National Survey on the Choice of Secondary Intraocular Lens Implantation in the UK

1. National Survey on the Choice of Secondary Intraocular Lens Implantation in the UK James Tildsley Sathish Srinivasan Alan Gaskell [All authors have no financial interest] Ayr Hospital, Ayr, Scotland, UK

2. Introduction • 270,000 cataract procedures were performed in UK National health service in 2008.1 • The reported incidence of PC rupture and zonular dehiscience is 1.92% and 0.46% respectively. 2 • Both of these complications have the potential to prevent primary lens insertion and aphakia

3. Introduction • Secondary lens implant is now the standard for managing aphakia.3 However there is a wide variation in the choice of lenses for secondary lens implant. • Given how common a secondary IOL may be required we conducted this national survey with the aim to collect data on current practice of UK Ophthalmology consultants on secondary IOL choice

4. Method • An anonymous questionnaire was mailed to all 896 NHS ophthalmology consultants currently practicing in the UK. • Data on surgical experience, number of secondary IOLs performed, preferred choice of secondary IOL with no capsular support +/- associated open angle glaucoma (POAG) and closed angle glaucoma (CAG) / peripheral anterior synechiae (PAS), and personal experience of using the lenses were collected.

5. Questionnaire

6. Results - Surgical experience • A total of 420 questionnaires were received, with a response rate of 47%. • 50% perform 5-10 cataract procedures a week, 30% over 10 and 20% less than 5. • 75% had less than 2 complications leading to aphakia, 16% had 2 - 5 and 7% had over 5

7. Results - choice of lens

8. Results - choice of lens

9. Results - experience with other lens types • 19% familiarized themselves with Artisan iris clip lens, mainly by wet lab. 12% have used the Artisan lens in 18 months. 21% say it has changed their practice • 23% have used an iris suture lens • 92% personally undertake open loop ACIOL insertion. For scleral sutured PCIOL, Artisan iris clip lens and iris sutured PCIOL the results were 43%, 27% and 22% respectively • 20 to 25% would prefer to refer to the appropriate sub-specialty for insertion of a secondary IOL other than open loop ACIOL

10. Conclusion • NHS Ophthalmology consultants currently working in the UK are using secondary IOLs for management of aphakia as recommended. 3,4,5,6 • Overall the open loop ACIOL was the most popular secondary IOL. However this changed with associated POAG and CAG/PAS suggesting there are limitations of the open loop ACIOL and advantages using an Artisan iris clip lens, iris sutured PCIOL and particularly the scleral sutured PCIOL. This result was supported by other studies.3-6, 8,10-13

11. Conclusion • Previous studies so far conclude that the outcomes of all the different secondary IOLs are comparable to each other but further research is required, and the choice of lens is based mainly on personal experience of using a lens.3, 7,9,12,13 • Our study found the same result, but due to the fact that the different lens techniques investigated have been available for at least 28 years it suggests that different lens techniques are not being attempted.13,14

12. References 1.DoH. Hospital Activity and Episode Statistics. http://www.doh.gov.uk/public/stats/htm 2.Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, Galloway P. The Cataract National Dataset electronic multicentre audit of 55567 operations: updating benchmark standards of care in the United Kingdom and internationally. Eye. 2007 Nov 23 3.Wagoner MD, Cox TA, Ariyasu RG, Jacobs DS, Karp CL American Academy of Ophthalmology. Intraocular lens implantation in the absence of capsular support: a report by the American Academy of Ophthalmology. Ophthalmology. 2003 Apr; 110(40:840-59 4.Zheng G, Chen Y, Wang L, Chen G, Zhang X. The choice of methods of intraocular lens implantation in traumatic cataract in the absence of capsular and zonular support. Zhonghua Yan Ke Za Zhi. 1998 Sep; 34(5): 327-9 5.Dick HB, Augustin AJ. Lens implant selection with absence of capsular support. Curr Opin Ophthalmol. 2001 Feb; 12(1): 47-57 6.Hannush SB. Sutured posterior chamber intraocular lenses: indications and procedure. Curr Opin Ophthalmol. 2000 Aug; 11(4): 233-40 7.Rosa N, Lanza M, Borrelli M. Artisan phakic intraocular lens. Ophthalmology. 2007 Jun;114(6):1133-42 8.Guell JL, Manero F. Artiflex(foldable iris claw IOL) secondary implantation for correction of aphaia after penetrating ocular injury. J Refract Surg. 2004 May-Jun;20(3):282-3 9.Kwong YY, Yuen HK, Lam RF, Lee VY, Rao SK, Lam DS. Comparison of outcomes of primary scleral-fixated versus primary anterior chamber intraocular lens implantation in complicated cataract surgeries. Ophthalmology. 2007 Jan;114(1):80-5 10.Bellamy JP, Queguiner F, Salame N, Montard M. Secondary intraocular lens implantation: methods and complications. J Fr Ophthalmol. 2000 Jan:23(1):73-80 11.Por YM, Lavin MJ. Techniques of intraocular lens suspension in the absence of capsular/zonular support. Surv Ophthamol. 2005 Sep-Oct;50(5):429-62 12.Krause L, Bechrakis NE, Heimann H, Salditt S, Foerster MH. Implantation of scleral fixated sutured posterior chamber lenses: a retrospective analysis of 119 cases. Int Ophthalmol. 2008 Apr 10. 13.Everklioglu C, Er H, Bekir NA, Borazan M, Zorlu F. Comparison of secondary implantation of flexible open loop anterior chamber and scleral fixated posterior chamber intraocular lenses. J Cataract Refract Surg. 2003 Feb; 29(2): 301-8 14.McCannel MA. A retrievable suture idea for anterior uveal problems. Ophthalmic surg. 1976 summer; 7(2): 98-103