Intraocular Lens Implantation in the Absence of Zonular Support: An Outcomes and Safety Update OTA

A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Cornea and Anterior Segment Disorders Panel

Joanne F. Shen, MD,¹ Sophie Deng, MD, PhD,² Kristin M. Hammersmith, MD,³ Anthony N. Kuo, MD,⁴ Jennifer Y. Li, MD,⁵ Mitchell P. Weikert, MD,⁶ Roni M. Shtein, MD, MS⁷ 

Ophthalmology, September 2020, Vol 127, 1234-1258, © 2020 by the American Academy of Ophthalmology. Click here for free access to the OTA.

Purpose: To review the published literature on the visual acuity results and complications of different surgical techniques for intraocular lens (IOL) implantation in the absence of zonular support.

Methods: Peer-reviewed literature searches were conducted last in PubMed and the Cochrane Library in July 2019. The searches yielded 734 citations of articles published in English. The panel reviewed the abstracts of these mostly retrospective case series studies, and 45 were determined to be relevant to the assessment objectives. Three articles were rated as level II evidence, and 42 articles were rated as level III evidence.

Results: Eight different types of IOL fixation techniques with at least 6-month follow-up were evaluated: anterior chamber IOL (ACIOL), iris-claw IOL, retropupillary iris-claw IOL, 10-0 polypropylene iris-sutured posterior chamber IOL (PCIOL), 10-0 polypropylene scleral-sutured PCIOL, 8-0 polypropylene scleral-sutured PCIOL, CV-8 polytetrafluoroethylene, and intrascleral haptic fixation (ISHF). Eight articles reported data comparing 2 techniques. The 45 studies had insufficient statistical power to compare the techniques conclusively. A qualitative analysis of similar types showed that trends in visual acuity outcomes were not inferior to those of ACIOL implantation, but the severity of preoperative pathologic features were not controlled for. Compared with ACIOL, complications of cystoid macular edema were higher in 10-0 polypropylene iris-sutured PCIOL and 8-0 polypropylene scleral-sutured PCIOL. Non-anterior chamber IOL techniques were less likely to report chronic uveitis. Chronic glaucoma was highest in the 8-0 polypropylene scleral-sutured PCIOL group. Although retinal detachment was infrequent overall, it was twice as common in both iris- and scleral-sutured PCIOLs (except CV-8 polytetrafluoroethylene suture) compared with nonsutured methods: ACIOL, iris-clipped IOL, and ISHF PCIOL. 

Conclusions: The evidence reviewed shows no superiority of any single IOL implantation technique in the absence of zonular support. The various techniques seem to have equivalent visual acuity outcomes and safety profiles. Each technique has its own profile of inherent risk of postoperative complications. Surgeons must educate patients on the importance of close, long-term follow-up as a result of the uncertain nature of these techniques. Large prospective studies are needed to confirm the long-term complication profiles of these various IOL implantation techniques. 

¹Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona

²Stein Eye Institute, University of California, Los Angeles, Los Angeles, California

³Wills Eye Hospital, Philadelphia, Pennsylvania

⁴Duke Eye Center, Duke University Medical Center, Durham, North Carolina

⁵UC Davis Eye Center, University of California, Davis, Sacramento, California

⁶Cullen Eye Institute, Baylor College of Medicine, Houston, Texas

⁷Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan