was no significant difference between the mean preoperative IOP (14.4 mm Hg) and the mean postoperative IOP (12.9 mm Hg). Iris depigmentation secondary to midperipheral suture placement was minimal at 12 months (Figure 3). The visual acuity was 20/40 or better in all eyes at the last follow-up.
Figure 1. (Parker) Limbal incision method for iris fixation of a PC IOL. Upper: The fixation suture is passed through a limbal incision. Middle: The fixation suture is passed back through the iris, and the needle is retrieved through the pupil. Lower: The PC IOL is sutured via a limbal approach (reprinted from J Cataract Refract Surg 2000; 26:1028 –1034).
Results The mean follow-up of the 7 eyes was 10.7 months (range 6 to 25 months) (Table 1). The mean age of the
Figure 2. (Parker) The appearance of an iris-fixated silicone PC IOL 12 months after placement.
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PC IOLS IN ANTICOAGULATED PATIENTS
Figure 3. (Parker) Minimal iris depigmentation secondary to midperipheral suture placement 12 months postoperatively.
Table 2. Incidence of intraocular hemorrhage associated with scleral-fixated PC IOLs. Incidence (%)
Study*
Year
Agapitos10
1989
2 hyphemas, 1 vitreous hemorrhage
3/19 (15.7)
Kora11
1991
5 vitreous hemorrhages
5/23 (21.7)
McClusky
1994
2 hyphemas, 1 vitreous hemorrhage
3/32 (9.3)
Price13
1995
8 hyphemas, 2 vitreous hemorrhages
10/75 (13.3)
12
Location
*First author listed
Discussion There is considerable debate about which technique of IOL fixation in the absence of capsule support gives the most favorable outcomes. Many physicians, as we do, favor using a PC IOL for many reasons. Its location behind the iris is the natural plane of the lens, it is closer to the nodal point of the eye, and it is situated farthest from the corneal endothelium. Many studies report comparable results in postoperative visual acuity, graft clarity, and IOP change with iris-fixated and scleral-fixated PC IOLs.1–7,11–13,15–19 However, when evaluating which technique is most appropriate, the anticoagulated patient deserves special consideration. Intraoperative and postoperative bleeding can be sight threatening, and the risk is maximized in patients who are anticoagulated. There have been several reports demonstrating increased intraocular bleeding in patients on Coumadin.8,9,20 952
When suture fixating a PC IOL to the sclera, a blind needle passed through the ciliary sulcus region can accidentally perforate the highly vascular ciliary body, resulting in intraoperative or postoperative hyphema or vitreous hemorrhage. Several studies report a relatively high incidence of intraocular bleeding from transscleral PC IOL fixation (Table 2).10 –13 The incidence of intraocular hemorrhage appears to be much less with suture fixation of a PC IOL to the iris; there is only 1 report describing a hyphema after suture fixation to the iris.21 Moreover, at our practice, approximately 2000 IOLs have been suture fixated to the iris. Postoperative hyphema has not been a problem. In this study of anticoagulated patients, who are at greatest risk for surgically induced bleeding, no cases of intraoperative bleeding occurred and there was only 1 case of a late postoperative hyphema secondary to limbal wound trauma. The lack of bleeding encountered is partly the result of penetration through a relatively avascular midperipheral iris. Furthermore, we believe that the lack of postoperative bleeding, even at 19 months, was the result of the 0-degree haptics and 12.5 mm diameter of the 3-piece silicone IOL. In a study of postmortem eyes with iris-sutured PC IOLs, Apple et al.22 found that in most cases, the only means of support for the lens was the fixation suture. In addition, they report that in almost all cases, the IOL haptics were suspended behind the iris and ciliary body and not located in the ciliary sulcus, minimizing uveal contact and ciliary body erosion from the haptics. Several studies describe recurrent hyphemas and microhyphemas secondary to sulcus-fixated haptics contacting the peripheral iris.23–25 That the haptics of the 3-piece silicone IOL are not angulated toward the posterior iris may minimize iris chafing and subsequent bleeding. Furthermore, the overall diameter of 12.5 mm conforms well with the reported ciliary ring diameter of 11.5 to 12.5 mm.22,26 Larger IOLs of 13.75 to 14.50 mm diameter have been reported to extend through the zonules onto the pars plana.27 In a series of 65 postmortem eyes, Champion and coauthors28 found ciliary body erosion in 54% and obliteration of the major arterial circle of the iris in 17%. Attempts to prevent these problems could be of significant benefit in reducing the chance of hemorrhage, especially in patients predisposed to enhanced bleeding.
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PC IOLS IN ANTICOAGULATED PATIENTS
We chose to suture fixate lenses with a silicone instead of poly(methyl methacrylate) (PMMA) optic to minimize the risk of long-term suture breakage. Previous studies report breakage of 9-0 Prolene fixation sutures on iris-fixated PMMA lenses, presumably as a result of the edge of the “positioning hole” rubbing against the suture.15,29 These suture breakages typically occur 8 to 10 years after implantation. With a silicone optic, the positioning hole is formed by passing the needle through the soft silicone; therefore, no sharp edges or abrasions of the suture occur. The technique could be performed with other IOLs with soft optics such as acrylic lenses. However, we recommend using lenses with rigid haptics and not 1-piece foldable IOLs as these lenses, at least the plate-haptic type, lead to significant pseudophacodonesis. In our experience, pseudophacodonesis does not routinely occur with 3-piece lenses that are suture fixated to the iris. None of the 7 treated eyes in the anticoagulated patients developed CME, which is consistent with findings that suture fixation of a PC IOL to the iris incurs a significantly lower risk for CME and other complications than scleral fixation of a PC IOL or placement of an AC IOL.7 In conclusion, our study further supports the low incidence of intraocular hemorrhage with suture fixation of a PC IOL to the iris. We believe this is the technique of choice for anticoagulated patients lacking capsule support.
7.
8. 9.
10.
11.
12.
13.
14.
15.
16.
17.
References 1. Davis RM, Best D, Gilbert GE. Comparison of intraocular lens fixation techniques performed during penetrating keratoplasty. Am J Ophthalmol 1991; 111:743–749 2. Lass JH, DeSantis DM, Reinhart WJ, et al. Clinical and morphometric results of penetrating keratoplasty with one-piece anterior-chamber or suture-fixated posteriorchamber lenses in the absence of lens capsule. Arch Ophthalmol 1990; 108:1427–1431 3. Lois N, Cohen EJ, Rapuano CJ, Laibson PR. Long-term graft survival in patients with flexible open-loop anteriorchamber intraocular lenses. Cornea 1997; 16:387–392 4. Price FW Jr, Whitson WE, Marks RG. Graft survival in four common groups of patients undergoing penetrating keratoplasty. Ophthalmology 1991; 98:322–328 5. Holland EJ, Daya SM, Evangelista A, et al. Penetrating keratoplasty and transscleral fixation of posterior chamber lens. Am J Ophthalmol 1992; 114:182–187 6. Heidemann DG, Dunn SP. Visual results and complica-
18.
19.
20.
21.
tions of transsclerally sutured intraocular lenses in penetrating keratoplasty. Ophthalmic Surg 1990; 21:609 – 614 Schein OD, Kenyon KR, Steinert RF, et al. A randomized trial of intraocular lens fixation techniques with penetrating keratoplasty. Ophthalmology 1993; 100:1437– 1443 Koehler MP, Sholiton DB. Spontaneous hyphema resulting from warfarin. Ann Ophthalmol 1983; 15:858 –859 Schiff FS. Coumadin related spontaneous hyphemas in patients with iris fixated pseudophakos. Ophthalmic Surg 1985; 16:172–173 Agapitos PJ, Lindstrom RL. Transcleral ciliary sulcus fixation of posterior chamber intraocular lens implants. Aust NZ J Ophthalmol 1989; 17:169 –172 Kora Y, Fukado Y, Yaguchi S. Sulcus fixation of posterior chamber lenses by transscleral sutures. J Cataract Refract Surg 1991; 17:636 –639 McCluskey P, Harrisburg B. Long-term results using scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg 1994; 20:34 –39 Price FW Jr, Wellemeyer M. Transscleral fixation of posterior chamber intraocular lenses. J Cataract Refract Surg 1995; 21:567–573 Zeh WG, Price FW Jr. Iris fixation of posterior chamber intraocular lenses. J Cataract Refract Surg 2000; 26: 1028 –1034 Price FW Jr, Whitson WE. Visual results of suture-fixated posterior chamber lenses during penetrating keratoplasty. Ophthalmology 1989; 96:1234 –1240; discussion by RF Steinert, 1239 –1240 Coli AF, Price FW Jr, Whitson WE. Intraocular lens exchange for anterior chamber intraocular lens-induced corneal endothelial damage. Ophthalmology 1993; 100: 384 –393 Lindquist TD, Agapitos PJ, Lindstrom RL, et al. Transscleral fixation of posterior chamber intraocular lenses in the absence of capsular support. Ophthalmic Surg 1989; 20:769 –775 Soong HK, Musch DC, Kowal V, et al. Implantation of posterior chamber intraocular lenses in the absence of lens capsule during penetrating keratoplasty. Arch Ophthalmol 1989; 107:660 –665 Stark WJ, Gottsch JD, Goodman DF, et al. Posterior chamber intraocular lens implantation in the absence of capsular support. Arch Ophthalmol 1989; 107:1078 – 1083 Butler L, Roper-Hall MJ. Delayed microhyphaema with intraocular lenses: a retrospective study of eight patients. Br J Ophthalmol 1989; 73:106 –110 Spigelman AV, Lindstrom RL, Nichols BD, et al. Implantation of a posterior chamber lens without capsular support during penetrating keratoplasty or as a secondary lens implant. Ophthalmic Surg 1988; 19:396 –398
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22. Apple DJ, Price FW, Gwin T, et al. Sutured retropupillary posterior chamber intraocular lenses for exchange of secondaryimplantation.Ophthalmology1989;96:1241– 1247 23. Masket S. Pseudophakic posterior iris chafing syndrome. J Cataract Refract Surg 1986; 12:252–256 24. Johnson SH, Kratz RP, Olson PF. Iris transillumination defect and microhyphema syndrome. Am Intra-Ocular Implant Soc J 1984; 10:425–428 25. Pavlin CJ, Harasiewicz K, Foster FS. Ultrasound biomicroscopy analysis of haptic position in late-onset, recurrent hyphema after posterior chamber lens implantation. J Cataract Refract Surg 1994; 20:182–185
954
26. Blum M, Tetz MR, Faller U, Vo¨ lcker HE. Age-related changes of the ciliary sulcus: implications for implanting sulcus-fixated lenses. J Cataract Refract Surg 1997; 23: 91–96 27. Apple DJ, Park SB, Merkley KH, et al. Posterior chamber intraocular lenses in a series of 75 autopsy eyes. Part I: loop location. J Cataract Refract Surg 1986; 12:358 –362 28. Champion R, McDonnell PJ, Green WR. Intraocular lenses. Histopathologic characteristics of a large series of autopsy eyes. Surv Ophthalmol 1985; 30:1–32 29. Price FW Jr, Whitson WE, Collins K, Johns S. Changing trends in explanted intraocular lenses: a single center study. J Cataract Refract Surg 1992; 18:470 –474
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I
n the absence of posterior capsule support, there are 3 methods to secure an intraocular lens (IOL): a posterior chamber IOL (PC IOL) suture fixated to the iris; a PC IOL suture fixated to the sclera; an anterior chamber IOL (AC IOL) placed in the anterior chamber. Many studies have documented the effectiveness of these techniques; however, there is no consensus on which technique produces the optimal outcomes. Several studies report successful outcomes regarding visual acuity and rates of graft survival, cystoid mac-
Accepted for publication September 4, 2002. From Eye Care Specialists, Cape Girardeau, Missouri (Parker), and Price Vision Group, Inc., Indianapolis, Indiana (Price), USA. Neither author has a financial or proprietary interest in any material or method mentioned. Reprint requests to Francis W. Price Jr., MD, Price Vision Group, Inc., 9002 North Meridian Street, Suite 100, Indianapolis, Indiana 46260, USA. © 2003 ASCRS and ESCRS Published by Elsevier Inc.
ular edema (CME), and intraocular pressure (IOP) rise using 1 or more of these techniques of securing IOLs.1– 4 In 567 eyes with pseudophakic or aphakic bullous keratopathy that had penetrating keratoplasty with suture fixation of a PC IOL to the iris, Price and coauthors4 report long-term graft survival of 98% and 92% at 2 years and 5 years, respectively. This is higher than that reported by Lois and coauthors3 in a study of eyes with open-looped AC IOLs (87% and 65% at 2 years and 6 years, respectively). In 102 patients with scleralfixated PC IOLs, Holland et al.5 report a graft survival rate of 97% at approximately 2 years. However, Heidemann and Dunn,6 using a scleral-fixation method, report a lower rate of graft survival, 89%, in 56 patients at approximately 1 year. In the only prospective randomized study comparing the 3 techniques, suture fixation of a PC IOL to the iris was shown to have a significantly lower risk for 0886-3350/03/$–see front matter doi:10.1016/S0886-3350(02)01810-2
PC IOLS IN ANTICOAGULATED PATIENTS
CME (P⫽.04) and a significantly lower complication index.7 One complication that can be especially problematic is intraoperative or postoperative hemorrhage. Although the rate of bleeding is usually relatively low with all 3 techniques, it can be significantly increased in anticoagulated patients. Spontaneous hyphemas resulting from warfarin sodium (Coumadin威) have been reported as well as Coumadin-related bleeding associated with iris-clip and sulcus-fixated IOLs.8,9 Furthermore, hyphema or vitreous hemorrhage can result in prolonged decreased vision, ghost cell glaucoma secondary to vitreous hemorrhage, and elevated IOP from a hyphema. Several studies show a significant incidence of anterior chamber or vitreous hemorrhage with transscleral suture-fixated PC IOLs.10 –13 Hemorrhage with scleral fixation is usually caused by the blind pass of the needle behind the iris and presumably through the ciliary sulcus. Unfortunately, the lack of visualization can lead to accidental puncture of the highly vascular ciliary body. This article describes a method of suture fixating silicone PC IOLs to the iris from a limbal approach and reports the outcomes in anticoagulated patients.
Patients and Methods A retrospective review of all patients from 1 surgeon’s practice (F.W.P.) was conducted to identify those who were anticoagulated with Coumadin while having suture fixation of a silicone PC IOL to the iris through a limbal incision. Seven eyes of 5 patients were identified. Of the 7 eyes, 5 had a 3-port pars plana vitrectomy, intracapsular cataract extraction, and suture fixation of a
3-piece silicone IOL to the iris from a limbal approach. Of these 5 eyes, 3 had been diagnosed with phacodonesis and 2 had a subluxated lens resulting in decreased vision, distortion, and monocular diplopia. The sixth eye had pars plana vitrectomy and iris fixation of a silicone PC IOL from a limbal approach secondary to aphakia and contact lens intolerance. The seventh eye had the same procedure with removal of a dislocated PC IOL (Table 1). The 3-piece silicone PC IOL has a 6.3 mm optic, 12.5 mm overall length, and 0-degree modified C-loop haptics (model AQ2003V, Staar Surgical Co.). With this lens, the positioning hole is formed by passing the needle through the soft silicone optic; therefore, no sharp edges or suture abrasions occur. The iris-sutured IOL technique from a limbal approach has been described.14 In brief, a 7.0 to 9.0 mm incision is created 1.0 mm posterior to the limbus and a beveled incision is carried forward to form a 3-step wound. A 3-port pars plana vitrectomy is then performed, removing the vitreous. A 9-0 polypropylene (Prolene威) suture on a 4.0 mm straight taper needle (Ethicon D-9904) is passed through the midperipheral iris at the 9 o’clock position using a Sutherland microforceps (#612.91, Grieshaber & Co.). A second suture is similarly passed through the midperipheral iris at the 3 o’clock position. The sutures are pulled back through the iris as the needle is retrieved through the pupil (Figure 1, upper and middle). Each suture needle is passed down through the optic of the PC IOL, penetrating the soft silicone at the periphery and then back up through the optic about 0.5 mm away. A loose loop tie is placed in each suture, and the PC IOL is inserted through the limbal incision to a position posterior to the iris. The IOL is oriented so the haptics are at the 3 and 9 o’clock positions. The knots are tied between the iris and the anterior surface of the optic (Figure 1, lower). All patients were examined 1 day and 1 week after surgery. They were then seen as required for routine postoperative care.
Table 1. Characteristics of anticoagulated patients receiving iris-sutured silicone PC IOLs. BCVA Eye
Diagnosis
IOP (mm Hg)
Preop
Postop
Preop
Postop
Follow-up (Mo)
Complications
1
Phacodonesis OD
20/30
20/20
18
17
8
2
Phacodonesis OS
20/60
20/40
14
10
25
Hyphema X1, superior bleb
3
Subluxated lens OD
20/200
20/25
13
12
10
None
4
Subluxated lens OS
20/50
20/30
15
10
6
None
5
Phacodonesis OS, cataract OS
20/70
20/30
16
15
7
None
6
Aphakia OD (contact lens intolerance)
20/40
20/25
11
12
6
None
7
Dislocated PC IOL OD
20/50
20/30
14
14
13
None
950
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None
PC IOLS IN ANTICOAGULATED PATIENTS
patients was 47.8 years (range 28 to 74 years). The reasons for anticoagulation therapy were Marfan’s syndrome with aortic valve replacement (n ⫽ 3), a history of venous thrombosis and pulmonary embolus (n ⫽ 1), and severe cardiac disease and chronic atrial fibrillation (n ⫽ 1). Intraoperatively, there were no intraocular hemorrhages. At each successive postoperative examination, no blood was noted in the anterior chamber or posterior segment in 6 of 7 eyes. In eye 2, a nonlayering hyphema and a new superior bleb were noted 6 weeks postoperatively. The hyphema resolved within 1 week and did not recur over a 23-month period. It was believed that the hyphema was not a result of the iris-fixated PC IOL but rather secondary to trauma to the limbal wound, resulting in light bleeding from episcleral vessels into the anterior chamber. This is supported by the fact that when the hyphema was present, a superior filtering bleb developed over the limbal wound. The filtering bleb eventually lead to hypotony maculopathy and subsequent wound revision. Pseudophacodonesis or lens decentration did not occur at any time during the follow-up (Figure 2), and there was no significant difference between the mean preoperative IOP (14.4 mm Hg) and the mean postoperative IOP (12.9 mm Hg). Iris depigmentation secondary to midperipheral suture placement was minimal at 12 months (Figure 3). The visual acuity was 20/40 or better in all eyes at the last follow-up.
Figure 1. (Parker) Limbal incision method for iris fixation of a PC IOL. Upper: The fixation suture is passed through a limbal incision. Middle: The fixation suture is passed back through the iris, and the needle is retrieved through the pupil. Lower: The PC IOL is sutured via a limbal approach (reprinted from J Cataract Refract Surg 2000; 26:1028 –1034).
Results The mean follow-up of the 7 eyes was 10.7 months (range 6 to 25 months) (Table 1). The mean age of the
Figure 2. (Parker) The appearance of an iris-fixated silicone PC IOL 12 months after placement.
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Figure 3. (Parker) Minimal iris depigmentation secondary to midperipheral suture placement 12 months postoperatively.
Table 2. Incidence of intraocular hemorrhage associated with scleral-fixated PC IOLs. Incidence (%)
Study*
Year
Agapitos10
1989
2 hyphemas, 1 vitreous hemorrhage
3/19 (15.7)
Kora11
1991
5 vitreous hemorrhages
5/23 (21.7)
McClusky
1994
2 hyphemas, 1 vitreous hemorrhage
3/32 (9.3)
Price13
1995
8 hyphemas, 2 vitreous hemorrhages
10/75 (13.3)
12
Location
*First author listed
Discussion There is considerable debate about which technique of IOL fixation in the absence of capsule support gives the most favorable outcomes. Many physicians, as we do, favor using a PC IOL for many reasons. Its location behind the iris is the natural plane of the lens, it is closer to the nodal point of the eye, and it is situated farthest from the corneal endothelium. Many studies report comparable results in postoperative visual acuity, graft clarity, and IOP change with iris-fixated and scleral-fixated PC IOLs.1–7,11–13,15–19 However, when evaluating which technique is most appropriate, the anticoagulated patient deserves special consideration. Intraoperative and postoperative bleeding can be sight threatening, and the risk is maximized in patients who are anticoagulated. There have been several reports demonstrating increased intraocular bleeding in patients on Coumadin.8,9,20 952
When suture fixating a PC IOL to the sclera, a blind needle passed through the ciliary sulcus region can accidentally perforate the highly vascular ciliary body, resulting in intraoperative or postoperative hyphema or vitreous hemorrhage. Several studies report a relatively high incidence of intraocular bleeding from transscleral PC IOL fixation (Table 2).10 –13 The incidence of intraocular hemorrhage appears to be much less with suture fixation of a PC IOL to the iris; there is only 1 report describing a hyphema after suture fixation to the iris.21 Moreover, at our practice, approximately 2000 IOLs have been suture fixated to the iris. Postoperative hyphema has not been a problem. In this study of anticoagulated patients, who are at greatest risk for surgically induced bleeding, no cases of intraoperative bleeding occurred and there was only 1 case of a late postoperative hyphema secondary to limbal wound trauma. The lack of bleeding encountered is partly the result of penetration through a relatively avascular midperipheral iris. Furthermore, we believe that the lack of postoperative bleeding, even at 19 months, was the result of the 0-degree haptics and 12.5 mm diameter of the 3-piece silicone IOL. In a study of postmortem eyes with iris-sutured PC IOLs, Apple et al.22 found that in most cases, the only means of support for the lens was the fixation suture. In addition, they report that in almost all cases, the IOL haptics were suspended behind the iris and ciliary body and not located in the ciliary sulcus, minimizing uveal contact and ciliary body erosion from the haptics. Several studies describe recurrent hyphemas and microhyphemas secondary to sulcus-fixated haptics contacting the peripheral iris.23–25 That the haptics of the 3-piece silicone IOL are not angulated toward the posterior iris may minimize iris chafing and subsequent bleeding. Furthermore, the overall diameter of 12.5 mm conforms well with the reported ciliary ring diameter of 11.5 to 12.5 mm.22,26 Larger IOLs of 13.75 to 14.50 mm diameter have been reported to extend through the zonules onto the pars plana.27 In a series of 65 postmortem eyes, Champion and coauthors28 found ciliary body erosion in 54% and obliteration of the major arterial circle of the iris in 17%. Attempts to prevent these problems could be of significant benefit in reducing the chance of hemorrhage, especially in patients predisposed to enhanced bleeding.
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We chose to suture fixate lenses with a silicone instead of poly(methyl methacrylate) (PMMA) optic to minimize the risk of long-term suture breakage. Previous studies report breakage of 9-0 Prolene fixation sutures on iris-fixated PMMA lenses, presumably as a result of the edge of the “positioning hole” rubbing against the suture.15,29 These suture breakages typically occur 8 to 10 years after implantation. With a silicone optic, the positioning hole is formed by passing the needle through the soft silicone; therefore, no sharp edges or abrasions of the suture occur. The technique could be performed with other IOLs with soft optics such as acrylic lenses. However, we recommend using lenses with rigid haptics and not 1-piece foldable IOLs as these lenses, at least the plate-haptic type, lead to significant pseudophacodonesis. In our experience, pseudophacodonesis does not routinely occur with 3-piece lenses that are suture fixated to the iris. None of the 7 treated eyes in the anticoagulated patients developed CME, which is consistent with findings that suture fixation of a PC IOL to the iris incurs a significantly lower risk for CME and other complications than scleral fixation of a PC IOL or placement of an AC IOL.7 In conclusion, our study further supports the low incidence of intraocular hemorrhage with suture fixation of a PC IOL to the iris. We believe this is the technique of choice for anticoagulated patients lacking capsule support.
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