Efficacy Analysis of Capsular Tension Ring Ciliary Sulcus Suture Fixation for Lens Subluxation

Efficacy Analysis of Capsular Tension Ring Ciliary Sulcus Suture Fixation for Lens Subluxation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy Analysis of Capsular Tension Ring Ciliary Sulcus Suture Fixation for Lens Subluxation Xianhai Lan, Huiran Bai, Yingli Teng, Jiajun Sun, Xiaoming Wu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9241947/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Objective: To explore the long-term therapeutic effect of capsular tension ring (CTR) suture fixation in patients with lens subluxation. Methods: A retrospective analysis was conducted on 29 patients (29 eyes) who underwent phacoemulsification + intraocular lens (IOL) implantation + CTR suture fixation for lens subluxation at Qingdao Eye Hospital Affiliated to Shandong First Medical University from October 2019 to July 2024. The patients' postoperative best-corrected visual acuity (BCVA), refraction, intraocular pressure (IOP), complications, and IOL position were observed. Results: All patients were followed up for at least 12 months (range: 12-48 months). Postoperative BCVA was significantly improved compared with preoperative values (t=-7.43, P=0). The average postoperative residual refractive error was 0.42±0.39D (range: 0-1.25 D). Postoperative IOP was significantly lower than preoperative IOP (t=2.42, P=0.023). Postoperatively, 2 eyes developed dislocation of the IOL-CTR-capsular bag complex and underwent complex suspension surgery; 1 eye had transient high IOP; 1 eye had a small amount of nasal vitreous hernia; and 1 eye developed posterior capsular opacification (PCO) during follow-up, which was treated with YAG posterior capsulotomy. Conclusion: CTR suture fixation can effectively improve visual acuity, maintain stable IOP, and has a low complication rate in patients with lens subluxation. It provides a safe and effective treatment method for lens subluxation. lens subluxation Capsular tension ring Ciliary sulcus Suture Fixation IOL-CTR-Capsular Bag Complex Figures Figure 1 Key Messages What is known: Lens subluxation causes severe visual impairment and complications; capsular tension ring (CTR) implantation improves surgical outcomes, but simple CTR is ineffective for extensive subluxation. Various suture fixation techniques have been developed, but most rely on special commercial devices with limited accessibility. What is new: Ciliary sulcus suture fixation of conventional CTR with 9-0 double-strand polypropylene suture effectively preserves the capsular bag, improves visual acuity, stabilizes intraocular pressure (IOP), and has a low complication rate for lens subluxation (90°–240°). This technique is a safe, cost-effective alternative without special devices, and provides an emergency option for intraoperatively detected subluxation. Introduction Lens dislocation is a common ophthalmic disease, which can be caused by both congenital development and acquired factors [1] . It can lead to severe complications such as decreased visual acuity, refractive errors and secondary glaucoma [2] , seriously affecting patients' visual quality and daily life. The surgical treatment is challenging, and how to effectively stabilize the IOL position and improve patients' visual function during surgery remains an urgent clinical problem. CTR implantation can effectively improve the success rate of surgery and reduce surgical complications [3] . However, for patients with a large range of lens dislocation, simple CTR implantation cannot effectively solve the problem. Innovative treatment methods such as various IOL suture techniques, implantable capsular hooks, and modified capsular tension ring(MCTR) suture fixation have gradually demonstrated unique advantages in clinical practice. These methods use sutures to fix the IOL and capsular bag to the scleral wall, thereby enhancing the support of the capsular bag [4–7] . This study analyzed patients with lens subluxation who underwent ciliary sulcus suture fixation with a CTR, aiming to evaluate the clinical efficacy of this treatment method and provide a reference for clinical practice. Materials and Methods 1.1 Clinical Data A tatol of 29 patients who underwent phacoemulsification + IOL implantation + CTR suture fixation for lens subluxation at Qingdao Eye Hospital Affiliated to Shandong First Medical University from October 2019 to July 2024 were collected. Exclusion Criteria: Patients with complete lens subluxation or dislocation exceeding 240 degrees who required vitrectomy combined with IOL suspension surgery; patients with lens subluxation caused by congenital diseases such as Marfan syndrome; patients with combined vitreous hemorrhage, retinal detachment, or other conditions requiring combined surgery such as vitrectomy; patients who failed to complete 12 months of follow-up. This study was approved by the Ethics Committee of Qingdao Eye Hospital Affiliated to Shandong First Medical University, and all patients signed informed consent forms before surgery in accordance with the Declaration of Helsinki. 1.2 Preoperative Examinations All patients underwent the following examinations: uncorrected visual acuity (UCVA) and BCVA, subjective refraction, non-contact IOP (TX-20, Canon Medical Systems Co., Kawasaki, Japan), slit-lamp (BM900, Haag-Streit AG, Koeniz, Switzerland), corneal endothelioscopy (SP-1P, Topcon Co., Tokyo, Japan), B-mode ultrasound (MD-2300S, MEDA Co., Ltd, Tianjin, China), ophthalmic biometry (IOL-Master 700, Carl Zeiss Meditec AG, Jena, Germany), non-mydriatic fundus photography (Daytona, Optos plc, Dunfermline, UK), optical coherence tomography (RTVue XR, Optovue Inc, 2800 Bayview Drive, Fremont, CA 94538, USA), and ultrasound biomicroscopy (UBM, SW-3200L, Suoer Co., Ltd, China). 1.3 Surgical Methods Peribulbar anesthesia combined with ciliary ganglion block was administered using 6 ml of 2% lidocaine. A standard 2.4 mm clear corneal incision was made at the 10 o’clock position. Sodium hyaluronate was injected into the anterior chamber to maintain the anterior chamber and stabilize the lens position to avoid excessive lens movement. A side incision was made at the 2 o'clock position, followed by continuous curvilinear capsulorhexis (CCC). A 1 mm limbal side incision was made at the site of zonular rupture, and 2–3 self-made capsular hooks (fabricated by thermoforming 5-0 polypropylene sutures) [8] were implanted. Sufficient hydrodissection was performed to fully free the lens nucleus and reduce zonular damage during subsequent procedures.Phacoemulsification was performed to aspirate the lens nucleus and cortex. Before removing the phacoemulsification needle and aspiration needle, sodium hyaluronate was injected through the side incision to maintain anterior chamber stability and prevent vitreous hernia. A 9-0 double-strand polypropylene suture (8065307901, Alcon Laboratories, Inc., TX, USA) was used to fix one end of the CTR (OPHTEC-276001G, Ophtec BV, Groningen, The Netherlands) by a cow-hitch knot, then the CTR was implanted into the capsular bag. The capsular hooks were removed, sodium hyaluronate was used to expand the anterior capsule and iris at the CTR fixation site. The polypropylene suture and a long needle were inserted into the anterior chamber through the main clear corneal incision, passed through the eyeball wall in the ciliary sulcus between the iris and anterior capsule, the suture was passed through the sclera twice parallel to the corneal limbus, and the suture tension was adjusted to ensure the capsular bag was centered. A foldable IOL was implanted into the capsular bag. The externally exposed suture was cut and pushed into the scleral tunnel. Sodium hyaluronate in the anterior chamber and capsular bag was aspirated, and the incision was hydrated and closed. For patients with vitreous hernia, triamcinolone was used for staining, and the herniated vitreous was removed using a capsulotomy scissors or anterior vitrectomy. The surgical process is shown in Figure 1. 1.4 Follow-up and Outcome Measures All surgeries were performed by the same experienced surgeon. Postoperatively, tobramycin-dexamethasone eye drops, pranoprofen eye drops, and gatifloxacin eye drops were administered. Postoperative observations included UCVA, BCVA, non-contact IOP, IOL position, and postoperative complications. 1.5 Statistical Methods SPSS version 25.0 was used for statistical analysis. The measurement data followed a normal distribution and were represented by x±s. Paired sample t-test was used to compare visual acuity and intraocular pressure before and after surgery. Results 2.1 Baseline Clinical Characteristics A total of 29 patients were included in this study, including 20 males (68.97%) and 9 females (31.03), aged from 38 to 80 years old, with lens subluxation ranging from 90° to 240°(Maximum 240°, minimum 90°). The causes of lens subluxation included ocular trauma (10 cases), complicated cataract after glaucoma surgery (11 cases), complicated cataract after vitrectomy (4 cases), and intraoperative discovered lens subluxation (4 cases) (Table 1). 2.2 Postoperative Outcomes All patients successfully completed the surgery without severe intraoperative complications such as posterior capsule rupture, vitreous hemorrhage, or explosive choroidal detachment. All patients were followed up for at least 12 months. Postoperative visual acuity was significantly improved compared to preoperative values (t=-7.43, P=0). At 12 months postoperatively, IOP was decreased to varying degrees compared with preoperative IOP (t=2.42, P=0.023). The average postoperative residual refractive error was 0.42±0.39 D. One patient developed high IOP (maximum IOP: 35 mmHg) during the 1-week postoperative review, which was stabilized after treatment with carteolol eye drops and brinzolamide eye drops, and the medication was discontinued. One patient had a small amount of nasal vitreous hernia after surgery. One patient developed posterior capsular opacification(PCO) during follow-up and underwent YAG posterior capsulotomy. Two patients developed dislocation of the IOL-CTR-capsular bag complex at 33 and 36 months postoperatively, respectively, and underwent complex suspension surgery (Table 2). Discussion The stability of the IOL depends on the coordinated function of multiple structures, including the zonules, ciliary body, and capsular bag. Preoperative factors such as a history of ocular surgery, zonular degeneration due to high myopia, or zonular rupture caused by ocular trauma can lead to significant individual differences in capsular bag elasticity and zonular support during surgery. For patients with a large range of lens dislocation, current surgical approaches are mainly divided into two categories: capsular bag-non-preserving and capsular bag-preserving techniques. Capsular bag-non-preserving techniques mainly include vitrectomy combined with lens extraction and IOL suspension surgery, or scleral fixation of the IOL. Such surgeries usually require combined vitrectomy. Their advantages include the possibility of secondary IOL implantation, but they are associated with higher costs, longer operation times, and a relatively higher risk of intraoperative and postoperative complications such as IOL tilt, suture breakage, vitreous hemorrhage, and retinal detachment [9] .The sutureless scleral fixation technique for IOLs invented by Yamane requires a 3-piece IOL with special material haptics to complete the surgery, and the postoperative incidence of intraocular lens clamping is relatively high [10] .Capsular bag preserving techniques typically require special commercial medical devices, such as MCTR [11–12] , new segmental capsular tension segments [13] , and capsular anchors [14] . The specificity of these devices limits their accessibility.Professor Jin Haiying reported using thermoformed 5 − 0 polypropylene sutures to fabricate implantable capsular hooks for stabilizing the dislocated IOL-capsular bag complex, a method that has been rapidly promoted in China [8,15] . However, the thermoforming of polypropylene sutures and their intraocular implantation require a learning curve, and large-sample, long-term data on the deformation and long-term efficacy of implanted capsular hooks are lacking. The ciliary sulcus suture fixation technique with CTR used in this study fixes the lens capsular bag using conventional CTRs and sutures. In the absence of special commercial medical devices such as MCTR, this technique can completely preserve the lens capsular bag, avoid additional vitrectomy, and create conditions for the implantation of intraocular lenses within the capsular bag.It can be used as a routine surgical plan or an emergency option for patients with intraoperatively detected lens dislocation, minimizing surgical trauma. The CTR ciliary sulcus suture fixation technique uses 9 − 0 polypropylene sutures to fix the CTR to the scleral wall, forming a mechanical support system of "sclera-suture-CTR-capsular bag". This system provides physical support to the capsular bag, restores its normal shape and tension, prevents vitreous hernia into the anterior chamber, and facilitates in-the-bag IOL implantation. It also reduces the risk of further zonular rupture and maintains the capsular bag in a relatively normal position.In the planar dimension, this technique improves the rate of IOL centration; in the longitudinal dimension, it maintains a more predictable effective lens position (ELP). Its mechanism of action is similar to that of MCTR, with comparable efficacy [16–17] . This fixation method can effectively resist the traction force in the direction of lens dislocation and the applicable range can reach 240° [18] .Compared with 10 − 0 polypropylene sutures, 9 − 0 double-strand polypropylene sutures are stronger, reducing the long-term risk of suture breakage and complex dislocation [19–20] . In this study, except for 2 patients with complex dislocation, no IOL decentration was observed in other patients during postoperative follow-up, confirming the reinforcing effect of this technique in enhancing capsular bag stability. Compared with conventional simple CTR implantation, suture fixation increases the stability of the complex, reduces the pressure on residual zonules, and avoids the risk of IOL rotation or displacement due to insufficient zonular support for the CTR. The improvement in postoperative visual acuity is closely related to the stability of the IOL position and minimal postoperative refractive error. Compared with traditional IOL suspension surgery where the ELP depends on the puncture needle position, this technique preserves the intact capsular bag, making the ELP closer to that of conventional cataract surgery. This ensures postoperative refractive state stability and minimizes postoperative refractive error, with efficacy comparable to that of simple CTR implantation, IOL suspension surgery, and MCTR implantation [21–23] .In this study, the mean postoperative residual refraction was 0.42 ± 0.39 D, and the postoperative BCVA was significantly improved compared with the preoperative level (t=-7.43, P = 0), especially in patients with ocular trauma, which may be related to preoperative lens eccentricity, opacification, and anisometropia [16] . In patients with combined glaucoma, the improvement of postoperative BCVA was relatively limited, which may be related to optic nerve damage, mydriasis, sluggish pupillary light reflex, and decreased corneal endothelial function caused by long-term elevated IOP. This suggests that for patients with glaucoma combined with lens dislocation, a comprehensive preoperative evaluation of optic nerve status and pupillary function is necessary, and adequate communication with patients should be conducted preoperatively. Phacoemulsification combined with IOL implantation can deepen the anterior chamber, widen the anterior chamber angle, and thereby reduce baseline IOP [24–25] . In this study, the mean postoperative IOP decreased by 4.2 mmHg (t = 2.42, P = 0.023). Intraoperative CTR implantation supports the capsular bag, further restoring the normal anatomical position of the lens-iris diaphragm and reducing the risk of pupillary block. For patients with vitreous herniation, intraoperative anterior vitrectomy removes the mechanical obstruction and compression of the anterior chamber angle by the vitreous, further reducing postoperative IOP [26–27] .However, during the follow-up process, 1 patient who received anterior chamber injection of triamcinolone acetonide for vitreous staining developed transient high IOP in the early postoperative period, which was relieved after treatment with two anti-glaucoma medications and subsequent medication discontinuation. This may be related to residual sodium hyaluronate in the anterior chamber or residual triamcinolone acetonide particles blocking the trabecular meshwork. This suggests that complete removal of sodium hyaluronate and triamcinolone acetonide particles from the anterior chamber is essential during surgery. Complications in this study included dislocation of the IOL-CTR-capsular bag complex (2 eyes), both in patients with a lens dislocation range of 240 degrees, occurring on the residual zonular side. This may be related to the large range of dislocation. During reoperation, the capsular membrane had already become organized, and only a single suture was required for complex suspension. The surgical procedure was simpler and less time-consuming than conventional IOL suspension, and the capsular bag was still preserved, which is more in line with the natural ocular anatomical structure.Improvement strategies: For patients with a large range of dislocation, Professor Jin Haiying's method of using 5 − 0 polypropylene suture to make an implantable capsular bag hook can be referred [8,15,18] . During surgery, a hook is implanted on the opposite side of the CTR suture fixation end to fix the capsular bag-CTR-IOL complex. Two-point fixation can significantly reduce the risk of postoperative IOL dislocation. Additionally, ensuring a scleral suture tunnel length of ≥ 2 mmand using ink to mark the fixation points during surgery can improve suture accuracy [28] .One patient had a small amount of vitreous hernia on the nasal side postoperatively, which may be related to incomplete removal of the herniated vitreous during surgery, leading to prolapse of liquefied vitreous into the pupillary area through the CTR gap. No IOL displacement or secondary glaucoma was observed during follow-up, and no special treatment was required.Improvement method: For patients with zonular rupture > 180 degrees, routine anterior chamber injection of triamcinolone acetonide for vitreous staining and anterior vitrectomy is recommended to avoid residual vitreous incarceration. The CTR itself can increase capsular bag tension, improve the adhere between the IOL and capsular bag, and thereby inhibit the proliferation and migration of lens epithelial cells to the visual axis, preventing the occurrence of PCO [29–30] . However, this technique has the disadvantage of suture traction on the anterior capsule opening and capsular bag wrinkling, which disrupts the ideal "sandwich structure" formed by the capsular membrane and IOL, which is not conducive to the prevention of PCO. In this study, only 1 case (1/29) occurred PCO during 12 months of follow-up. Further large-sample and long-term follow-up are needed to evaluate the balance between the negative effects of suture traction on the anterior capsule opening and the positive effects of the CTR in preventing PCO. This patient developed PCO at 3 months postoperatively, and visual acuity was restored after YAG laser posterior capsulotomy. No complications such as posterior capsule tear or IOL displacement occurred during the procedure. This may be because the lens capsular membrane had already become organized at 3 months postoperatively, which could resist the expansion force of the CTR and avoid capsule tear during YAG laser. However, it is still necessary to note that the timing of laser should not be too early, and the incision range should not be too large [31–32] . This study also has limitations. First, the sample size was small (29 eyes), and patients with lens dislocation > 240 degrees or combined complex fundus diseases were not included. Secondly, the follow-up period was relatively short, with an average of 18 months, lacking longer-term data.Long-term complications (e.g., IOL decentration) caused by suture degradation or aging of scleral fixation points have not been observed. Finally, no control group was established. In future studies, patients undergoing simple CTR implantation, traditional IOL suspension surgery, or CTR suture fixation combined with capsular hook implantation can be included for comparative analysis to select the appropriate surgical method for patients with different ranges of lens dislocation. For patients with congenital lens dislocation such as Marfan syndrome, the method of double-suture bilateral fixation of the CTR should be explored to compensate for the lack of MCTR. Conclusion The results of this study show that CTR suture fixation using double-strand 9-0 polypropylene sutures can significantly improve visual acuity in patients with lens subluxation, and is a safe, effective, and cost-effective method, especially in the absence of special commercial medical devices such as MCTRs. Although a certain proportion of postoperative complications occurred, they were effectively controlled after active treatment. However, the success rate and safety of the surgery are affected by multiple factors. A comprehensive preoperative evaluation and personalized surgical plan design are necessary. Postoperative regular follow-up is also required to ensure surgical efficacy and timely detection and management of potential problems. Declarations Funding Support The authors declare that this study did not receive any funding support related to research, copyright, or publication. Author information Authors and Affiliations Yidu Central Hospital Affiliated to Shandong Second Medical University, Qingzhou, Weifang, People’s Republic of China. Xianhai Lan Qingdao Eye Hospital Affiliated to Shandong First Medical University, Qingdao, People’s Republic of China. Huiran Bai, Yingli Teng, Jiajun Sun, Xiaoming Wu State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, People’s Republic of China. Huiran Bai, Yingli Teng, Jiajun Sun, Xiaoming Wu Author Contributions Xianhai Lan wrote the manuscript; Huiran Bai and Yingli Teng were responsible for data collection and literature review; Jiajun Sun and Xiaoming Wu contributed to the conception of the study and provided advice on the manusciript; all authors participated in manuscript revision and approved the final submitted version. Corresponding author Correspondence to Xiaoming Wu. Ethics approval The study was approved by the Institutional Review Board of Qingdao Eye Hospital of Shandong First Medical University. The approval number is QEFT [2026] 18. Data availability All data relevant to the study are included in the article. 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Curr Opin Ophthalmol 26(1):10-5. https://doi.org/10.1097/ICU.0000000000000118 Cho YK, Kim MS(2023) Stability of neodymium:YAG laser posterior capsulotomy in eyes with capsular tension rings. Int J Ophthalmol 16(6):891-896. https://doi.org/10.18240/ijo.2023.06.09 Sadullah Keles,Baki Kartal,Aytekin Apil, et al(2014) Nd: YAG laser posterior capsulotomy rates in myopic eyes after implantation of capsular tension ring. Med Sci Monit 20:1469-73. https://doi.org/10.12659/MSM.890767 Tables Table 1: Preoperative Baseline Characteristics of Patients Clinical Features Values Male 20 cases (68.97%) Female 9 cases (31.03%) Average age (years old) 62.03±10.38 Average dislocation range (°) 141.72±38.99 Causes of lens subluxation Ocular trauma Complicated cataract after glaucoma surgery Complicated cataract after vitrectomy Intraoperative discovery of lens subluxation 10 cases 11 cases 4 cases 4 cases Table 2: Postoperative Outcomes Visual acuity (logMAR) Preoperative 1.17±0.64 Postoperative 0.36±0.48 t=-7.43, P=0 Intraocular pressure (mmHg) Preoperative 18.8±9.08 Postoperative 14.61±3.65 t=2.42, P=0.023 Postoperative average residual refraction (D) 0.42±0.39 Postoperative complications Ocular hypertension 1 case (3.4%) Vitreous hernia 1 case (3.4%) Posterior capsular opacification 1 case (3.4%) Dislocation of IOL-tension ring-capsular bag complex 2 cases (6.9%) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 15 May, 2026 Reviews received at journal 13 May, 2026 Reviews received at journal 03 May, 2026 Reviewers agreed at journal 03 May, 2026 Reviews received at journal 29 Apr, 2026 Reviewers agreed at journal 29 Apr, 2026 Reviewers agreed at journal 28 Apr, 2026 Reviewers invited by journal 21 Apr, 2026 Editor invited by journal 31 Mar, 2026 Editor assigned by journal 31 Mar, 2026 Submission checks completed at journal 31 Mar, 2026 First submitted to journal 27 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9241947","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":631157867,"identity":"aa7aaef8-b24a-4de9-a522-b84f6ad10d61","order_by":0,"name":"Xianhai Lan","email":"","orcid":"","institution":"Yidu Central Hospital of Weifang","correspondingAuthor":false,"prefix":"","firstName":"Xianhai","middleName":"","lastName":"Lan","suffix":""},{"id":631157868,"identity":"f5da645a-a5af-47b6-bb1b-bd5a7b208aa4","order_by":1,"name":"Huiran Bai","email":"","orcid":"","institution":"Shandong Eye Institute \u0026 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Huiran","middleName":"","lastName":"Bai","suffix":""},{"id":631157869,"identity":"f2c8a226-f8dd-4f02-9063-e01c07eb7f68","order_by":2,"name":"Yingli Teng","email":"","orcid":"","institution":"Shandong Eye Institute \u0026 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yingli","middleName":"","lastName":"Teng","suffix":""},{"id":631157871,"identity":"167613fa-4dfd-46bb-b88f-ecee0ced5ff1","order_by":3,"name":"Jiajun Sun","email":"","orcid":"","institution":"Shandong Eye Institute \u0026 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jiajun","middleName":"","lastName":"Sun","suffix":""},{"id":631157873,"identity":"cbadefd3-22bc-421a-ae9c-f8aa9ccf37c0","order_by":4,"name":"Xiaoming Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYJCCA0DMw8DA3MDAUCEhx0+CFkagljMWxpINxFsG1MLYVpG4gZAWgxs5hgd+VGyTMedf2Lrp5jwJxg0MzA8f3cCrJS3hYM+Z2zyWMx623c7dJsFszsBmbJyDR4vZjeQDB3jbbvMY3DgI1sJm2cDDJo1fS2LDwb9wLXMkeAwOENSSfOAw2JbzjUAtDRISBLXYn3mWcFjmDMgWxrbbOcckDCSbCfhFsj3H+OObitv2BucPH7udU1NX38/e/PAxPi0IIJEAZTATpRwE+A8QrXQUjIJRMApGGAAARw1V560NLmEAAAAASUVORK5CYII=","orcid":"","institution":"Shandong Eye Institute \u0026 Hospital","correspondingAuthor":true,"prefix":"","firstName":"Xiaoming","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2026-03-27 08:10:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9241947/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9241947/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108097694,"identity":"78f51316-9f21-4bf8-8fcf-38f3f8e9520c","added_by":"auto","created_at":"2026-04-29 10:15:31","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":419870,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical process of CTR suture fixation for lens subluxation\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9241947/v1/a0cd4ce5fdf40372db042f4e.jpg"},{"id":108181999,"identity":"0659b8bc-9e41-411b-aa6e-c8207113606b","added_by":"auto","created_at":"2026-04-30 08:59:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":614028,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9241947/v1/39c07380-1eb2-475b-9724-08c08ab326a4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy Analysis of Capsular Tension Ring Ciliary Sulcus Suture Fixation for Lens Subluxation","fulltext":[{"header":"Key Messages","content":"\u003cp\u003e\u003cstrong\u003eWhat is known:\u003c/strong\u003e Lens subluxation causes severe visual impairment and complications; capsular tension ring (CTR) implantation improves surgical outcomes, but simple CTR is ineffective for extensive subluxation. Various suture fixation techniques have been developed, but most rely on special commercial devices with limited accessibility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is new:\u0026nbsp;\u003c/strong\u003eCiliary sulcus suture fixation of conventional CTR with 9-0 double-strand polypropylene suture effectively preserves the capsular bag, improves visual acuity, stabilizes intraocular pressure (IOP), and has a low complication rate for lens subluxation (90°–240°).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis technique is a safe, cost-effective alternative without special devices, and provides an emergency option for intraoperatively detected subluxation.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eLens dislocation is a common ophthalmic disease, which can be caused by both congenital development and acquired factors \u003csup\u003e[1]\u003c/sup\u003e. It can lead to severe complications such as decreased visual acuity, refractive errors and secondary glaucoma \u003csup\u003e[2]\u003c/sup\u003e, seriously affecting patients' visual quality and daily life. The surgical treatment is challenging, and how to effectively stabilize the IOL position and improve patients' visual function during surgery remains an urgent clinical problem. CTR implantation can effectively improve the success rate of surgery and reduce surgical complications \u003csup\u003e[3]\u003c/sup\u003e. However, for patients with a large range of lens dislocation, simple CTR implantation cannot effectively solve the problem. Innovative treatment methods such as various IOL suture techniques, implantable capsular hooks, and modified capsular tension ring(MCTR) suture fixation have gradually demonstrated unique advantages in clinical practice. These methods use sutures to fix the IOL and capsular bag to the scleral wall, thereby enhancing the support of the capsular bag\u003csup\u003e[4\u0026ndash;7]\u003c/sup\u003e. This study analyzed patients with lens subluxation who underwent ciliary sulcus suture fixation with a CTR, aiming to evaluate the clinical efficacy of this treatment method and provide a reference for clinical practice.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003e1.1 Clinical Data\u0026nbsp;\u003c/strong\u003eA tatol of 29 patients who underwent phacoemulsification + IOL implantation + CTR suture fixation for lens subluxation at Qingdao Eye Hospital Affiliated to Shandong First Medical University from October 2019 to July 2024 were collected. Exclusion Criteria:\u003c/p\u003e\n\u003cp\u003ePatients with complete lens subluxation or dislocation exceeding 240 degrees who required vitrectomy combined with IOL suspension surgery; patients with lens subluxation caused by congenital diseases such as Marfan syndrome; patients with combined vitreous hemorrhage, retinal detachment, or other conditions requiring combined surgery such as vitrectomy; patients who failed to complete 12 months of follow-up. This study was approved by the Ethics Committee of Qingdao Eye Hospital Affiliated to Shandong First Medical University, and all patients signed informed consent forms before surgery in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2 Preoperative Examinations\u0026nbsp;\u003c/strong\u003eAll patients underwent the following examinations: uncorrected visual acuity (UCVA) and BCVA, subjective refraction, non-contact IOP (TX-20, Canon Medical Systems Co., Kawasaki, Japan), slit-lamp (BM900, Haag-Streit AG, Koeniz, Switzerland), corneal endothelioscopy (SP-1P, Topcon Co., Tokyo, Japan), B-mode ultrasound (MD-2300S, MEDA Co., Ltd, Tianjin, China), ophthalmic biometry (IOL-Master 700, Carl Zeiss Meditec AG, Jena, Germany), non-mydriatic fundus photography (Daytona, Optos plc, Dunfermline, UK), optical coherence tomography (RTVue XR, Optovue Inc, 2800 Bayview Drive, Fremont, CA 94538, USA), and ultrasound biomicroscopy (UBM, SW-3200L, Suoer Co., Ltd, China).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.3 Surgical Methods\u0026nbsp;\u003c/strong\u003ePeribulbar anesthesia combined with ciliary ganglion block was administered using 6 ml of 2% lidocaine. A standard 2.4 mm clear corneal incision was made at the 10 o\u0026rsquo;clock position. Sodium hyaluronate was injected into the anterior chamber to maintain the anterior chamber and stabilize the lens position to avoid excessive lens movement. A side incision was made at the 2 o\u0026apos;clock position, followed by continuous curvilinear capsulorhexis (CCC). A 1 mm limbal side incision was made at the site of zonular rupture, and 2\u0026ndash;3 self-made capsular hooks (fabricated by thermoforming 5-0 polypropylene sutures) \u003csup\u003e[8]\u003c/sup\u003e were implanted. Sufficient hydrodissection was performed to fully free the lens nucleus and reduce zonular damage during subsequent procedures.Phacoemulsification was performed to aspirate the lens nucleus and cortex. Before removing the phacoemulsification needle and aspiration needle, sodium hyaluronate was injected through the side incision to maintain anterior chamber stability and prevent vitreous hernia. A 9-0 double-strand polypropylene suture (8065307901, Alcon Laboratories, Inc., TX, USA) was used to fix one end of the CTR (OPHTEC-276001G, Ophtec BV, Groningen, The Netherlands) by a cow-hitch knot, then the CTR was implanted into the capsular bag. The capsular hooks were removed, sodium hyaluronate was used to expand the anterior capsule and iris at the CTR fixation site. The polypropylene suture and a long needle were inserted into the anterior chamber through the main clear corneal incision, passed through the eyeball wall in the ciliary sulcus between the iris and anterior capsule, the suture was passed through the sclera twice parallel to the corneal limbus, and the suture tension was adjusted to ensure the capsular bag was centered. A foldable IOL was implanted into the capsular bag. The externally exposed suture was cut and pushed into the scleral tunnel. Sodium hyaluronate in the anterior chamber and capsular bag was aspirated, and the incision was hydrated and closed. For patients with vitreous hernia, triamcinolone was used for staining, and the herniated vitreous was removed using a capsulotomy scissors or anterior vitrectomy. The surgical process is shown in Figure 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.4 Follow-up and Outcome Measures\u0026nbsp;\u003c/strong\u003eAll surgeries were performed by the same experienced surgeon. Postoperatively, tobramycin-dexamethasone eye drops, pranoprofen eye drops, and gatifloxacin eye drops were administered. Postoperative observations included UCVA, BCVA, non-contact IOP, IOL position, and postoperative complications.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.5 Statistical Methods\u0026nbsp;\u003c/strong\u003eSPSS version 25.0 was used for statistical analysis. The measurement data followed a normal distribution and were represented by x\u0026plusmn;s. Paired sample t-test was used to compare visual acuity and intraocular pressure before and after surgery.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e2.1 Baseline Clinical Characteristics\u003c/strong\u003e A total of 29 patients were included in this study, including 20 males (68.97%) and 9 females (31.03), aged from 38 to 80 years old, with lens subluxation ranging from 90° to 240°(Maximum 240°, minimum 90°). The causes of lens subluxation included ocular trauma (10 cases), complicated cataract after glaucoma surgery (11 cases), complicated cataract after vitrectomy (4 cases), and intraoperative discovered lens subluxation (4 cases) (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Postoperative Outcomes\u0026nbsp;\u003c/strong\u003eAll patients successfully completed the surgery without severe intraoperative complications such as posterior capsule rupture, vitreous hemorrhage, or explosive choroidal detachment. All patients were followed up for at least 12 months. Postoperative visual acuity was significantly improved compared to preoperative values (t=-7.43, P=0). At 12 months postoperatively, IOP was decreased to varying degrees compared with preoperative IOP (t=2.42, P=0.023). The average postoperative residual refractive error was 0.42±0.39 D. One patient developed high IOP (maximum IOP: 35 mmHg) during the 1-week postoperative review, which was stabilized after treatment with carteolol eye drops and brinzolamide eye drops, and the medication was discontinued. One patient had a small amount of nasal vitreous hernia after surgery. One patient developed posterior capsular opacification(PCO) during follow-up and underwent YAG posterior capsulotomy. Two patients developed dislocation of the IOL-CTR-capsular bag complex at 33 and 36 months postoperatively, respectively, and underwent complex suspension surgery (Table 2).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe stability of the IOL depends on the coordinated function of multiple structures, including the zonules, ciliary body, and capsular bag. Preoperative factors such as a history of ocular surgery, zonular degeneration due to high myopia, or zonular rupture caused by ocular trauma can lead to significant individual differences in capsular bag elasticity and zonular support during surgery. For patients with a large range of lens dislocation, current surgical approaches are mainly divided into two categories: capsular bag-non-preserving and capsular bag-preserving techniques. Capsular bag-non-preserving techniques mainly include vitrectomy combined with lens extraction and IOL suspension surgery, or scleral fixation of the IOL. Such surgeries usually require combined vitrectomy. Their advantages include the possibility of secondary IOL implantation, but they are associated with higher costs, longer operation times, and a relatively higher risk of intraoperative and postoperative complications such as IOL tilt, suture breakage, vitreous hemorrhage, and retinal detachment \u003csup\u003e[9]\u003c/sup\u003e.The sutureless scleral fixation technique for IOLs invented by Yamane requires a 3-piece IOL with special material haptics to complete the surgery, and the postoperative incidence of intraocular lens clamping is relatively high \u003csup\u003e[10]\u003c/sup\u003e.Capsular bag preserving techniques typically require special commercial medical devices, such as MCTR\u003csup\u003e[11\u0026ndash;12]\u003c/sup\u003e, new segmental capsular tension segments \u003csup\u003e[13]\u003c/sup\u003e, and capsular anchors \u003csup\u003e[14]\u003c/sup\u003e. The specificity of these devices limits their accessibility.Professor Jin Haiying reported using thermoformed 5\u0026thinsp;\u0026minus;\u0026thinsp;0 polypropylene sutures to fabricate implantable capsular hooks for stabilizing the dislocated IOL-capsular bag complex, a method that has been rapidly promoted in China \u003csup\u003e[8,15]\u003c/sup\u003e. However, the thermoforming of polypropylene sutures and their intraocular implantation require a learning curve, and large-sample, long-term data on the deformation and long-term efficacy of implanted capsular hooks are lacking. The ciliary sulcus suture fixation technique with CTR used in this study fixes the lens capsular bag using conventional CTRs and sutures. In the absence of special commercial medical devices such as MCTR, this technique can completely preserve the lens capsular bag, avoid additional vitrectomy, and create conditions for the implantation of intraocular lenses within the capsular bag.It can be used as a routine surgical plan or an emergency option for patients with intraoperatively detected lens dislocation, minimizing surgical trauma.\u003c/p\u003e \u003cp\u003eThe CTR ciliary sulcus suture fixation technique uses 9\u0026thinsp;\u0026minus;\u0026thinsp;0 polypropylene sutures to fix the CTR to the scleral wall, forming a mechanical support system of \"sclera-suture-CTR-capsular bag\". This system provides physical support to the capsular bag, restores its normal shape and tension, prevents vitreous hernia into the anterior chamber, and facilitates in-the-bag IOL implantation. It also reduces the risk of further zonular rupture and maintains the capsular bag in a relatively normal position.In the planar dimension, this technique improves the rate of IOL centration; in the longitudinal dimension, it maintains a more predictable effective lens position (ELP). Its mechanism of action is similar to that of MCTR, with comparable efficacy \u003csup\u003e[16\u0026ndash;17]\u003c/sup\u003e. This fixation method can effectively resist the traction force in the direction of lens dislocation and the applicable range can reach 240\u0026deg;\u003csup\u003e[18]\u003c/sup\u003e.Compared with 10\u0026thinsp;\u0026minus;\u0026thinsp;0 polypropylene sutures, 9\u0026thinsp;\u0026minus;\u0026thinsp;0 double-strand polypropylene sutures are stronger, reducing the long-term risk of suture breakage and complex dislocation \u003csup\u003e[19\u0026ndash;20]\u003c/sup\u003e. In this study, except for 2 patients with complex dislocation, no IOL decentration was observed in other patients during postoperative follow-up, confirming the reinforcing effect of this technique in enhancing capsular bag stability. Compared with conventional simple CTR implantation, suture fixation increases the stability of the complex, reduces the pressure on residual zonules, and avoids the risk of IOL rotation or displacement due to insufficient zonular support for the CTR.\u003c/p\u003e \u003cp\u003eThe improvement in postoperative visual acuity is closely related to the stability of the IOL position and minimal postoperative refractive error. Compared with traditional IOL suspension surgery where the ELP depends on the puncture needle position, this technique preserves the intact capsular bag, making the ELP closer to that of conventional cataract surgery. This ensures postoperative refractive state stability and minimizes postoperative refractive error, with efficacy comparable to that of simple CTR implantation, IOL suspension surgery, and MCTR implantation\u003csup\u003e[21\u0026ndash;23]\u003c/sup\u003e.In this study, the mean postoperative residual refraction was 0.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39 D, and the postoperative BCVA was significantly improved compared with the preoperative level (t=-7.43, P\u0026thinsp;=\u0026thinsp;0), especially in patients with ocular trauma, which may be related to preoperative lens eccentricity, opacification, and anisometropia \u003csup\u003e[16]\u003c/sup\u003e. In patients with combined glaucoma, the improvement of postoperative BCVA was relatively limited, which may be related to optic nerve damage, mydriasis, sluggish pupillary light reflex, and decreased corneal endothelial function caused by long-term elevated IOP. This suggests that for patients with glaucoma combined with lens dislocation, a comprehensive preoperative evaluation of optic nerve status and pupillary function is necessary, and adequate communication with patients should be conducted preoperatively.\u003c/p\u003e \u003cp\u003ePhacoemulsification combined with IOL implantation can deepen the anterior chamber, widen the anterior chamber angle, and thereby reduce baseline IOP \u003csup\u003e[24\u0026ndash;25]\u003c/sup\u003e. In this study, the mean postoperative IOP decreased by 4.2 mmHg (t\u0026thinsp;=\u0026thinsp;2.42, P\u0026thinsp;=\u0026thinsp;0.023). Intraoperative CTR implantation supports the capsular bag, further restoring the normal anatomical position of the lens-iris diaphragm and reducing the risk of pupillary block. For patients with vitreous herniation, intraoperative anterior vitrectomy removes the mechanical obstruction and compression of the anterior chamber angle by the vitreous, further reducing postoperative IOP \u003csup\u003e[26\u0026ndash;27]\u003c/sup\u003e.However, during the follow-up process, 1 patient who received anterior chamber injection of triamcinolone acetonide for vitreous staining developed transient high IOP in the early postoperative period, which was relieved after treatment with two anti-glaucoma medications and subsequent medication discontinuation. This may be related to residual sodium hyaluronate in the anterior chamber or residual triamcinolone acetonide particles blocking the trabecular meshwork. This suggests that complete removal of sodium hyaluronate and triamcinolone acetonide particles from the anterior chamber is essential during surgery.\u003c/p\u003e \u003cp\u003eComplications in this study included dislocation of the IOL-CTR-capsular bag complex (2 eyes), both in patients with a lens dislocation range of 240 degrees, occurring on the residual zonular side. This may be related to the large range of dislocation. During reoperation, the capsular membrane had already become organized, and only a single suture was required for complex suspension. The surgical procedure was simpler and less time-consuming than conventional IOL suspension, and the capsular bag was still preserved, which is more in line with the natural ocular anatomical structure.Improvement strategies: For patients with a large range of dislocation, Professor Jin Haiying's method of using 5\u0026thinsp;\u0026minus;\u0026thinsp;0 polypropylene suture to make an implantable capsular bag hook can be referred\u003csup\u003e[8,15,18]\u003c/sup\u003e. During surgery, a hook is implanted on the opposite side of the CTR suture fixation end to fix the capsular bag-CTR-IOL complex. Two-point fixation can significantly reduce the risk of postoperative IOL dislocation. Additionally, ensuring a scleral suture tunnel length of \u0026ge;\u0026thinsp;2 mmand using ink to mark the fixation points during surgery can improve suture accuracy \u003csup\u003e[28]\u003c/sup\u003e .One patient had a small amount of vitreous hernia on the nasal side postoperatively, which may be related to incomplete removal of the herniated vitreous during surgery, leading to prolapse of liquefied vitreous into the pupillary area through the CTR gap. No IOL displacement or secondary glaucoma was observed during follow-up, and no special treatment was required.Improvement method: For patients with zonular rupture\u0026thinsp;\u0026gt;\u0026thinsp;180 degrees, routine anterior chamber injection of triamcinolone acetonide for vitreous staining and anterior vitrectomy is recommended to avoid residual vitreous incarceration.\u003c/p\u003e \u003cp\u003eThe CTR itself can increase capsular bag tension, improve the adhere between the IOL and capsular bag, and thereby inhibit the proliferation and migration of lens epithelial cells to the visual axis, preventing the occurrence of PCO\u003csup\u003e[29\u0026ndash;30]\u003c/sup\u003e. However, this technique has the disadvantage of suture traction on the anterior capsule opening and capsular bag wrinkling, which disrupts the ideal \"sandwich structure\" formed by the capsular membrane and IOL, which is not conducive to the prevention of PCO. In this study, only 1 case (1/29) occurred PCO during 12 months of follow-up. Further large-sample and long-term follow-up are needed to evaluate the balance between the negative effects of suture traction on the anterior capsule opening and the positive effects of the CTR in preventing PCO. This patient developed PCO at 3 months postoperatively, and visual acuity was restored after YAG laser posterior capsulotomy. No complications such as posterior capsule tear or IOL displacement occurred during the procedure. This may be because the lens capsular membrane had already become organized at 3 months postoperatively, which could resist the expansion force of the CTR and avoid capsule tear during YAG laser. However, it is still necessary to note that the timing of laser should not be too early, and the incision range should not be too large \u003csup\u003e[31\u0026ndash;32]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study also has limitations. First, the sample size was small (29 eyes), and patients with lens dislocation\u0026thinsp;\u0026gt;\u0026thinsp;240 degrees or combined complex fundus diseases were not included. Secondly, the follow-up period was relatively short, with an average of 18 months, lacking longer-term data.Long-term complications (e.g., IOL decentration) caused by suture degradation or aging of scleral fixation points have not been observed. Finally, no control group was established. In future studies, patients undergoing simple CTR implantation, traditional IOL suspension surgery, or CTR suture fixation combined with capsular hook implantation can be included for comparative analysis to select the appropriate surgical method for patients with different ranges of lens dislocation. For patients with congenital lens dislocation such as Marfan syndrome, the method of double-suture bilateral fixation of the CTR should be explored to compensate for the lack of MCTR.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results of this study show that CTR suture fixation using double-strand 9-0 polypropylene sutures can significantly improve visual acuity in patients with lens subluxation, and is a safe, effective, and cost-effective method, especially in the absence of special commercial medical devices such as MCTRs. Although a certain proportion of postoperative complications occurred, they were effectively controlled after active treatment. However, the success rate and safety of the surgery are affected by multiple factors. A comprehensive preoperative evaluation and personalized surgical plan design are necessary. Postoperative regular follow-up is also required to ensure surgical efficacy and timely detection and management of potential problems.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Support\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that this study did not receive any funding support related to research, copyright, or publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYidu Central Hospital Affiliated to Shandong Second Medical University, Qingzhou, Weifang, People\u0026rsquo;s Republic of China.\u003c/p\u003e\n\u003cp\u003eXianhai Lan\u003c/p\u003e\n\u003cp\u003eQingdao Eye Hospital Affiliated to Shandong First Medical University, Qingdao, People\u0026rsquo;s Republic of China.\u003c/p\u003e\n\u003cp\u003eHuiran Bai, Yingli Teng, Jiajun Sun, Xiaoming Wu\u003c/p\u003e\n\u003cp\u003eState Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University \u0026amp; Shandong Academy of Medical Sciences, Qingdao, People\u0026rsquo;s Republic of China.\u003c/p\u003e\n\u003cp\u003eHuiran Bai, Yingli Teng, Jiajun Sun, Xiaoming Wu\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXianhai Lan wrote the manuscript; Huiran Bai and Yingli Teng were responsible for data collection and literature review; Jiajun Sun and Xiaoming Wu contributed to the conception of the study and provided advice on the manusciript; all authors participated in manuscript revision and approved the final submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Xiaoming Wu.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Board of Qingdao Eye Hospital of Shandong First Medical University. The approval number is QEFT [2026] 18.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data relevant to the study are included in the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients in the study received informed consent before using their clinical data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSoon-Phaik Chee,Seng-Ei Ti,Nicole Shu-Wen Chan (2021) Management of the subluxated crystalline lens: A review. Clin Exp Ophthalmol 49(9):1091-1101. https://doi.org/10.1111/ceo.13975\u003c/li\u003e\n \u003cli\u003eLixia Luo,Mei Li,Yimin Zhong, et al(2013) Evaluation of secondary glaucoma associated with subluxated lens misdiagnosed as acute primary angle-closure glaucoma J Glaucoma. 22(4):307-310. https://doi.org/10.1097/ijg.0b013e318241b85b\u003c/li\u003e\n \u003cli\u003eJoanne F Shen,Sophie Deng,Kristin M Hammersmith, et al(2020) Intraocular Lens Implantation in the Absence of Zonular Support: An Outcomes and Safety Update: A Report by the American Academy of Ophthalmology. Ophthalmology 127(9):1234-1258. https://doi.org/10.1016/j.ophtha.2020.04.018\u003c/li\u003e\n \u003cli\u003ePeiquan Zhao,Zhongmin Ou,Qi Zhang, et al(2019) Adjustable Buckle-Slide Suture: A Novel Surgical Technique for Transscleral Fixation of Intraocular Lenses. Retina 39 Suppl 1:S24-S29. https://doi.org/10.1097/IAE.0000000000002207\u003c/li\u003e\n \u003cli\u003eFrancesco Barca,Tomaso Caporossi,Lorenzo de Angelis, et al(2020) Trans-scleral plugs fixated IOL: a new paradigm for sutureless scleral fixation. J Cataract Refract Surg 46(5):716-720. https://doi.org/10.1097/j.jcrs.0000000000000135\u003c/li\u003e\n \u003cli\u003eRenato Correia Barbosa,Rui Carvalho, et al(2023) Pediatric Microspherophakia Treatment With Scleral Fixated IOL Using a Z-suture Technique. Cureus 15(12):e50445. https://doi.org/10.7759/cureus.50445\u003c/li\u003e\n \u003cli\u003eZexu Chen, Wannan Jia, Tianhui Chen, et al(2024) Safety and efficacy of capsular tension ring and capsular hook implantation for managing ectopia lentis in Marfan syndrome: real-world study. J Cataract Refract Surg 50:698-706. https://doi.org/10.1097/j.jcrs.0000000000001434\u003c/li\u003e\n \u003cli\u003eHaiying Jin,Zhongmin Ou,Qi Zhang, et al(2019) Intrascleral Fixation of Implantable Polypropylene Capsular Hook(s): A New Sutureless Technique to Reposition Dislocated Intraocular Lens-Capsular Bag Complex. Retina 39 Suppl 1:S44-S49.https://doi.org/10.1097/IAE.0000000000001915\u003c/li\u003e\n \u003cli\u003eBrendan J Vote,Paris Tranos,Catey Bunce, et al(2006) Long-term outcome of combined pars plana vitrectomy and scleral fixated sutured posterior chamber intraocular lens implantation. Am J Ophthalmol 141(2):308-312. https://doi.org/10.1016/j.ajo.2005.09.012\u003c/li\u003e\n \u003cli\u003eShin Yamane,Shimpei Sato,Maiko Maruyama-Inoue, et al(2017) Flanged Intrascleral Intraocular Lens Fixation with Double-Needle Technique. Ophthalmology 124(8):1136-1142. https://doi.org/10.1016/j.ophtha.2017.03.036\u003c/li\u003e\n \u003cli\u003eLei Cai,Xiaoyan Han,Yongxiang Jiang, et al(2021) Three-Year Outcomes of Cionni-Modified Capsular Tension Ring Implantation in Children Under 8 Years Old With Ectopia Lentis. Am J Ophthalmol,2021,224:74-83. https://doi.org/ 10.1016/j.ajo.2020.11.011\u003c/li\u003e\n \u003cli\u003eAhmed Samir,Ayman M Abdelrahman Elsayed,Ahmed Alyan, et al(2020) Double-Flanged polypropylene Suture for Scleral Fixation of Cionni Capsule Tension Ring. Clin Ophthalmol 14:1055-1058. https://doi.org/10.2147/OPTH.S244751\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMalkit K Singh,Balamurali K Ambati,Alan S Crandall, et al(2017) New capsular tension segment with 2-point fixation for zonular weakness. J Cataract Refract Surg 43(5):590-592. https://doi.org/10.1016/j.jcrs.2017.04.021\u003c/li\u003e\n \u003cli\u003eYokrat Ton,Modi Naftali,Ruth Lapid-Gortzak, et al(2016) Management of subluxated capsular bag-fixated intraocular lenses using a capsular anchor. J Cataract Refract Surg 42(5):653-8. https://doi.org/10.1016/j.jcrs.2016.04.002\u003c/li\u003e\n \u003cli\u003eHaiying Jin,Qi Zhang,Peiquan Zhao, et al(2022) Intrascleral Fixation of Implantable Polypropylene Capsular Hook(s) to Reconstruct Capsular Support for Out-of-the-Bag Intraocular Lens Fixation in Vitrectomized Eyes. Retina 42(9):1816-1821. https://doi.org/10.1097/IAE.0000000000002554\u003c/li\u003e\n \u003cli\u003eShalhevet Goldfeather Ben-Zaken,Guy Kleinmann(2021) Results of using the AssiAnchor capsule device for subluxated crystalline lenses. Indian J Ophthalmol 69(12):3511-3514. https://doi.org/10.4103/ijo.IJO_576_21\u003c/li\u003e\n \u003cli\u003eHao Jiang, Wei Zhang, Yan-Hua Chu(2023) Technique of using Cionnimodified capsular tension ring in the management of severely traumatic lens subluxation. Int J Ophthalmol 16(7):1078-1083. https://doi.org/10.18240/ijo.2023.07.12\u003c/li\u003e\n \u003cli\u003eNing Li,Jie Dong,Jianfeng Wang, et al(2025) Treatment of traumatic subluxation of the crystalline lens with custom-made capsular hook. Front Med (Lausanne) 12:1569767. https://doi.org/10.3389/fmed.2025.1569767\u003c/li\u003e\n \u003cli\u003eJulia M Byrd,Marielle P Young,Wei Liu, et al(2018) Long-term outcomes for pediatric patients having transscleral fixation of the capsular bag with intraocular lens for ectopia lentis. J Cataract Refract Surg 44(5):603-609. https://doi.org/10.1016/j.jcrs.2018.02.016\u003c/li\u003e\n \u003cli\u003eNatalia S Anisimova,Lisa B Arbisser,Natalya F Shilova, et al(2021) Late dislocation of the capsular bag-intraocular lens-modified capsular tension ring complex after knotless transscleral suturing using 9-0 polypropylene. Digit J Ophthalmol 26(2):7-16. https://doi.org/10.5693/djo.02.2020.04.001\u003c/li\u003e\n \u003cli\u003eG\u0026uuml;ltekin Irgat Saadet,\u0026Ouml;zcura Fatih(2021) Effect of the capsular tension ring on refractive outcome after phacoemulsification. Rom J Ophthalmol 65(1):59-63. https://doi.org/10.22336/rjo.2021.11\u003c/li\u003e\n \u003cli\u003eTan Wang,Youxin Chen,Jun Lu, et al(2023) A novel surgical approach for fixation of a posterior chamber intraocular lens of Rayner 620 H with Gore-Tex suture. BMC phthalmol 23(1):20. https://doi.org/10.1186/s12886-022-02759-3\u003c/li\u003e\n \u003cli\u003eZexu Chen,Min Zhang,Michael Deng, et al(2021) Surgical outcomes of modified capsular tension ring and intraocular lens implantation in Marfan syndrome with ectopia lentis. Eur J Ophthalmol 2021:11206721211012868. https://doi.org/10.1177/11206721211012868\u003c/li\u003e\n \u003cli\u003eKentaro Iwasaki,Ryohei Komori,Shogo Arimura, et al(2024) Intraocular Pressure-Lowering Effect of Intraocular Lens Refixation in Patients with Elevated Intraocular Pressure Due to Intraocular Lens Subluxation. Medicina (Kaunas) 60(9). https://doi.org/10.3390/medicina60091440\u003c/li\u003e\n \u003cli\u003eLi Ning,Yinuo Wen,Lina Lan, et al(2022) Effect of Different Preoperative Intraocular Pressures on the Prognosis of Traumatic Cyclodialysis Cleft Associated with Lens Subluxation. Ophthalmol Ther 11(2):689-699. https://doi.org/10.1007/s40123-022-00468-0\u003c/li\u003e\n \u003cli\u003eCara E. Capitena Young, Leonard K. Seibold, Malik Y. Kahook(2020) Cataract surgery and intraocular pressure in glaucoma. Curr Opin Ophthalmol 31(1):15-22. https://doi.org/10.1097/ICU.0000000000000623\u003c/li\u003e\n \u003cli\u003eMojtaba Ghadamzadeh,Farshid Karimi,Somayeh Ghasemi Moghaddam, et al(2022) Anterior Chamber Angle Changes in Primary Angle-closure Glaucoma Following Phacoemulsification Versus Phacotrabeculectomy: A Prospective Randomized Clinical Trial. J Glaucoma 31(3):147-155. https://doi.org/10.1097/IJG.0000000000001977\u003c/li\u003e\n \u003cli\u003eJong Hwa Jun, Joon-Ho Kwak, Chang-Hyun Park, et al(2024) Impact of scleral tunnel length on the position of intraocular lenses in flanged intrascleral haptic fixation. J Cataract Refract Surg 50(8):840-846. https://doi.org/10.1097/j.jcrs.0000000000001460\u003c/li\u003e\n \u003cli\u003eCarl Mulholland,David Lockington((2020) Trainee experience with capsular tension rings in Scotland-the need for structured simulation exposure to surgical adjuncts. Eye (Lond) 34(9):1497-1498. https://doi.org/10.1038/s41433-020-0856-6\u003c/li\u003e\n \u003cli\u003eCharles H Weber,Robert J Cionni(2015) All about capsular tension rings. Curr Opin Ophthalmol 26(1):10-5. https://doi.org/10.1097/ICU.0000000000000118\u003c/li\u003e\n \u003cli\u003eCho YK, Kim MS(2023) Stability of neodymium:YAG laser posterior capsulotomy in eyes with capsular tension rings. Int J Ophthalmol 16(6):891-896. https://doi.org/10.18240/ijo.2023.06.09\u003c/li\u003e\n \u003cli\u003eSadullah Keles,Baki Kartal,Aytekin Apil, et al(2014) Nd: YAG laser posterior capsulotomy rates in myopic eyes after implantation of capsular tension ring. Med Sci Monit 20:1469-73. https://doi.org/10.12659/MSM.890767\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: Preoperative Baseline Characteristics of Patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eClinical Features\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eValues\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e20 cases (68.97%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e9 cases (31.03%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eAverage age (years old)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e62.03\u0026plusmn;10.38\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eAverage dislocation range \u0026nbsp;(\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e141.72\u0026plusmn;38.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eCauses of lens subluxation\u003c/p\u003e\n \u003cp\u003eOcular trauma\u003c/p\u003e\n \u003cp\u003eComplicated cataract after glaucoma surgery\u003c/p\u003e\n \u003cp\u003eComplicated cataract after vitrectomy\u003c/p\u003e\n \u003cp\u003eIntraoperative discovery of lens subluxation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 cases\u003c/p\u003e\n \u003cp\u003e11 cases\u003c/p\u003e\n \u003cp\u003e4 cases\u003c/p\u003e\n \u003cp\u003e4 cases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2: Postoperative Outcomes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eVisual acuity (logMAR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003ePreoperative 1.17\u0026plusmn;0.64 \u0026nbsp;Postoperative 0.36\u0026plusmn;0.48 \u0026nbsp;t=-7.43, P=0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eIntraocular pressure (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003ePreoperative 18.8\u0026plusmn;9.08 \u0026nbsp;Postoperative 14.61\u0026plusmn;3.65 \u0026nbsp;t=2.42, P=0.023\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003ePostoperative average residual refraction (D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e0.42\u0026plusmn;0.39 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 568px;\"\u003e\n \u003cp\u003ePostoperative complications\u003c/p\u003e\n \u003cp\u003eOcular hypertension \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;1 case (3.4%) \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVitreous hernia \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;1 case (3.4%) \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePosterior capsular opacification \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 1 case (3.4%) \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDislocation of IOL-tension ring-capsular bag complex \u0026nbsp; \u0026nbsp;2 cases (6.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"lens subluxation, Capsular tension ring, Ciliary sulcus Suture Fixation, IOL-CTR-Capsular Bag Complex","lastPublishedDoi":"10.21203/rs.3.rs-9241947/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9241947/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eTo explore the long-term therapeutic effect of capsular tension ring (CTR) suture fixation in patients with lens subluxation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA retrospective analysis was conducted on 29 patients (29 eyes) who underwent phacoemulsification + intraocular lens (IOL) implantation + CTR suture fixation for lens subluxation at Qingdao Eye Hospital Affiliated to Shandong First Medical University from October 2019 to July 2024. The patients' postoperative best-corrected visual acuity (BCVA), refraction, intraocular pressure (IOP), complications, and IOL position were observed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e All patients were followed up for at least 12 months (range: 12-48 months). Postoperative BCVA was significantly improved compared with preoperative values (t=-7.43, P=0). The average postoperative residual refractive error was 0.42±0.39D (range: 0-1.25 D). Postoperative IOP was significantly lower than preoperative IOP (t=2.42, P=0.023). Postoperatively, 2 eyes developed dislocation of the IOL-CTR-capsular bag complex and underwent complex suspension surgery; 1 eye had transient high IOP; 1 eye had a small amount of nasal vitreous hernia; and 1 eye developed posterior capsular opacification (PCO) during follow-up, which was treated with YAG posterior capsulotomy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eCTR suture fixation can effectively improve visual acuity, maintain stable IOP, and has a low complication rate in patients with lens subluxation. It provides a safe and effective treatment method for lens subluxation.\u003c/p\u003e","manuscriptTitle":"Efficacy Analysis of Capsular Tension Ring Ciliary Sulcus Suture Fixation for Lens Subluxation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-29 10:15:27","doi":"10.21203/rs.3.rs-9241947/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-15T11:34:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-13T14:30:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T15:49:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"300282523702001365860293065894710290566","date":"2026-05-03T10:00:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T03:15:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165054388292578795037266366818705122662","date":"2026-04-29T23:48:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259540115289088596496277136741707432927","date":"2026-04-28T10:20:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-21T09:48:20+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-31T09:49:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-31T06:51:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-31T06:51:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2026-03-27T07:50:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"34bcc161-cd59-4568-b3f4-c1f8a4ce31a7","owner":[],"postedDate":"April 29th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-15T11:34:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-13T14:30:22+00:00","index":64,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T15:49:02+00:00","index":61,"fulltext":""},{"type":"reviewerAgreed","content":"300282523702001365860293065894710290566","date":"2026-05-03T10:00:55+00:00","index":60,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T03:15:25+00:00","index":59,"fulltext":""},{"type":"reviewerAgreed","content":"165054388292578795037266366818705122662","date":"2026-04-29T23:48:06+00:00","index":58,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T11:40:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-29 10:15:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9241947","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9241947","identity":"rs-9241947","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}