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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 4  |  Page : 657-659

Scleral thinning with haptic exposure following intra-scleral haptic fixation of intraocular lens


1 Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
2 Department of Ophthalmology, Lady Hardinge Medical College, New Delhi, India

Date of Submission09-Jan-2021
Date of Acceptance10-May-2021
Date of Web Publication09-Oct-2021

Correspondence Address:
Dr. Prafulla K Maharana
Assistant Professor of Ophthalmology, Cornea, Cataract and Refractive Surgery Services, Room Number S-5, First Floor, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_53_21

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  Abstract 


In the current times, scleral-fixated intraocular lens (SFIOL) has become the treatment of choice for the management of cases of aphakia without capsular support. In this retrospective case series, we describe the risk factors and management of three cases of scleral thinning with haptic exposure following SFIOL. Medical records of cases with scleral thinning with haptic exposure following SFIOL over the last 1 year were reviewed for demographic factors, type of surgery, and outcomes. Out of 116 eyes that underwent SFIOL, 3 cases developed scleral thinning within 1 week of surgery. The indication of SFIOL was aphakia with operated penetrating keratoplasty (2 eyes) and complicated cataract surgery (1 eye). Surgical records revealed that all cases had undergone SFIOL with conjunctival closure using fibrin glue without any intraoperative complication. Post-operative day 1 findings showed conjunctival mound formation due to excessive fibrin glue in all cases. Scleral thinning was noted on follow-up (day 7, 2 cases and day 5, 1 case). Cases were managed with conjunctival advancement (n = 1) and amniotic membrane graft (n = 2). Thinning resolved within 1 week of follow-up.

Keywords: Amniotic membrane graft, scleral-fixated IOL, scleral thinning, SFIOL


How to cite this article:
Goel S, Sahay P, Beniwal A, Maharana PK, Sinha R, Titiyal JS. Scleral thinning with haptic exposure following intra-scleral haptic fixation of intraocular lens. Indian J Ophthalmol Case Rep 2021;1:657-9

How to cite this URL:
Goel S, Sahay P, Beniwal A, Maharana PK, Sinha R, Titiyal JS. Scleral thinning with haptic exposure following intra-scleral haptic fixation of intraocular lens. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Oct 18];1:657-9. Available from: https://www.ijoreports.in/text.asp?2021/1/4/657/327646



Patients with aphakia in the absence of adequate capsular support can be managed by implantation of intraocular lens (IOL) in the anterior chamber, the ciliary sulcus, fixated to the iris or fixated to the sclera. Lack of capsular bag support can occur in cases of ocular trauma, metabolic or inherited conditions such as Marfan's syndrome, homocystinuria, or pseudoexfoliation, or following complicated cataract surgery. Scleral-fixated IOLs (SFIOLs) have lately become the surgical treatment of choice for the management of aphakia considering the high rate of complications associated with the anterior chamber IOLs (ACIOLs) and iris-fixated IOLs. SFIOLs are especially indicated in cases where ACIOL or iris-fixated IOLs are rendered unsuitable like patients with low endothelial cell count, peripheral anterior synechiae, shallow anterior chamber, glaucoma, young patients, eyes with large iris defects, and traumatic mydriasis.[1]

The risks in SFIOL implantation include ocular hypertension (30.5%), corneal edema (15.4%), vitreous and suprachoroidal hemorrhage (11.5%), lens tilt (11.4–16.7%), retinal detachment (1–5%), endophthalmitis, cystoid macular edema (5.5–7.3%), suture-related complications (1.3–27.9%), and risk of haptic extrusion and scleral melt. Immediate post-operative scleral thinning with haptic exposure following SFIOL has rarely been reported in the literature. Herein, we present a series of three patients who underwent SFIOL with post-operative conjunctival recession with scleral thinning and haptic exposure and their management outcomes.


  Case Reports Top


A total of 116 eyes underwent SFIOL at our center during the study period. All cases had undergone intrascleral haptic fixation of a foldable multipiece IOL (Alcon Laboratories, Inc.; Model: MN60AC, 13.0 mm length, 6.0 mm anterior asymmetric biconvex optic, 10-degree monoflex haptics), and the scleral flap as well as conjunctival closure were achieved with the help of fibrin glue (TISSEEL, Baxter) in all the cases. Three cases of scleral thinning with haptic exposure could be identified.

The detailed characteristics of these cases have been summarized in [Table 1].
Table 1: Summary of the cases

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The first case was a 22-year-old male patient who presented with a diagnosis of penetrating keratoplasty (PKP) with aphakia in the right eye. The indication for keratoplasty was microbial keratitis (viral) which was performed 1 year back. Following PKP, the patient had a visual acuity of 1/60 which was improving to 6/24 with refraction. There was no evidence of any capsular support, and thus, the patient was planned for SFIOL. On post-operative day 1 following SFIOL, Best corrected visual acuity (BCVA) was 6/18 with an IOP of 18 mmHg. The IOL was well-centered and the conjunctival and scleral flaps were well-apposed without any evidence of haptic exposure. On day 7, the patient had symptoms of mild foreign body sensation, but on examination, there was retraction of the conjunctival flap along with the thinning of the underlying scleral flap with exposure of the haptic on the nasal side. There was no history of any ocular trauma or vigorous eye [Figure 1] rubbing. Past medical history did not reveal any predisposing factor for scleral necrosis such as collagen vascular disease, rheumatoid arthritis, or keratoconjunctivitis sicca. The patient underwent a multilayered amniotic membrane graft (AMG) [Figure 2].
Figure 1: Clinical photograph of case 1 showing conjunctival recession with congestion, scleral flap melt, uveal tissue show, and IOL haptic exposure on post-operative day 7

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Figure 2: Clinical photograph of case 1; 1 week following multilayered amniotic membrane grafting showing complete healing and resolution of scleral thinning

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The second case was a 48-year-old male patient who presented with a right eye post-traumatic cataractous lens and 9 o'clock hours of zonular laxity. Intracapsular cataract extraction with SFIOL was performed. On post-operative day 1, BCVA was 6/12 with an IOP of 20 mmHg and a well-apposed conjunctival flap without any haptic exposure. However, on day 5 of follow-up, the patient presented with symptoms of increased watering. On examination, there was evidence of conjunctival recession with scleral thinning and haptic exposure for which conjunctival advancement was performed.

The third case was a 27-year-old man with a history of left eye-operated PKP for perforated corneal ulcer and aphakia. Similar to the first case, the immediate post-operative course was uneventful, however, on day 7 of follow-up, scleral thinning with haptic exposure was noted. The case was managed similar to case 1.

The posterior segment evaluation was found to be normal in all the cases. All the cases were referred to rheumatology for a detailed systemic workup to rule out any connective tissue disorder that could lead to the risk of scleral melting. No systemic cause was identified in any patient. In all the patients, the thinning resolved at 1 week after surgery. There was no change in BCVA in all the patients following intervention for scleral thinning. No significant post-operative complication was noted in any of the cases.


  Discussion Top


Scleral necrosis following ocular surgery is not an unknown entity. This has been reported in the past by several authors following pterygium surgery,[2],[3] strabismus surgery,[4],[5] trabeculectomy, deep sclerectomy, buckling surgery, and transscleral diode laser cyclophotocoagulation. The proposed predisposing factors for scleral necrosis include excessive cauterization of scleral bed causing ischemia, overuse of antimetabolites like mitomycin C or beta-irradiation, infection, high myopia, associated collagen vascular diseases, systemic vasculitis, and autoimmune disorders.[3]

Various mechanisms have been proposed to explain scleral necrosis following ocular surgery. Localized interruptions of the tear film and local dehydration of the sclera can lead to scleral dellen formation and subsequent thinning.[4],[6] Surgical trauma and disruption of episcleral vasculature may lead to scleral ischemia, and thus, impaired healing response causing scleral thinning.[7] The creation of superficial thin flaps can also lead to post-operative flap thinning or erosion of haptics.

Various surgical approaches for the management of scleral thinning include donor scleral patch graft,[8] multilayered amniotic membrane grafting,[9] lamellar corneal graft, preserved dura mater or pericardium, rotational scleral graft, and autologous scleral patch graft.[10]

Scleral thinning following SFIOL has been rarely reported in the literature. This may be due to the rarity of the condition or under-reporting. In our series, three patients (2.6%, n = 3/116) developed scleral thinning with haptic exposure following SFIOL over a period of 1 year. The complication rate is unusually high considering the lack of any such report in literature. Various factors could have led to this high rate in our series. The poor compliance to medication, poor compliance to instructions regarding post-operative care of the eye (such as to avoid eye rubbing, splashing of eye with water), and lack of awareness among the patients could have contributed to this high rate. This is highlighted by cases 1 and 3 where in spite of having increased watering, the patients did not report immediately to the clinic, rather opted to follow-up as per the advice given on day 1 of surgery.

The causes of scleral thinning could be multifactorial. First, two of the cases had a corneal graft with 10-0 nylon sutures in situ. Poor compliance with lubricating eye drops combined with a poor ocular surface could have led to scleral thinning. In all the cases, conjunctival closure was achieved at the end of the surgery using fibrin glue. Young patients have a relatively thicker tenon tissue and poor conjunctival flap creation with retained tenon tissue tags at the time of conjunctival closure could lead to conjunctival retraction and scleral exposure. This combined with poor lubrication could have led to scleral thinning. In this series, two of our patients were below 30 years of age. The poor technique of conjunctival closure could also lead to conjunctival recession and scleral exposure with consequent thinning following SFIOL. In a few of our cases, we have noticed that excessive fibrin glue application to achieve conjunctival closure can lead to an elevated irregular conjunctival flap with subsequent localized tear film disturbance. In addition, the correct technique of tissue glue reconstitution and proper drying of the scleral bed before fibrin glue application is of great significance. Besides, the use of excessive cautery during scleral flap creation can also lead to scleral ischemia and flap thinning. We believe, a combination of these factors could have led to the scleral thinning and/or melting in our cases.


  Conclusion Top


To conclude, scleral thinning with haptic exposure following SFIOL is not that rare. Unfortunately, such cases are not that symptomatic and an ignorant patient could present late with significant scleral thinning and exposure of the haptic. Untreated, these cases may result in complications such as endophthalmitis. Hence, close monitoring in the immediate post-operative state is essential for the timely management of such cases. The treating physician must be extra careful while treating young patients or in cases with thick tenon tissue or scarred conjunctiva. Post-operative instructions must be conveyed to the patients clearly to avoid delayed presentation of such cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Stem MS, Todorich B, Woodward MA, Hsu J, Wolfe JD. Scleral-fixated intraocular lenses: Past and present. J Vitreoretin Dis 2017;1:144-52.  Back to cited text no. 1
    
2.
TsaiY-Y, Lin J-M, Shy J-D. Acute scleral thinning after pterygium excision with intraoperative mitomycin C: A case report of scleral dellen after bare sclera technique and review of the literature. Cornea 2002;21:227-9.  Back to cited text no. 2
    
3.
Lu L, Xu S, Ge S, Shao C, Wang Z, Weng X, et al. Tailored treatment for the management of scleral necrosis following pterygium excision. Exp Ther Med 2017;13:845-50.  Back to cited text no. 3
    
4.
Pujari A, Sharma P, Basheer S, Phuljhele S. Scleral dellen following strabismus surgery. Case Reports 2018;2018:bcr-2018-224675.  Back to cited text no. 4
    
5.
Sharma P, Aryad AV, Prakash P. Scleral dellen in strabismus surgery. Acta Ophthalmologica 1990;68:493-4.  Back to cited text no. 5
    
6.
Accorinti M, Gilardi M, Giubilei M, De Geronimo D, Iannetti L. Corneal and scleral dellen after an uneventful pterygium surgery and a febrile episode. Case Rep Ophthalmol 2014;5:111-5.  Back to cited text no. 6
    
7.
Pai V, Shetty J, Amin H, Thomas M. Management of scleral thinning: An alternate approach. Nitte University J Health Sci 2016;6:88-90.  Back to cited text no. 7
    
8.
Stunf S, Lumi X, Drnovšek-Olup B. Preserved scleral patch graft for unexpected extreme scleral thinning found at the scleral buckling procedure: A case report. Indian J Ophthalmol 2011;59:235-8.  Back to cited text no. 8
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9.
Sridhar MS, Bansal AK, Rao GN. Multilayered amniotic membrane transplantation for partial thickness scleral thinning following pterygium surgery. Eye (Lond) 2002;16:639-42.  Back to cited text no. 9
    
10.
Polat N. Use of an autologous lamellar scleral graft to repair a scleral melt after mitomycin application. Ophthalmol Ther 2014;3:73-6.  Back to cited text no. 10
    


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