Long-Term Surgical Outcomes of Scleral Flap versus Scleral Pocket Technique for Sutureless Intrascleral One-Piece Lens Fixation

Abstract

Objectives: This study compared long-term surgical outcomes of the scleral flap versus scleral pocket technique for sutureless intrascleral one-piece intraocular lens (IOL) fixation. Methods: A retrospective comparative study was conducted at a single center, involving consecutive patients undergoing sutureless intrascleral one-piece IOL implantation, between January 2020 and May 2022. Eyes were divided into two groups based on the surgical technique: group 1 underwent scleral flap (n = 64), and group 2 received scleral pocket technique (n = 59). Visual acuity, refractive outcomes, and complications were assessed over a minimum 24-month follow-up period. Results: Both groups showed improvements in best-corrected visual acuity (BCVA), increasing from 0.84 ± 0.56 logMAR at baseline to 0.39 ± 0.23 logMAR (p = 0.042) at 24 months in group 1 and from 0.91 ± 0.63 logMAR at baseline to 0.45 ± 0.38 logMAR (p = 0.039) at 24 months in group 2. No significant differences in BCVA were observed between the groups at baseline (p = 0.991), 12 (p = 0.496) and 24 months (p = 0.557). Mean spherical equivalent (-0.73 ± 1.32 D in group 1 and -0.92 ± 0.99 D in group 2, p = 0.447), refractive prediction error (-0.21 ± 1.1 D in group 1 and -0.35 ± 1.8 D in group 2, p = 0.377), and surgically induced astigmatism (0.74 ± 0.89 D in group 1 and 0.85 ± 0.76 in group 2, p = 0.651) were comparable between the two groups. An IOL tilt of 5.5 ± 1.8 and 5.8 ± 2.0 degrees (p = 0.867) and an IOL decentration of 0.41 ± 0.21 mm and 0.29 ± 0.11 mm (p = 0.955) were obtained, respectively, in group 1 and group 2 at 24 months. Mean endothelial cell density remained stable at 24 months in both groups (p = 0.832 in group 1 and p = 0.443 in group 2), and it was 1747.20 ± 588.03 cells/mm² in group 1 and 1883.71 ± 621.29 cells/mm² in group 2 (p = 0.327) at baseline, 1545.36 ± 442.3 cells/mm² in group 1 and 1417.44 ± 623.40 cells/mm² in group 2 (p = 0.483) at 24 months. No cases of endophthalmitis were observed. Conclusions: The scleral pocket technique for sutureless intrascleral one-piece IOL fixation is comparable to the traditional scleral flap technique in terms of long-term visual outcomes and safety. The scleral pocket technique offers a simplified approach and a viable option even for less experienced surgeons.

Keywords: long-term outcomes; scleral flap; scleral pocket; secondary intraocular lens implantation; sutureless intrascleral one-piece lens; sutureless scleral fixation.

Figure 1

Schematic representation of the two surgical techniques: scleral flap (a) versus slceral pocket (b). The figures show the sutureless intrascleral one-piece lens in the background, indicating its placement in the posterior chamber with sutureless scleral fixation of the haptics. (a) illustrates the scleral flap technique: on the right, the scleral flap before closure on the IOL haptics, and on the left, the flap closed. (b) shows the scleral pocket technique: on the left, the scleral pocket still open with the IOL haptics inside, and on the right, the pocket closed.

Figure 2

Mean best-corrected visual acuity (BCVA) in the two study groups throughout the follow-up.

Figure 3

Frequency distribution of spherical equivalent (a), refractive prediction error (b), and surgically induced astigmatism (c) in the two study groups.

Figure 4

Boxplot of IOL tilt (a) and decentration (b) at 24 months in the two study groups.

Figure 5

Mean endothelial cell density in the two study groups throughout the follow-up.