Preferred practice patterns in aphakia management in adults in India: A survey

Quick Response Code:Purpose: To assess different approaches in the management of aphakia in adults in Indian ophthalmologists via an online survey. Methods: A survey-monkey based online questionnaire was fielded to Indian ophthalmologists in accordance with the CHERRIES guidelines. We recorded participants' demographics, practice settings, and preferred surgical options including the type of intraocular lens (IOL) preferred when encountering a case of aphakia in adults with and without adequate capsular support. Differences between anterior segment (AS) surgeons and vitreoretinal (VR) surgeons as well as differences between surgeons with more or less than 10 years of surgical experience were evaluated using analytic statistics. Results: Of the 481 surgeons who responded to the survey, 369 (77%) were AS surgeons and the remaining 112 (23%) were VR surgeons and represented all regions of India. When encountering posterior capsular rent during cataract surgery, a three-piece IOL in the ciliary sulcus was the most preferred (n = 275, 57%) when there was adequate capsular support, while a retrofixated iris-claw IOL (n = 91, 19%) was the commonest choice in eyes without adequate capsular support. With associated nucleus drop, 85% of surgeons preferred to refer the patient to a VR surgeon and left the eye aphakic. Multivariable logistic regression showed that VR surgeons were more than six times likely to prefer a scleral fixated intraocular lens (SFIOLs) [odds ratio (OR) = 6.5, 95% confidence interval (CI) = 3.4-12.5, P < 0.001] and surgeons with >10 years of experience were also twice more likely to prefer an SFIOL (OR = 2.4, 95% CI = 1.2-4.9, P = 0.02). Conclusion: The choice of IOL in absence of capsular support in adult eyes differs between AS and VR surgeons and is also influenced by the surgeon's experience.
The incidence of post-cataract surgery aphakia is <1% but causes a lot of morbidity in patients. [bib_ref] Postoperative aphakia in modern cataract surgery: Part 1: Analysis of incidence and..., Lundstrom [/bib_ref] Management of aphakia has undergone paradigm shifts from anterior chamber intraocular lenses (ACIOLs) of various designs to scleral fixated intraocular lenses (SFIOLs) and more recently, retrofixated iris-claw lenses. [bib_ref] Scleral fixafiguretion of intraocular lenses, Jacob [/bib_ref] [bib_ref] Flanged fixation: Yamane technique and its application, Yamane [/bib_ref] [bib_ref] Flanged intrascleral intraocular lens fixation with double-needle technique, Yamane [/bib_ref] [bib_ref] Choices in correction of aphakia during vitrectomy, Bastawrous [/bib_ref] The SFIOL fixation has also seen major shifts from being a predominantly suture-assisted surgery to being sutureless over the past decade. [bib_ref] Sutureless intrascleral posterior chamber intraocular lens fixation, Gabor [/bib_ref] [bib_ref] Comparison of sutured versus sutureless scleral-fixated intraocular lenses, Sindal [/bib_ref] [bib_ref] Sutureless 27-gauge needle-assisted transconjunctival intrascleral intraocular lens fixation: Initial experience, Kelkar [/bib_ref] [bib_ref] Comparison of two modified sutureless techniques of scleral fixation of intraocular lens, Kelkar [/bib_ref] After the introduction of the sutureless SFIOL by Gabor et al. [bib_ref] Sutureless intrascleral posterior chamber intraocular lens fixation, Gabor [/bib_ref] in 2007, the glued intraocular lens (IOL) by Narang et al. [bib_ref] Glued intrascleral haptic fixation of an intraocular lens, Narang [/bib_ref] and the flange fixation by Yamane [bib_ref] Flanged intrascleral intraocular lens fixation with double-needle technique, Yamane [/bib_ref] have increased the popularity and adoption of the sutureless SFIOL techniques. With a few other modifications such as the XNIT surgery by Baskaran et al., [bib_ref] Extraocular needle-guided haptic insertion technique of scleral fixation intraocular lens surgeries (X-NIT), Baskaran [/bib_ref] and the introduction of novel IOL designs for sutureless SFIOL fixation such as the one by Madanagopalan et al., [bib_ref] A novel sutureless scleral fixated lens that eliminates extra ocular haptic manipulation:..., Madanagopalan [/bib_ref] management of aphakia has truly come a long way in not only improving the ease of surgery but also improving patient comfort and visual outcomes.
Given the myriad choice of IOLs in the management of aphakia, with many comparative studies showing similar visual outcomes, the choice of IOL depends upon the operating surgeon. Other factors include IOL availability, adequacy of capsular support, coexistent nucleus or cortex drop, white to white diameter, and primary (i.e., at the time of cataract surgery) vs. secondary surgery (after previous surgery).
To the best of our knowledge, surgeon preferences for the management of aphakia in India, in terms of choice of IOL and the factors determining these choices, have not been elucidated to date. In this survey of cataract surgeons across India, we sought to assess preferences in the surgical management of aphakia, especially in the absence of adequate capsular support.

# Methods
The study was approved by the Institutional Ethics Committee and the study was carried out as per the tenets of the Declaration of Helsinki. The identity of all participating surgeons was kept anonymous during data collection and analysis. A questionnaire (Annexure 1) was used during the survey and its administration followed the guidelines from the CHERRIES checklist. [bib_ref] Improving the quality of web surveys: The checklist for reporting results of..., Eysenbach [/bib_ref] The questions were pilot tested by members of the core survey team and questions and/or their options were modified by consensus over an online zoom meeting. The survey was fielded to members of the All-India Ophthalmic Society (AIOS) with valid email ID and phone numbers using emails and WhatsApp messages from March to April 2021. Single responses from participants were ensured by hosting the survey on the survey-monkey platform and tagging responses using the participant's IP address. Participation was voluntary and was not remunerated. Responses were registered as complete when all the survey questions were answered. The initial part of the questionnaire recorded the type of surgeon (anterior segment (AS) vs. posterior segment), years of surgical experience, region of practice in India (north, east, west, south, and central), type of practice (institutional, private, and combined), area of practice (urban vs. rural), the number of cataract surgeries performed per month, and the number of aphakia patients encountered in practice per month.
The next parts of the questionnaire were designed to assess surgeon preferences and choice of IOL for managing aphakia in adults under the following headings: [bib_ref] Postoperative aphakia in modern cataract surgery: Part 1: Analysis of incidence and..., Lundstrom [/bib_ref] planning when the patient is seen in the outpatient setting, [bib_ref] Scleral fixafiguretion of intraocular lenses, Jacob [/bib_ref] aphakia management during primary surgery without nucleus or cortex drop, [bib_ref] Flanged fixation: Yamane technique and its application, Yamane [/bib_ref] aphakia management during primary surgery with nucleus or cortex drop, and [bib_ref] Flanged intrascleral intraocular lens fixation with double-needle technique, Yamane [/bib_ref] IOL placement preferences during secondary surgery without adequate capsular support. For management during primary surgery, surgeons were asked about whether they manage the surgery themselves or refer, if managing themselves then do they place an IOL in the same or secondary sitting, how long they prefer to wait for IOL placement of choosing a secondary sitting and the type of IOL they prefer in cases with and without capsular support. Options for IOL types provided were single-piece IOL in sulcus and three-piece IOL in sulcus for eyes with capsular support, and SFIOL, anterior fixated iris-claw, retrofixated iris-claw, iris sutured IOL, and ACIOL for eyes without capsular support. Surgeons were also asked whether performed a peripheral iridectomy while placing a retrofixated iris-claw IOL. If preferring an SFIOL, surgeons were asked if they preferred a sutured or sutureless technique of fixation. If preferring a sutureless technique, the choices provided were glued SFIOL, Gabor Schariott's technique (or its modification), or the Yamane technique (or its modification). If preferring a sutured technique, surgeons were asked about the type of suture (9-0 prolene, 10-0 prolene, or Gortex) and the type of SFIOL preferred (SFIOL with eyelets, routine three-piece IOL anchored with haptics, or foldable acrylic IOL with plate haptics (Akreos IOL, Bausch and Lomb, USA). Lastly, surgeons were asked about their preference for managing cases with bilateral aphakia.

# Statistical analysis
All categorical variables were expressed as proportions (n, %) and denominators for each question were based on the total responses received for that particular question. Chi-square tests were used to analyze differences between groups. Logistic regression analysis was used to predict the choice of SFIOL in eyes without nucleus drop and no capsular support and covariates included were surgeon type (anterior vs. posterior segment surgeon), surgeon experience, and type of practice (institutional vs. private vs. both).
All data were exported from the survey server into Microsoft Excel and analyzed using STATA 12.1 I/c (Stata Corp, Fort Worth, Texas, USA). All P values < 0.05 were considered statistically significant.

# Results

## Surgeon characteristics
The survey questionnaires were sent to 10,000 ophthalmologists. A total of 481 (4.8%) surgeons responded to our survey of which 369 (77%) were AS surgeons, whereas the remaining 112 (23%) were vitreoretinal (VR) surgeons. About two-thirds of the participating surgeons had surgical experience of more than 10 years (n = 319, 66%), majority were based in urban areas (n = 413, 86%), and there was good representation from north (n = 78, 16%), south (n = 114, 24%), east (n = 99, 21%), central (n = 42, 9%), and western (n = 142, 29%) Indian regions. Participants were almost equally distributed in terms of institutional (n = 194, 40%) and private practice (n = 184, 38%) while the remaining 103 practitioners were engaged in both institutional and private practice. In terms of surgical cataract volumes, 113 (24%) operated on fewer than 25 cases per month, 138 (28%) did between 25 and 50 surgeries, 107 (22%) did 50 and 100 surgeries, and 74 (15%) did more than 100 surgeries per month while 49 (10%) reported not doing regular cataract surgery.
The majority (n = 375, 78%) preferred phacoemulsification as the primary mode of cataract surgery.

## Aphakia planning when seen in outpatient clinics
Most participants saw fewer than 10 aphakia patients per month (n = 430, 89%) and postoperative aphakia was the commonest etiology encountered by participants (n = 351, 73%). Traumatic aphakia (n = 86, 18%) was the second commonest cause reported followed by spontaneous dislocation of IOL (n = 20, 4%). Nearly two-thirds of participants reported managing aphakia themselves when seeing cases in the clinic setting while the rest opted to refer patients to VR surgeons. Placing a three-piece IOL in the ciliary sulcus when available was the commonest choice for surgeons when planning for surgery in the operation department (OPD) [ [fig_ref] Table 1: Choice of IOL based on whether following PCR, there is nucleus/cortex drop... [/fig_ref] ], whereas an SFIOL was the commonest choice followed by retrofixated iris-claw IOL in the eyes with inadequate capsular support [ [fig_ref] Table 1: Choice of IOL based on whether following PCR, there is nucleus/cortex drop... [/fig_ref] ].

## Aphakia management during primary surgery -without nucleus or cortex drop
When encountering posterior capsule rent (PCR) during surgery without nucleus or cortex drop, 390 (81%) participants said that they managed the surgery themselves while 21 (4%) preferred to manage aphakia in a second sitting. A separate 20 (4%) preferred to call a VS in the same sitting and another 20 (4%) referred to a VS in a second sitting and 30 did not comment. [fig_ref] Figure 1: Management patterns in case of PCR with inadequate capsular support [/fig_ref] shows management patterns in the case of PCR with inadequate capsular support. A three-piece IOL in the ciliary sulcus was the preferred IOL of choice when there was adequate capsular support [ [fig_ref] Table 1: Choice of IOL based on whether following PCR, there is nucleus/cortex drop... [/fig_ref] ] while a retrofixated iris-claw IOL was the commonest choice in eyes without adequate capsular support.

## Aphakia management during primary surgery -with nucleus or cortex drop
When encountering PCR during surgery with nucleus or cortex drop, nearly half (n = 202, 42%) preferred to refer the patient to a VR surgeon in a secondary sitting while about a third (n = 132, 27%) called a VR surgeon in the same sitting. In terms of IOL placement in this scenario, a vast majority (85%) preferred to leave the patient aphakic. The choice of IOL in the few that placed it is shown in [fig_ref] Table 1: Choice of IOL based on whether following PCR, there is nucleus/cortex drop... [/fig_ref].

## Practices for iol placement during secondary surgery in eyes without capsular support
Most participants who preferred retrofixated iris-claw IOLs (n = 246) performed a peripheral iridotomy (n = 183, 75%) at the time of its placement. The commonest response to a time interval between primary cataract surgery and a secondary IOL placement was 2-6 weeks [ [fig_ref] Figure 2: Response time interval between primary cataract surgery and a secondary IOL placement [/fig_ref] ]. For those who preferred SFIOL, 125 participants (54%) preferred a sutured IOL while 108 preferred a sutureless SFIOL. In those who went with sutured SFIOL, most preferred to use the polymethyl methacrylate (PMMA) SFIOL with eyelets on the haptics (n = 98/120, 82%), 20 (17%) used a foldable three-piece and 2 (2%) opted for the Akreos plate haptic IOL. Similarly, 10-O prolene suture was used most commonly for fixation (n = 68, 57%) followed by 9-O prolene (n = 44, 37%) and Gortex (n = 8, 7%). In those choosing sutureless SFIOL, the glued IOL was the most preferred (n = 42, 40%) followed closely by the Yamane technique (n = 37, 35%) and the Gabor technique (n = 26, 25%). In patients with bilateral aphakia already using spectacles or contact lenses, 212 (44%) participants offered a secondary IOL while 77 (16%) were advised to continue aphakic glasses and 125 (26%) would give the option of contact lenses for visual rehabilitation, and 67 (14%) did not comment. [fig_ref] Table 2: Comparison of practice settings and patterns in the management of aphakia between... [/fig_ref] shows a comparison of practice patterns between AS and VR surgeons. There were more AS surgeons with > 20 years of surgical experience. Only about half of the AS surgeons preferred to manage cases of aphakia when seeing them in the OPD compared to nearly all VR surgeons. In aphakia without [fig_ref] Figure 3: Difference in the choices among AS surgeons and VR surgeons while doing... [/fig_ref] ], though these differences were not statistically significant [ [fig_ref] Table 2: Comparison of practice settings and patterns in the management of aphakia between... [/fig_ref] ].

## Comparison in practice patterns for aphakia management between anterior and posterior segment surgeons
Comparison in practice patterns for aphakia management with respect to surgeon experience Participants with experience <10 years were most commonly in institutional practice while more experienced surgeons were in private practice [ [fig_ref] Table 3: Comparison of practice settings and patterns in the management of aphakia between... [/fig_ref] ]. A significantly higher proportion of younger surgeons preferred the retrofixated iris-claw IOL when encountering aphakia without adequate capsular support while senior surgeons preferred the SFIOL and retrofixated iris-claw almost equally [fig_ref] Table 3: Comparison of practice settings and patterns in the management of aphakia between... [/fig_ref] ]. Similarly, if doing sutureless SFIOL, younger surgeons preferred the Preferred practice in aphakia management in adults in India
Yamane technique while older surgeons preferred the glued IOL.
A multivariable logistic regression analysis with the type of surgeon, surgeon experience, and type of practice (institutional vs. private) found that VR surgeons were more than six times likely to prefer an SFIOL (OR = 6.5, 95% CI = 3.4-12.5, P < 0.001) compared to AS surgeons. In the same model, surgeons with >10 years of experience were more than twice likely to prefer an SFIOL (OR = 2.4, 95% CI = 1.2-4.9, P = 0.02). Institutional practitioners did not differ from private practitioners in terms of the type of IOL and for most other parameters (data not shown).

# Discussion
This study presents data on various preferences for management of aphakia from all parts of India with a good mix of institutional vs. private practitioners and a good distribution over years of surgical practice, hence possibly representing practice patterns across India. AS surgeons managed cases of aphakia with no nucleus drop about half the time and resorted to iris-claw IOL more frequently in the same sitting. As opposed to this, VR surgeons preferred an SFIOL more often in all scenarios. While choosing an SFIOL, AS surgeons preferred the sutured SFIOL while VR surgeons chose sutureless IOL more frequently. Additionally, VR surgeons and surgeons with more experience chose SFIOL more often.
In aphakic eyes without adequate capsular support, AS surgeons were comfortable in managing cases with no nucleus drop about half the time and preferred assistance from a VR surgeon at other times. Also, they showed a trend toward using retro pupillary iris-claw IOL more frequently at the time of the primary surgery. Interestingly, when they saw patients in OPD, they chose SFIOL more frequently, showing that iris-claw is perceived to be an easier and quicker option at the time of encountering aphakia during primary cataract surgery. As opposed to this, VR surgeons preferred an SFIOL much more often and in all scenarios. Previous studies comparing iris-claw vs. SFIOL have shown delayed visual recovery in the iris-claw group compared to SFIOL. [bib_ref] Comparative analysis of retropupillary iris claw versus scleral-fixated intraocular lens in the..., Madhivanan [/bib_ref] [bib_ref] Five-year follow-up of secondary iris-claw intraocular lens implantation for the treatment of..., Toro [/bib_ref] [bib_ref] Retropupillary iris-claw intraocular lens implantation in aphakic patients, Sumitha [/bib_ref] Additionally, the long-term data on retro pupillary iris-claw IOLs is scant, [bib_ref] Five-year follow-up of secondary iris-claw intraocular lens implantation for the treatment of..., Toro [/bib_ref] and its influence on pupil dynamics has not been studied. The commonest complication with iris-claw IOLs is D-shaped disfigurement of the pupil, [bib_ref] Comparative analysis of retropupillary iris claw versus scleral-fixated intraocular lens in the..., Madhivanan [/bib_ref] [bib_ref] Retropupillary iris-claw intraocular lens implantation in aphakic patients, Sumitha [/bib_ref] localized iris atrophy, and poor mydriasis making future VR procedures difficult, likely prompting VR surgeons to avoid this approach.
While choosing an SFIOL, AS surgeons preferred the sutured SFIOL while VR surgeons chose sutureless IOL more frequently. A previous robust study showed equivalent results with sutured vs. sutureless SFIOL, [bib_ref] Comparison of sutured versus sutureless scleral-fixated intraocular lenses, Sindal [/bib_ref] hence surgeon preference may not influence visual outcomes much. However, there may be a fear of IOL drop while performing sutureless SFIOLs due to the inherent maneuvers involved. This fear is also demonstrated when doing sutureless SFIOL where AS surgeons preferred glued IOL more often for security compared to the Yamane technique by VR surgeons.
Lastly, VR surgeons and surgeons with more experience choose SFIOL more often. There could be several reasons to explain this trend. It is possible that this group had more exposure to the SFIOL technique during training, or this shows changing trends with time in view of retrofixated IOLs becoming recently available with ease of fixation making them preferable in recent times. It is also possible that retro pupillary iris-claw IOLs don't do well in the long term with pigment dispersion, secondary glaucoma, persistent uveitis, and poor mydriasis, and hence experienced surgeons' resort to SFIOL more, though these were not inquired in the survey.
The limitations of this study are possible under-representation of rural practitioners. To the best of our knowledge, this is the first survey showing the preferences of Indian surgeons in the management of aphakia to the best of our knowledge. However, surveys with a larger sample are required to confirm or refute the preferences of surgeons in managing aphakia in the Indian context.

# Conclusion
In conclusion, this survey showed current trends in the management of aphakia among Indian ophthalmologists. Retro pupillary iris-claw IOLs are preferred increasingly by AS surgeons especially in the primary cataract setting without adequate capsular support, whereas VR surgeons and more experienced AS surgeons preferred SFIOL in this scenario. A similar survey may be repeated periodically to document changing trends in the surgical management of aphakia in the future, and results from this survey can be used as a benchmark for future comparisons.

# Acknowledgments
T h e a u t h o r s a c k n o w l e d g e t h e a s s i s t a n c e o f Dr. Sabyasachi Sengupta from Sengupta's Research Academy in statistics and content editing for this manuscript.

## Financial support and sponsorship
Nil.

## Conflicts of interest
There are no conflicts of interest.
[fig] Figure 1: Management patterns in case of PCR with inadequate capsular support [/fig]
[fig] Figure 2: Response time interval between primary cataract surgery and a secondary IOL placement [/fig]
[fig] Figure 3: Difference in the choices among AS surgeons and VR surgeons while doing sutureless SFIOL [/fig]
[table] Table 1: Choice of IOL based on whether following PCR, there is nucleus/cortex drop and whether there is adequate capsular support [/table]
[table] Table 2: Comparison of practice settings and patterns in the management of aphakia between AS surgeons vs. VR surgeons [/table]
[table] Table 3: Comparison of practice settings and patterns in the management of aphakia between surgeons with more or less than 10 years of surgical experienceChoice of IOL with aphakia and no capsular with no nucleus drop:SFIOL Retro-fixated iris-claw IOL ACIOL [/table]