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ediatric surgeries are a major challenge for an ophthalmologist. The smaller dimensions of the eye make manipulations easier said than

Scleral Fixated Intraocular Lens Implantation in Pediatric Age Group An Overview

(Presenting Author: Dr. Gunjan Abhijit Deshpande)

Dr. Girish Shiva Rao

done. Pediatric aphakia is yet another domain which is relatively untouched. Correction within adequate time is necessary to prevent

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development of amblyopia and to preserve binocular vision. Aphakic eyes with lack of capsular support require a special mention. Rehabilitation of vision by secondary intraocular lens (IOL) implantation in such eyes is very tricky.

Results

Material and Methods

Literature describes various studies which advocate the implantation of an IOL in such cases. The IOL can be placed in the anterior chamber (AC), fixed to the anterior surface of iris, fixed to the posterior surface of iris or sutured to the posterior chamber sulcus.

Our study was a retrospective, non-comparative, interventional case series of 63 eyes of 47 patients operated over 11 years from January 1998 to March 2009. Patient information was inclusive of demographic data (pediatric age was considered <12 years in our study), past surgical history, age-appropriate assessment of visual acuity (Snellen, picture or fix and follow), refraction, presence of amblyopia, maximum follow up, post operative IOL position and complications. Changes in visual acuity of one line or more on a standard visual acuity chart or analogous changes (i.e. patient with only light perception before surgery, counts fingers post surgery) were considered significant. Axial length was measured using A and B scan ultrasonography depending on the co-operation of the patient. Keratometry was performed using a Javal-Schiotz keratometer.

All eyes lacked a capsular support to place the IOL in the capsular bag. 18(28.57%) eyes had already been operated upon at the time of surgery (either a wound repair or a cataract surgery). All eyes underwent parsplana vitrectomy with SFIOL implantation with/without lensectomy. In addition 3(4.76%) eyes required IOL removal operated elsewhere and 1(1.58%) required iridodialysis repair. Amblyopia treatment was started in 19(30.15%) eyes of which only 8(12.69%) eyes completed the treatment adequately. The major causes of reduced vision in our study were corneal and retinal pathologies and amblyopia.

Medical records of patients below 12 years of age who underwent SFIOL implantation were analyzed. Mean age at the time of surgery was 8.02 years (range 3-12 years). The average postoperative follow up was 13.92 months (range 1-84 months).

General or local anesthesia was employed. After creating 3 port sclerotomies (2.5mm behind limbus aphakes and pseudophakes; 3mm behind limbus - phakes) parsplana lensectomy (in phakes) with complete parsplana vitrectomy were performed. Sclera tunnel or a corneoscleral section was fashioned. 10-0 polypropylene suture was passed 1.5mm behind the limbus from 9 o clock to 3 o clock position and vice versa. AC was entered. The suture was cut into two after bringing it out from the section and tied to the eyelets of the SFIOL. The SFIOL was then carefully placed into the sulcus, tied to the sclera and knots were buried. Sclerotomies and conjunctiva were closed using 7-0 polyglactin. Eye was patched. Postoperatively, they received topical steroid-antibiotic combination in tapering dose.

5 eyes which developed retinal detachment underwent buckling procedure and retina remained attached till the last follow up. Out of these, 1 eye developed secondary optic atrophy. 1 eye developed acute postoperative endophthalmitis within 1 week of surgery. The inflammation resolved completely after 2 months of treatment with intravitreal antibiotics based on the sensitivity reports. 1 eye developed subluxation of IOL after 6 months of surgery and was repositioned immediately. The position of the IOL was maintained till the last follow up.
Features

Table-1

Indications For Surgery: Subluxated Crystalline Lens Cataract Unsuccessful Cataract Surgery Complications: Retinal Detachment Acute Endophthalmitis Subluxation of IOL

(N) 41 17 5 5 1 1 (N) 51 9 3

% 65.07 26.98 7.93 7.93 1.58 1.58 (%) 80.95 14.28 4.76

Features

Table-2

Bcva: Increased Decreased Maintained

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Ideally, the aphakic correction in pediatric agegroup must compensate for the childs growing eye. Furthermore, the correction provided must also account for a clear visual image to prevent the development of amblyopia. Keeping this in mind, there a few options left with an ophthalmologist. Correction of pediatric aphakia can be both optical and surgical. Spectacles can be used in bilateral aphakia. Though they are cheap and easily available, they are known to induce prismatic effect, aberrations, image magnification, loss of depth perception, scotomas and cosmetic blemish which preclude their wide spread use. Also, they are futile for treating unilateral aphakia as they lead to diplopia as a result of anisekonia1.

Discussion

Scleral fixated posterior chamber IOL on the other hand, is the most physiologic option available to correct aphakia. Studies by Kumar et al2,4,8 have shown that transscleral fixated IOL are well tolerated in pediatric age group. Similar results have been shown by our study. Jacobi et al9 described scleral fixation of multifocal IOL in children and yound adults.

posterior chamber IOL in pediatric aphakia. They placed the IOL behind the iris and sutured it to the iris tissue instead of sclera. They reported I case of retinal detachment and IOL capture each.

Contact lenses have been preferred by many authors. They induce lesser optical distortion when compared to spectacles. However, at the same time they are costly, not easily available, cumbersome to use in children and result in frequent lens loss.2,3,4 If the child is intolerant or poorly motivated, an alternative treatment is mandatory.5 Anterior chamber IOL implantation has well known long term complications like corneal endothelial loss, corneal decompensation, iris atrophy, pupil ectopia, glaucoma.6

Most important complications reported in literature with SFIOL implantation are suture breakage with IOL subluxation, endopthalmitis and retinal detachment. Literature search shows no cases of retinal detachment or vision loss from dislocation of transscleral sutured IOL.10. Other minor complications reported are suprachoroidal hemorrhage and hypotony8, 11, 12. Apprehension has been raised concerning the long term safety of 10-0 polypropylene sutures used for fixing the IOL to the sclera.10,13,14,15,16 Recent studies recommend the usage of thicker suture material like merislene or 9-0 polypropylene.10,15 Visual improvement and amblyopia was not precisely the target measures of our study. However, it is important to note that amblyopia forms an important cause of poor vision in pediatric aphakia as reported by us and other studies.6,10

Yen et al6 have recently described iris fixated

Iris-claw lenses are placed in the AC and are attached to the anterior surface of the iris by the help of clips 6. Kopel et al7 studied iris-sutured IOL in children with ecotopia lentis and reported a significant risk of IOL dislocation (33%). Though they may be tolerated in adult population, they are not available for pediatric use in all countries6.

1. Abrams, Duke-Elders Practice of refraction, 10th ed. Butterwirth-Heinemann 2006:71-78. 2. Kumar et al, Scleral-fixated intraocular lens implantation in unilateral aphakic children. Ophthalmology 1999;106:2184-9. 3. Mittelviefhaus et al, Transcleral suture fixation of posterior chamber intraocular lenses in children under 3 years. Graefes Arch Clin Exp Ophthalmol 2000;238:143-8. 4. Bardorf et al, Pediatric transscleral sutured intraocular lenses: efficacy and safety in 43 eyes followed

References

Scleral fixated intraocular lens implantation is a safe and effective procedure. It is the most physiologic option available for correction of aphakia. Our study shows few surgical complications. This procedure can be considered the treatment of choice to correct aphakia in pediatric population in presence of inadequate capsular support to place IOL in capsular bag.
an average of 3 years. J AAPOS 2005;9: 240-2. 5. Von Noorden GK. Binocular vision and ocular motility: Theory and management of strabismus, St Louis: Mosby, 1990;4:200-82. 6. Yen et al, Iris fixated posterior chamber intraocular lenses in children. Am J Ophthalmol, 2009;147:121-6. 7. Kopel et al,Iris-sutured intraocular lenses for ectopia lentis in children. J Cataract Refract Surg, 2008;34:596-600. 8. Buckley EG. Scleral fixated (sutured) posterior chamber intraocular lens implantation in children. J

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AAPOS 1999;3:289-94. 9. Jacobi et al, Scleral fixation of secondary foldable multifocal intraocular lens implants in children and young adults. Ophthalmology, 2002;109:2315-24. 10. Buckley EG. Hanging by a thread: the long term efficacy and safety of transscleral sutured intraocular lenses in children (an American Ophthalmologist Society Thesis). Trans Am Ophthalmol Soc 2007;105:294-311. 11. Awad et al. Secondary posterior chamber intraocular lens implantation in children. J AAPOS 1998;2:269-74. 12. Kaiura et al. complications arising from iris-fixated posterior chamber intraocular lenses. J Cataract

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Refract Surg 2005;31:2420-2. 13. Kim et al. Subluxation of transscleral sutures posterior chamber intraocular lens (TSIOL). Am J Ophthalmol 2003;136:382-4. 14. Vote et al. long term outcome of combined parsplana vitrectomy and scleral fixated sutures posterior chamber intraocular lens implantation. Am J Opthalmol 2006;141:308-12. 15. Price et al. late dislocation of scleral sutured posterior chamber intraocular lenses. J Cataract Refract Surg 2005,31:1320-6. 16. Asadi R and Kheirkhah A. long term results of posterior chamber intraocular lenses in children. Opthalmology 2008;115:67-72.