What are the complications after scleral sutured intraocular lens (IOL) implantation?

Complications After Scleral Sutured Intraocular Lens Implantation

The most common complications after scleral sutured intraocular lens implantation include suture erosion, IOL dislocation/decentration, hypotony, and conjunctival erosion, which can significantly impact patient morbidity and quality of vision.

Major Complications

Suture-Related Complications

• Suture erosion: Occurs in approximately 17.9% of cases 1

  • Can lead to exposed sutures through the scleral flap (4 eyes in one study) or through both flap and conjunctiva (2 eyes) 2
  • Exposed sutures increase risk of endophthalmitis through the suture tract 3
  • Prevention strategies include:
    • Using nylon sutures rather than braided Mersilene polyester sutures
    • Rotating knots posteriorly underneath suture tabs
    • Leaving suture tails long for lower profile knots 4

• Suture breakage: Reported in 3 eyes in one pediatric study 2

  • Can lead to late IOL dislocation (1.3% in one study) 5

IOL Position Problems

• IOL dislocation/decentration:

  • Decentration >1.5mm occurs in approximately 1.9% of cases 1
  • Reported in 3 eyes in a pediatric population study 2

• IOL tilt: Observed in 6 eyes in a pediatric study 2

  • Can cause visual aberrations and reduced quality of vision

• Iris capture of IOL optic: Reported in 4 eyes in pediatric cases 2

Wound-Related Complications

• Hypotony: Common complication following implantation 4

  • Typically arises from inadequate closure of sclerotomies
  • Less commonly due to damage to ciliary body
  • Can lead to choroidal detachments and anterior chamber flattening
  • Prevention requires:
    • Vigilant attention to closure, especially around array cable
    • Proper initial wound construction with straight sclerotomies
    • Mattress sutures with long scleral passes
    • Thorough checking for wound leakage 4

• Wound leak: Requiring resuturing in 7.7% of cases 5

Inflammatory and Retinal Complications

• Cystoid macular edema (CME):

  • Reported in 5.8% of cases 1
  • Higher incidence (38%) in post-traumatic cases compared to post-cataract surgery cases (6.8%) 6

• Retinal detachment:

  • Occurs in approximately 1.4% of cases 1
  • One case reported in post-trauma pediatric patient 2

• Vitreous hemorrhage: Reported in 1.0% of cases 1

• Anterior uveitis:

  • Severe uveitis in 0.5% of cases 1
  • Reported in 2 eyes in pediatric patients 2

• Transient corneal edema: Observed in 15.4% of cases 5

• Glaucoma: Reported in 2 eyes in pediatric patients 2

Prevention Strategies

1. Proper Surgical Technique:

   • Use 4-point scleral fixation technique which has shown no serious postoperative complications such as suture exposure and endophthalmitis 6
   • Ensure proper wound construction with straight sclerotomies directed perpendicular to the sclera 4
   • Use mattress sutures with long scleral passes to increase vector forces in re-apposing wound edges 4

2. Suture Management:

   • Use nylon sutures rather than braided Mersilene polyester sutures which may contribute to erosion 4
   • Rotate knots posteriorly underneath suture tabs and leave suture tails long for lower profile knots 4
   • Consider burying the knots in the globe to prevent exposure 6

3. Wound Closure:

   • Thoroughly dry and check sutured wounds for leakage 4
   • Consider additional techniques such as fluid-air exchange, partial thickness scleral flaps, or sealants like corneal gel or fibrin glue for persistent leakage 4

4. Post-operative Management:

   • Close follow-up with pressure patching for hypotony if no other serious adverse signs 4
   • Prompt return to operating room for wound revision if persistent hypotony or complications like enlarging choroidal detachments occur 4
   • Use topical antibiotics for conjunctival erosion until surgical repair can be performed 4

Management of Complications

1. For suture erosion:

   • Topical antibiotics until surgical repair
   • Wound revision should include:
     • Adequately opening the area of eroded conjunctiva
     • Releasing areas of traction
     • Debriding or cauterizing areas of epithelialization
     • Re-covering exposed areas with pericardium or grafted conjunctiva 4

2. For hypotony:

   • Short period of close follow-up with pressure patching for mild cases
   • Reopening of the conjunctival/pericardial graft with further inspection and suturing of the sclerotomy for persistent cases 4

3. For IOL dislocation/decentration:

   • Surgical repositioning or exchange may be required
   • Consider anterior chamber IOL placement as an alternative to re-suturing if appropriate 3

Despite these potential complications, scleral-sutured IOLs can achieve good visual outcomes, with studies showing improved or unchanged visual acuity in 92.0% of cases 1 and 91.3% of cases 5.