Intrascleral Knotless Zigzag Suture Fixation of Four-Haptic Hydrophilic Acrylic Foldable IOL: Clinical Outcomes

Figures & data

Figure 1 Intrascleral knotless zigzag suture fixation of Akreos AO60 foldable intraocular lens (IOL) technique. (A) Conjunctival peritomy at 3 and 9 o’clock to expose the sclera. (B) Limbus corneal incision at 12 o’clock. (C) One haptic is externalized through the corneal incision. (D) A double thread 10-0 or 9-0 polypropylene suture is passed through the eyelet. (E) The needle is passed between the arms of the thread. (F and G) The needle is inserted through the corneal incision, passed behind the iris, and came out through the sclera at about 2 mm from the limbus. (H and J) The steps are repeated using the 180º away haptic and orienting the needle to the opposite side. (K) Centration of the IOL. (L–O) The suture is run through the partial thickness of the sclera in a zigzag pattern (4 intrascleral passages), and the thread is cut flush to the sclera without knotting (this procedure is performed in the nasal and temporal sides). (P) Conjunctival suture.

Figure 2 Postoperative slit-lamp photography of a patient that underwent intrascleral knotless zigzag suture fixation of Akreos AO60.

Table 1 Baseline Characteristics of Study Population

	All (n=99)	Spontaneous IOL Dislocation (n=53)	Complicated Cataract Surgery (n=23)	Traumatic Natural Lens or IOL Dislocation (n=17)	Other Causes* (n=6)	p-value†
Age, mean±SD	72.1±15.2	74.9± (14.5)	73.8±16.3	65.5±11.7	60.0±16.7	0.003
Male, n (%)	58 (58.6)	30 (56.6)	9 (39.1)	15 (88.2)	4 (67)	0.19
Follow-up (months), median (range)	19.5 (3–81)	21.3 (3–81)	17.1 (3–59)	13.0 (3–48)	30.0 (5–69)	0.322
Baseline BCVA (logmar), mean±SD	1.34±0.70	1.28±0.73	1.51±0.68	1.32±0.68	1.35±0.60	0.721
Pseudoexfoliative syndrome	29 (29.3%)	23 (43.4%)	6 (11.3%)	0 (0.0%)	0 (0.0%)	NA
Glaucoma	13 (13.1%)	10 (18.9%)	2 (8.7%)	1 (5.9%)	0 (0.0%)	NA
Diabetic retinopathy	6 (6.1%)	5 (9.4%)	1 (4.3%)	0 (0.0%)	0 (0.0%)	NA
Retinal detachment	4 (4.0%)	1 (1.9%)	0 (0.0%)	1 (5.9%)	2 (33.3%)	NA
Uveitis‡	3 (3.0%)	3 (5.7%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	NA
Others diseases**	17 (17.0%)	12 (22.6%)	4 (17.4%)	1 (5.9%)	0 (0.0%)	NA
Prior ocular surgery***	15 (15.2%)	9 (17.0%)	2 (8.7%)	1 (5.9%)	3 (50.0%)	NA

Notes: *Including spontaneous natural lens dislocation (n=4, 2 of them with Marfan syndrome), and corneal decompensation due to anterior chamber IOL in eyes without capsular support (n=2). **Including pigmentary retinitis, epiretinal membrane, age-related macular degeneration, high myopia, Fuchs dystrophy, and strabismus. ***Including pars plana vitrectomy, refractive surgery, corneal transplant and glaucoma surgery. ^‡Including 2 cases of uveitis–glaucoma–hyphaema syndrome after scleral fixation of AcrySof SN60WF IOL. ^†Comparison between intraoperatively complicated cataract surgery, complicated cataract surgery, traumatic natural lens or IOL dislocation, and other causes.

Abbreviations: SD, standard deviation; IOL, intraocular lens; VEGF, vascular endothelial growth factor; NA, non-applicable.

Table 2 Visual and Refractive Surgical Outcomes

	All (n=99)	Spontaneous IOL Dislocation (n=53)	Intraoperatively Complicated Cataract Surgery (n=23)	Traumatic Natural Lens or IOL Dislocation (n=17)	Other Causes (n=6)	p-value†
BCVA (logmar), mean±SD	0.49±0.56	0.48±0.51	0.51±0.63	0.54±0.71	0.37±0.29	0.928
BCVA variation (logmar), mean±SD	−0.87±0.79	−0.79±0.78	−1.04±0.83	−0.85±0.82	−0.98±0.76	0.741
Cylinder error (D), mean±SD	1.43±1.35	1.62±1.45	1.14±1.15	1.17±1.41	1.43±0.84	0.290
Spherical equivalent (D), mean±SD	−1.24±1.82	−1.50±1.58	−0.70±2.25	−1.09±2.08	−1.33±1.39	0.424
Prediction error (D), mean±SD	−0.51±1.16	−0.65±1.08	−0.40±1.52	−0.14±0.88	−1.05±1.15	0.545
Absolute prediction error (D), mean±SD	0.92±0.87	0.95±0.81	1.09±1.00	0.58±0.64	1.22±1.04	0.468

Notes: ^†Comparison between intraoperatively complicated cataract surgery, complicated cataract surgery, traumatic natural lens or IOL dislocation, and other causes.

Abbreviations: BCVA, best corrected visual acuity; IOL, intraocular lens; D, diopters.

Table 3 Perioperative Complications

	All (n=99)	Spontaneous IOL Dislocation (n=53)	Intraoperatively Complicated Cataract Surgery (n=23)	Traumatic Natural Lens or IOL Dislocation (n=17)	Other Causes (n=6)
Ocular hypertension	20 (20.2%)	11 (20.8%)	5 (21.7%)	3 (17.6%)	1 (16.7%)
Cystoid macular edema	15 (15.2%)	6 (11.3%)	5 (21.7%)	3 (17.6%)	1 (16.7%)
IOL dislocation	7 (7.0%)	3 (5.7%)	2 (8.7%)	1 (5.6%)	1 (16.7%)
Pseudophakic bullous keratopathy	3 (3.0%)	2 (3.8%)	1 (4.3%)	0 (0.0%)	0 (0.0%)
Endophthalmitis	1 (1.0%)	0 (0.0%)	1 (4.3%)	0 (0.0%)	0 (0.0%)
Uveitis–glaucoma–hyphaema syndrome	1 (1.0%)	1 (1.9%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Iridodialysis	1 (1.0%)	1 (1.9%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Iris herniation	1 (1.0%)	0 (0.0%)	1 (4.3%)	0 (0.0%)	0 (0.0%)
Corneal leakage	1 (1.0%)	1 (1.9%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Retained lens fragments	1 (1.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)

Abbreviation: IOL, intraocular lens.

Figure 3 Perioperative complications rate.