Sulcus implantation of single-piece foldable acrylic intraocular lens after posterior capsule tear during phacoemulsification: Visual outcome and complications

Sunil Kumar; Neha Shilpy; Rajiv Kumar Gupta

doi:10.4103/jcor.jcor_132_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 10 | Issue : 3 | Page : 110-113

Sulcus implantation of single-piece foldable acrylic intraocular lens after posterior capsule tear during phacoemulsification: Visual outcome and complications

Sunil Kumar, Neha Shilpy, Rajiv Kumar Gupta
Regional Institute of Ophthalmology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India

Date of Submission	11-Sep-2021
Date of Decision	23-Jun-2022
Date of Acceptance	29-Oct-2022
Date of Web Publication	1-Dec-2022

Correspondence Address:
Neha Shilpy
Regional Institute of Ophthalmology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcor.jcor_132_21

Abstract

Background: Posterior capsule tear (PCT) during phacoemulsification affects the type, site, and timing of intraocular lens (IOL) implantation. Aim: The aim was to evaluate the visual outcomes and complications following sulcus implantation of single-piece foldable acrylic IOL after PCT during phacoemulsification. Setting and Design: The retrospective observational study was conducted at a tertiary care center in eastern India. Methods: Records of patients between July 2017 and March 2020 were reviewed. Thirty-six eyes of 36 patients, in whom PCT had occurred during phacoemulsification, were included. Statistical Analysis Used: Microsoft Excel 2007 and SPSS 108 software were used. Preoperative and postoperative visual acuity was compared using paired t-tests. Postoperative visual outcomes and complications were assessed in percentage. Results: Postoperative visual acuity was ≥6/12 in 22 (61.11%) patients on day 1 and 30 (83.33%) patients on day 30, with a statistically significant improvement compared to preoperative vision (P < 0.05). On the first postoperative day, corneal edema was seen in 8 (22.22%) patients, increased anterior chamber reaction in 5 (13.89%) patients, and raised IOP in 4 (11.11%) patients. After 3 months, 2 (5.56%) patients needed antiglaucoma medications for IOP control, 1 (2.78%) had iridocyclitis, and 1 (2.78%) had chronic cystoid macular edema. The mean follow-up duration was 17.44 ± 12.15 months (range: 3–46 months). Conclusion: To conclude, sulcus implantation of posterior chamber IOL during phacoemulsification surgery complicated with PCT may be considered if the adequate lens is not available, and sufficient capsular support exists. Our study revealed a good final visual acuity with minimal complications, though more research to ascertain our results is warranted.

Keywords: Foldable single-piece acrylic intraocular lens, posterior capsule tear, sulcus implantation

How to cite this article:
Kumar S, Shilpy N, Gupta RK. Sulcus implantation of single-piece foldable acrylic intraocular lens after posterior capsule tear during phacoemulsification: Visual outcome and complications. J Clin Ophthalmol Res 2022;10:110-3

How to cite this URL:
Kumar S, Shilpy N, Gupta RK. Sulcus implantation of single-piece foldable acrylic intraocular lens after posterior capsule tear during phacoemulsification: Visual outcome and complications. J Clin Ophthalmol Res [serial online] 2022 [cited 2023 Mar 24];10:110-3. Available from: https://www.jcor.in/text.asp?2022/10/3/110/362499

Phacoemulsification with in-the-bag implantation of single-piece foldable intraocular lens (IOL) is the standard procedure for cataract surgery. Posterior capsule tear (PCT) is one of the most feared complications of phacoemulsification, with reported incidence ranging from 0.7% to 16%.^[1] Apart from the technique of cataract surgery, the incidence also depends on the type, etiology, and stage of cataracts, and the skill of the surgeon.^[1] It can occur at any stage of the procedure, and in-the-bag implantation of the lens becomes difficult if the PCT is large.^[1] The alternative options for IOL placement in such cases are implantation of rigid polymethylmethacrylate (PMMA) or foldable multipiece IOL in the sulcus or with iris-fixation or scleral-fixation, or implantation of an anterior chamber (AC) IOL.^{[1],[2],[3],[4],[5],[6],[7]}

In the presence of an intact capsular rim, placement of IOL in the ciliary sulcus over the capsule is easy to perform and yields a good anatomic and visual outcome.^[8] However, the backup of 3-piece foldable IOL is not always available, and in those cases, sometimes single-piece acrylic IOL is primarily implanted in the sulcus.

Previous studies have evaluated the visual outcomes and complications associated with sulcus placement of lenses meant for in-the-bag implantation, and there have been mixed opinions.^{[9],[10],[11],[12]} Therefore, this retrospective study was conducted to evaluate the visual and surgical outcomes of sulcus implantation of single-piece foldable acrylic IOL in cases with PCT during phacoemulsification.

Methods

This was a retrospective observational study conducted at a tertiary care center in eastern India. Records of patients who underwent phacoemulsification between July 2017 and March 2020 were reviewed. Thirty-six eyes of 36 patients were included, in whom PCT had occurred during phacoemulsification, and single-piece foldable IOL was implanted in the sulcus, due to nonavailability of 3-piece foldable IOL. We excluded those patients in whom 3-piece foldable IOL or rigid PMMA IOL was inserted following PCT. Approval was taken from the institute's Ethics Committee, and the study adhered to the tenets of the Declaration of Helsinki.

All the surgeries were performed by a single surgeon under topical or peribulbar anesthesia. A 2.8-mm temporal clear corneal main incision and two side ports were made. After injecting viscoelastics, 5.0–5.5 mm continuous curvilinear capsulorhexis was done. After hydroprocedure, phacoemulsification was performed by direct chop technique using Oertli faros phacoemulsification system. The cortex was removed using bimanual irrigation/aspiration cannula. After noting the PCT, dispersive viscoelastics were used to plug the tear, and dry aspiration was done to aspirate the remaining cortex. Bimanual anterior vitrectomy was done from the limbal route using a 23G vitrectomy cutter in the same machine. Single-piece acrylic IOL of the same power as available for in-the-bag implantation, was implanted in the ciliary sulcus. Intracameral pilocarpine was injected to constrict the pupil and identify any residual vitreous at the pupillary margin, which if present, was subsequently removed using cutter, and subsequently, the wound was closed with hydration.

As a routine protocol, in the postoperative period, all patients received topical antibiotics (moxifloxacin 0.5%) for 2 weeks, topical steroid (prednisolone acetate 1%) in tapering doses for 6 weeks, and cycloplegics (homatropine 2%) for 1 week. Nondiabetics were also advised systemic steroids starting with 1 mg/kg/day tapered over 2 weeks. Follow-ups were done on day 1, 1 week, 1 month, and 3 months postoperatively and thereafter as and when needed. In every visit, best-corrected visual acuity (BCVA) was recorded, and intraocular pressure (IOP) was measured using noncontact tonometry. Detail slit lamp examination of the anterior segment and posterior segment examination was done on every follow-up visit. Posterior segment optical coherence tomography (OCT) (Cirrus HD-OCT 4000, Carl Zeiss Meditec, Dublin, California, USA) was done in cases with clinical evidence of cystoid macular edema (CME) or postoperative visual acuity ≤6/12.

Statistical analysis was performed using Microsoft Excel 2007 and SPSS 108 software (version 20.0 Armonk, NY, USA: IBM corp.). Data were described in terms of mean, standard deviation, range, and/or percentage. Preoperative and postoperative visual acuity was compared using paired t-test. P < 0.05 was considered statistically significant. Postoperative visual outcomes and complications were assessed in percentage.

Results

Of the total 36 patients included, 19 were male (53%) and 17 were female (47%). The average age of the patients was 65.81 ± 7.04 years. The mean preoperative visual acuity was 1.28 ± 0.35 logMAR. Immature nuclear sclerosis was observed as the most common cataract type in 20 cases (55.56%), followed by mature cataract in 8 (22.22%) cases, posterior subcapsular cataract (PSC) in 6 (16.67%) cases, and posterior polar cataract (PPC) in 2 (5.56%) cases. The mean axial length was 24.19 ± 1.32 mm (range: 22.0–26.5 mm).

PCT occurred at the stage of irrigation and aspiration in 19 cases (53%), during nucleus handling in 14 (39%) cases, during IOL placement in 2 (5%) cases, and during polishing of the posterior capsule in 1 (2.78%) case. Acrysof^® SA60AT (Alcon; USA) was implanted in 14 (39%) cases, Acrysof^® SN60WF (Alcon; USA) in 13 (36%) cases, and Supraphob (Appasamy Associates, Chennai, India) was implanted in the remaining 9 (25%) cases. IOL power ranged from 16D to 24 D.

The postoperative visual acuity on day 1 ranged from 6/24–6/9 on Snellen chart, with 22 (61.11%) patients having BCVA of 6/12 or better. After a 30-day follow-up period, 30 patients had visual acuity of 6/12 or better (83.33%), with 16 (44.44%) cases having a BCVA of 6/9 and another 14 (38.89%) cases having a BCVA of 6/12. There was a statistically significant improvement in the postoperative visual acuity at all follow-up visits compared to the preoperative vision (P < 0.0001). The mean IOP in the preoperative and postoperative period was not significantly different [Table 1].

Table 1: Comparison of preoperative and postoperative visual acuity and intraocular pressure following phacoemulsification with posterior capsule tear with sulcus implanted single-piece foldable acrylic intraocular lens

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On the first postoperative day, corneal edema was seen in eight patients (22.22%), followed by increased anterior chamber reaction in 5 (13.89%) patients. Raised IOP was seen in 4 (11.11%) patients, and 3 (8.33%) patients had irregular pupil. After 3 months, 2 (5.56%) patients needed antiglaucoma medications for IOP control, 1 (2.78%) patient had on-and-off iridocyclitis, and another 1 (2.78%) had chronic CME [Table 2]. None of our patients had intraocular hemorrhage or retinal detachment. IOL decentration was not noticed in any of the patients till the last follow-up. The mean axial length of 4 patients with chronic complications in our study was 22.31 ± 0.30 mm, which was significantly shorter than those without complications (P = 0.002). The mean follow-up duration was 17.44 ± 12.15 months (range: 3–46 months).

Table 2: Postoperative complications following phacoemulsification with posterior capsule tear with sulcus implanted single-piece foldable acrylic intraocular lens

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Discussion

Phacoemulsification is one of the most satisfying surgeries in terms of outcome for the patient as well as the surgeon. A PCT, however, makes the surgery challenging and may impact the outcome.^[1] The presence of an intact anterior capsular rim still provides an opportunity for sulcus implantation of IOL in the same sitting. As 3-piece IOL meant for sulcus implantation is not always available, and rigid PMMA IOL needs wound enlargement, implantation of single-piece acrylic IOL in the sulcus is the next commonly chosen option at various places. Therefore, we aimed to study the visual outcome and complications following sulcus implantation of single-piece acrylic IOL.

Nuclear cataract was the most common in our study (77.78%; immature: 55.56%, mature: 22.22%), followed by PSC and PPC (16.67% and 5.56%, respectively). This is similar to a large-scale multicenter study by Vashist et al., in which they found that the nuclear cataract was the most common type (48% in north India), followed by PSC (21%) and cortical cataract (7.6%).^[13]

PCT can occur during any stage of phacoemulsification surgery. In our experience, PCT occurred most commonly at the stage of irrigation and aspiration (19 cases, 53%), followed by during nucleus handling (14 cases, 39%). Gimbel et al.^[14] and Zheng and Lin.^[15] have also reported PCT most commonly during irrigation-aspiration, while Mulhern et al.^[16] (49%) and Osher and Cionni.^[17] reported it most commonly during the stage of nuclear emulsification.

Following sulcus implantation of acrylic IOL, we found a good postoperative vision with 30 cases (83.33%) having visual acuity of 6/12 or better after 30 days (6/9: 16 cases, 44.44%; 6/12: 14 cases, 38.89%). In the study by Mohebbi et al., 87.50% of patients had visual acuity of ≥20/40 (6/12) after surgery.^[10] Chang et al. reported a visual acuity of 20/40 or better in 86.67% of patients. They found that most patients attained a final vision of 20/20, except for those who had chronic CME or poorly controlled IOP.^[9]

In the early postoperative period, 55.56% (20) of patients had some complications; the most common being corneal edema (22.22%), followed by increased anterior chamber reaction (13.89%), raised IOP (11.11%), and irregular pupil (8.33%). These early complications could be attributed to the complicated surgery and not the IOL. Chronic complications were seen in four (11.11%) of our patients, with two cases requiring topical antiglaucoma medications for IOP control, one case showing on and off iridocyclitis, and one case with chronic CME.

Previous studies have mentioned complications such as pigment dispersion syndrome, iris transillumination defects, iridocyclitis, increased IOP, uveitis–glaucoma–hyphema syndrome, IOL tilt and decentration, intraocular hemorrhage, and CME following sulcus implantation of acrylic IOL.^{[9],[10],[11]} The relatively low incidence of complications in our study compared to them could be due to the longer axial length of the patients (mean: 24.19 ± 1.32 mm). Mohebbi et al. compared the mean axial length in groups with and without complications, and they found that few of the complications were higher in patients with shorter axial lengths.^[10] The mean axial length of five patients with chronic complications in our study was 22.31 ± 0.30 mm, which was significantly shorter than those without complications (P = 0.002).

Bar-Sela and Fleissig. conducted a study on sulcus implantation of single-piece acrylic IOL designed for both in-the-bag and sulcus positioning (SeeLens AF, Hanita, Israel), following PCT in 12 patients. They found a mean postoperative visual acuity of 0.18 ± 0.13 LogMAR. Except for IOP rise in two patients, they did not find any complication, and concluded that instead of enlarging the wound and placing a backup IOL during phacoemulsification with PCT, appropriately designed single-piece acrylic IOL may be implanted in the ciliary sulcus.^[12]

Conventionally, sulcus implantation of single-piece PMMA IOL or 3-piece IOL is preferred in phacoemulsification complicated by posterior capsule rupture. However, our results are comparable to a study by Brazitikos et al., where 3-piece hydrophobic acrylic IOL was implanted in the sulcus. The study results in a sample size of 28 patients showed that in the immediate postoperative period, corneal edema was seen in 12 (42.85%) patients and increased IOP was seen in 11 (39.29%) patients. In the late postoperative period, one patient had recurrent iridocyclitis (3.6%), three had CME (10.71%), and one had inferior retinal tear (3.6%). The final visual acuity at 6 months was between 20/15 and 20/25 in 18 patients, 20/30 in two, between 20/40 and 20/50 in four, and between 20/60 and 20/200 in four.^[5]

To conclude, PCT during cataract surgery must not be a deterrent in providing quality vision. Of the various available techniques, our option for sulcus fixation of posterior chamber IOL has given a good postoperative vision with minimal complications. Implantation of posterior chamber IOL in the sulcus following a PCT is a good option in our setup, wherein a secondary IOL, i.e., scleral fixation or ACIOLs is in deficiency. The retrospective design of our study and small sample size pose some limitations. A larger sample of patients may be needed to further observe the visual outcome and long-term postoperative complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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