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Iris fixation or scleral fixation of dislocated IOLs improves corrected distance visual acuity

Issue: October 25, 2015

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Iris fixation and scleral fixation of dislocated IOLs had similar visual outcomes, but iris fixation was associated with more postoperative inflammation and less stable refraction, according to a study in South Korea.

“The iris fixation techniques for the repositioning of dislocated IOL showed similar efficacy to the scleral fixation. However, despite iris fixation having the advantage of shorter operation time, it had several drawbacks, including increased rates of induced astigmatism and immediate postoperative inflammation, as well as earlier recurrence and less stable refraction,” Kyeong Hwan Kim, MD, the first author, told Ocular Surgery News.

Risks with scleral fixation include refractive instability due to lens tilt and decentration, intraocular hemorrhage due to the passage of a needle through vascular uveal tissue, and suture breakage or endophthalmitis due to connecting the suture material outside, Kim said.

Risks with iris fixation include iris chafing, pigment dispersion, chronic inflammation, progressive peripheral anterior synechia formation and photic phenomena such as glare or halo due to pupillary distortion, he said.

Study design and measures

The retrospective comparative case series, published in American Journal of Ophthalmology, included 44 eyes of 44 patients who underwent scleral fixation of dislocated IOLs and 35 eyes of 34 patients who underwent iris fixation.

Scleral fixation was performed a mean 1.4 months after onset of IOL dislocation, and iris fixation was performed a mean 1.1 months after dislocation. Mean follow-up was 16.6 months in the scleral fixation group and 16.3 months in the iris fixation group.

An ab externo suture loop retrieval and fixation technique was used in the scleral fixation group. The McCannel suture technique was used in the iris fixation group.

Primary outcome measures were visual acuity, refractive stability, surgery time and perioperative complications such as recurrence of IOL dislocation.

Surgery time was 37.9 minutes in the iris fixation group and 51.6 minutes in the scleral fixation group. The difference was statistically significant (P = .0007).

Visual, refractive outcomes

“[The] iris fixation group showed less refractive stability, with a greater hyperopic change after 1 week, than the scleral fixation group,” Kim said. “The amount of astigmatism in the iris fixation group also increased significantly during the first month after surgery.”

Corrected distance visual acuity improved significantly at 1 week in the scleral fixation group (P = .040) but not in the iris fixation group. It improved significantly 1 month postoperatively in the scleral fixation group (P = .0002) and in the iris fixation group (P = .0001) and was stable up to 12 months.

Refractive error decreased significantly 1 day after surgery in the scleral fixation group (P = .028) and in the iris fixation group (P = .046). However, a significant hyperopic change was seen from 1 week to 12 months in the iris fixation group (P = .043). Refraction was stable in the scleral fixation group.

Astigmatism increased significantly for 1 month in the iris fixation group but decreased to baseline at 3 months and was stable out to 12 months.

Inflammation, complications

Immediate postoperative inflammation was significantly more severe in the iris fixation group than in the scleral fixation group (P = .001).

“We found that the recurrence rates in the two groups were similar, but the recurrence was significantly earlier in the iris fixation group, with all recurrences observed within 3 months after surgery,” Kim said.

The rate of recurrent IOL dislocation was 13.6% in the iris fixation group and 17.1% in the scleral fixation group. The mean time to recurrence was 1.7 months in the iris fixation group and 10.4 months in the scleral fixation group; the difference was statistically significant (P = .031).

“Owing to ethnic differences in iris thickness and strength, the use of iris fixation techniques in ethnic groups other than Asians may be even more disadvantageous, in terms of recurrence,” Kim said.

The incidence of perioperative complications such as intraocular bleeding, corneal endothelial cell loss, cystoid macular edema and retinal detachment was similar in both groups.

IOP was higher in the iris fixation group during follow-up, but the difference was not significant.

Kim said an IOL with a broad optic-haptic junction may be more prone to recurrent dislocation than other models.

“Further studies are necessary to assess whether the type of dislocated IOL could have an effect on the surgical result,” he said. – by Matt Hasson

• Reference:
• Kim KH, et al. Am J Ophthalmol. 2015;doi:10.1016/j.ajo.2015.06.010.

• For more information:
• Kyeong Hwan Kim, MD, can be reached at Department of Ophthalmology, Haeundae Paik Hospital, Inje University College of Medicine, 875 Haeundae-Ro, Haeundae-Gu, Busan, 612-896, South Korea; email: khkim@inje.ac.kr.

Disclosure: Kim reports no relevant financial disclosures.