This is a case report of a middle-aged woman who presented with chronic right eye irritation and redness. Three years prior to presentation, the patient had a scleral-sutured intraocular lens (IOL) implant placed by another surgeon after her initial lens implant dislocated. Her past social and drug histories were unremarkable.

On examination, her best-corrected visual acuity (BCVA) was 20/20 in both eyes (OU). Extraocular movements were intact, and pupils were round and reactive with no relative afferent pupil defect (RAPD). The intraocular pressures (IOP) by applanation were 15 mmHg OU. The slit lamp exam of both eyes was unremarkable except for 2.5x1.5 mm demarcated plaque with hyperpigmentation in the temporal border of the limbus adjacent to what appeared to be an exposed Gore-Tex suture (W.L. Gore and Associates) with adjacent sectoral conjunctival injection in the right eye (Figure 1, A and B). The anterior chambers of both eyes were deep and quiet. Fundus examination revealed no vitreous cells, normal optic nerve with cup-disc ratio of 0.3, normal retinal vessels, and complete retinal attachment in both eyes.

Given the concern for an indolent infection, surgical exploration and possible explant with conjunctival reconstruction was recommended. Intravitreal antibiotics were not injected, given the absence of intraocular extension of the suspected infection.

The conjunctiva around the plaque was tightly adherent and scarred (Video 1). Thus, the conjunctival peritomy was performed further from the limbus and was mobilized for six clock-hours temporally. After removing the plaque (which was sent for culture), the subconjunctival space was irrigated with subconjunctival broad-spectrum antibiotics. The lens appeared stable and the suture appeared intact. Thus, the suture was not removed and the lens was not explanted. Given the concern for recurrent exposure, a scleral patch graft was placed over the exposed area and conjunctiva was mobilized to cover the defect with a double layer closure. The bacterial culture from the plaque grew Bacillus species. Six months after surgery, the conjunctival injection was improved and the previously exposed area was covered with the scleral patch graft without any clinical evidence of recurrent infection (Figure 1C). The vision remained 20/20 without any evidence of intraocular inflammation.

VIDEO 1. A 3-minute video showing the removal of plaque that had formed around the exposed suture, placement of a scleral patch graft over the exposed area, and mobilization of conjunctiva to cover the defect with a double layer closure.

DISCUSSION

In typical cases of successful cataract surgery, the IOL implants are routinely placed in the capsular bag. However, in the case of capsular bag violation and inadequate capsular support, alternative techniques include sulcus IOL, anterior chamber IOL, iris-fixated posterior chamber IOL, and scleral-fixated posterior chamber IOL, with or without suture.^1,2 The choice of each option is based on the patient’s age and past ocular history, considering such factors as past trauma, glaucoma, iris tissue loss, zonular dehiscence, previous ocular surgery, and concurrent retinal surgery. The scleral fixation of IOL with polytetrafluoroethylene (Gore-Tex) suture with four-point fixation has various advantages, including diminished IOL tilt, relative simplicity of insertion and fixation, lack of iris contact, and a lower overall risk of lens dislocation.^3,4

In recent years, many ophthalmologists have moved toward using the Gore-Tex suture due to the long-term durability of the material, suture memory, record of good outcomes, and greater tensile strength than polypropylene sutures.^4,5 Gore-Tex is a non-absorbable suture which is currently FDA approved for use in cardiovascular procedures, although use in the eye is still off-label. Because the Gore-Tex suture is bulkier and has “memory,” it may be more difficult to bury the suture knot in the sclera, which may lead to erosion through the conjunctiva over time.

Although lens dislocation from a Gore-Tex suture is uncommon, as these lenses are fairly stable with 4-point fixation, it is crucial to bury the knots adequately to prevent the knot eroding through the conjunctiva with a resultant risk of infection. It is also critical to assess the conjunctiva preoperatively and assess for any history of intraocular surgery, conjunctival cauterization for conjunctivochalasis, history of prior scleral buckling, and glaucoma filtration procedures where the conjunctiva was manipulated, as this may shift the positions of conjunctival peritomies and haptics.⁶

To minimize the risk of exposed Gore-Tex suture, surgeons may consider rotating and burying the knot into the eye prior to trimming the suture. If the knot is not rotated, a double layer closure (closing the Tenon capsule and conjunctiva separately) may help to reduce the risk of exposure by flattening the tail of the knots. During the conjunctiva closure at the limbus, it is important to ensure the Gore-Tex sutures are covered by conjunctiva. Creating a partial-thickness scleral groove with a beaver blade and placing the suture within the groove may reduce the risk of exposure. If the knots cannot be safely rotated or there is concern for exposure, scleral patch grafts or half-moon cornea grafts to cover the sutures is helpful, as this minimizes the risk of erosion. In case of friable or scarred conjunctiva, extending the conjunctival peritomy and Tenon capsule dissection allows conjunctiva to be mobilized to cover the defect, as amniotic membrane grafts are typically only a temporary solution.

In case of inadequate conjunctival coverage or erosion, the exposed suture may lead to infectious complications. In a recent case report, a middle-aged male with a scleral-sutured IOL and exposed Gore-Tex suture and scleromalacia presented with culture-positive endophthalmitis.⁷ This patient received intravitreal antibiotics, followed by prompt suture removal, pars plana vitrectomy, and IOL explant, which resulted in visual recovery to the preoperative visual acuity.⁷

CONCLUSION

Gore-Tex sutures are commonly used off-label in ophthalmic surgery due to a low rate of suture breakage and greater tensile strength. Evaluation of the conjunctiva, systemic conditions, and prior history of ocular surgery should be considered prior to selecting a secondary IOL implantation technique. Rotating and burying the knot into the sclerotomy, double layer conjunctival peritomy closure, creation of a partial-thickness scleral groove, and patch grafting are techniques that may reduce the risk of exposure and infectious complications. If suture exposure without obvious infection is discovered, prompt surgery to correct the exposure should be considered. If there are signs of infectious complications, prompt surgery is paramount to remove the plaque (with bacterial cultures), as well as the suture and IOL implant if needed. If there is evidence of endophthalmitis, standard intravitreal antibiotic injections at the time of presentation as well as during surgery are indicated. NRP

REFERENCES

1. 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;110(4):840-859. doi:10.1016/s0161-6420(02)02000-6.
2. Stem MS, Todorich B, Woodward MA, Hsu J, Wolfe JD. Scleral-fixated intraocular lenses: past and present. J Vitreoretin Dis. 2017;1(2):144-152. doi:10.1177/2474126417690650. Epub 2017 Mar 2.
3. Khan MA, Rahimy E, Gupta OP, Hsu J. Combined 27-gauge pars plana vitrectomy and scleral fixation of an Akreos AO60 intraocular lens using Gore-Tex suture. Retina. 2016;36(8):1602-1604. doi:10.1097/IAE.0000000000001147.
4. Khan MA, Gerstenblith AT, Dollin ML, et al. Scleral fixation of posterior chamber intraocular lenses using Gore-Tex suture with concurrent 23-gauge pars plana vitrectomy. Retina. 2014;34:1477-1480. doi:10.1097/IAE.0000000000000233
5. Botsford BW, Williams AM, Conner IP, Martel JN, Eller AW. Scleral fixation of intraocular lenses with Gore-Tex suture: refractive outcomes and comparison of lens power formulas. Ophthalmol Retina. 2019;3(6):468-472. doi:10.1016/j.oret.2019.02.005.
6. Rahimy E, Khan MA, Gupta OP, Hsu J. Gore-Tex sutured intraocular lens: a beginner’s guide for scleral fixation of posterior-chamber IOLs. Retinal Physician. 2016;13(4):36-38,40,58.
7. Mogil RS, Ferenchak K, Starr MR. Gore-Tex suture–associated endophthalmitis in a scleral-sutured intraocular lens. Retin Cases Brief Rep. 2023 Jan 2 (Epub ahead of print). doi: 10.1097/ICB.0000000000001400.