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Needle-free method can be used to suture IOL to sclera
This technique is an option for IOL implantation in an eye without capsular support.
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 Thomas John |
In anatomically compromised eyes with violated posterior lens capsule, the choice of placement of an IOL includes the anterior chamber, iris-fixation, and scleral-fixation with transscleral sutures or without sutures by tucking the haptics of a posterior chamber IOL into the scleral pockets.
While anterior chamber IOL placement may be a relatively easy surgical technique, it is usually contraindicated in the presence of extensive anterior chamber angle and iris damage, peripheral anterior synechiae, glaucoma, shallow anterior chamber and low endothelial cell count. Alternatively, the sole requirement for iris-fixation of a posterior chamber IOL is the presence of sufficient iris tissue to support the IOL. However, such IOL placement has raised concerns over IOL-iris interaction that may result in cystoid macular edema, secondary iritis and potential deleterious effects of iris pigment dispersion.
Moving more posterior within the eye, the choice may be to use scleral-fixation, which has an advantage in that it may be performed in the presence of significant anterior chamber structural abnormalities and is less damaging to the corneal endothelium by virtue of its location as compared with a more anterior location within the eye. It is important to note that a review of the literature by Wagoner and colleagues suggests that all three IOL location options are safe and effective choices in the absence of lens capsular support for IOL implantation. Hence, surgeon comfort and experience will dictate the site of IOL placement in anatomically compromised eyes.
In this column, Dr. Fass describes his needle-free method of suturing a posterior chamber IOL to the sclera in the absence of capsular support.
Thomas John, MD
OSN Surgical Maneuvers Editor
 Oren N. Fass |
This technique borrows from the work of Richard S. Hoffman, MD, and begins with placement of two 300-µm-deep limbal incisions that are 180° apart. A Mendez degree gauge is used to stabilize the globe and to provide a running track for a standard LRI adjustable diamond blade, set at 300 µm. Two areas are picked, 180° apart (eg, 90° and 270°), to place the corneal-based pockets. Avoid the long posterior ciliary arteries that run along the 180° meridian. Once two locations separated by 180° are chosen, the LRI knife is balanced along the inner diameter of the degree gauge so that it can be moved in a circular fashion, using the degree gauge as a guiding track. An approximate 2-mm incision at 300 µm is placed at, for example, 90° and 270°. Often the tunnels are placed slightly more obliquely, making one partially nasal and one partially temporal. Each incision lip is gently grasped with forceps, and a mini crescent blade is used to create a tunnel at the level of the 300-µm cut with a gentle sweeping motion away from the limbus, until approximately 2 mm from the limbus at each tunnel site (Figure 1).
 Figure 1. A mini crescent blade is used to tunnel back from the limbus in order to make a limbus-based scleral tunnel. |
 Figure 2. Calipers-based measurement of 1.25 mm is made over the tunnel, and two scleral entry sites are pre-marked about 1 mm to 2 mm apart. Images: Fass ON |
 Figure 3. A schematic diagram of the eye depicts the relationship of the limbal wounds, the sulcus wounds, the main wound and the preparation of the Prolene for insertion into the eye. |
 Figure 4. The Prolene suture is passed from its insertion of the Kuglen hook to micro-forceps and withdrawn out of the main wound. |
Caliper measurement of 1.25 mm is performed, and ink demarcations are placed over each tunnel in two locations, approximately 1 mm to 2 mm apart from each other and 1.25 mm away from the limbus (Figure 2). Next, an anterior chamber maintainer is placed through a paracentesis wound. Immediate control over IOP will be useful if there is any evidence of hemorrhage from manipulation or entry into the sulcus. The sulcus is entered through the four pre-marked sites with a 1-mm diamond blade. A main incision of 3 mm to 3.5 mm at the clear corneal limbus is created. This is the appropriate stage in the surgery to clean up any capsular bag remnants, as well as anterior vitrectomy, if needed. A Kuglen hook is used to push a 9-0 Prolene suture through the inferior nasal sulcus incision into the anterior chamber (Figure 3) where it is retrieved by micro-forceps and withdrawn through the main wound (Figure 4). During this step, the eye may be inflated with the use of viscoelastic, or the anterior chamber maintainer may be used to make sure the eye does not lose volume as the wounds are manipulated. Additionally, careful attention should be paid to any hemorrhage from the sulcus wound. Short periods of raised IOP via the anterior chamber maintainer will tamponade any bleeding.
The Prolene, which has now been passed from outside the eye, through the inferior sulcus incision into the eye and back out through a limbal main incision, is now wound through the haptics of the Akreos IOL (Bausch + Lomb) and then re-inserted into the eye through the main incision. A Kuglen hook inserted via the superior nasal sulcus incision retrieves the Prolene from the eye, pulling the suture outside the eye. This identical process is performed at the location of the second corneal-based scleral tunnel.
 Figure 5. The lens will unfold spontaneously once inserted in the eye. |
 Figure 6a. Centration of the lens is monitored carefully during tying of the Prolene sutures. |
 Figure 6b. Postoperative week 1 photo shows a well-centered IOL. |
 Figure 6c. A healthy, non-manipulated conjunctiva and quiet eye with a well-centered IOL. |
Once all sutures are in place for the four-point-fixation, the Akreos IOL can be folded and introduced into the eye with the anterior chamber maintainer (Figure 5). With the lens in place within the eye, the main incision is sutured with 10-0 nylon. From each sulcus incision a segment of Prolene exits the eye. In order to tie the Prolene so that it is appropriately buried in the tunnel, each of these segments must be re-oriented so that it exits via the limbal opening of the tunnel. This is accomplished by inserting a Sinskey hook into the tunnel twice to capture each Prolene segment and pull it out of the limbal opening of the wound. The Prolene suture is tied with a view on IOL centration (Figures 6a, 6b and 6c). Depending on the case, vitrectomy, Miochol-E (Bausch + Lomb) and intraocular steroids may be used to be sure that there is no vitreous coming into the anterior chamber around the IOL. All wound sites must be checked for leakage and sutured or hydrated, as needed.
References:
- Fass ON, Herman WK. Four-point suture scleral fixation of a hydrophilic acrylic IOL in aphakic eyes with insufficient capsule support. J Cataract Refract Surg. 2010;36(6):991-996.
- Fass ON, Herman WK. Needle free, 4-point fixated, small-incision sutured IOL. Film presented at: ASCRS Symposium on Cataract, IOL and Refractive Surgery; April 2010; Boston.
- Fass ON, Herman WK. Sutured intraocular lens placement in aphakic post-vitrectomy eyes via small-incision surgery. J Cataract Refract Surg. 2009;35(9):1492-1497.
- Hoffman RS. Scleral fixation without conjunctival dissection. Film presented at: ASCRS Symposium on Cataract, IOL and Refractive Surgery; April 2008; Chicago.
- Por YM, Lavin MJ. Techniques of intraocular lens suspension in the absence of capsular/zonular support. Surv Ophthalmol. 2005;50(5):429-462.
- Wagoner MD, Cox TA, Ariyasu RG, Jacobs DS, Karp CL; American Academy of Ophthalmology. Intraocular lens implantation in the absence of capsular support: a report by the American Academy of Ophthalmology. Ophthalmology. 2003;110(4):840-859.
- Thomas John, MD, is a clinical associate professor at Loyola University at Chicago and is in private practice in Oak Brook, Tinley Park and Oak Lawn, Ill. He can be reached at 708-429-2223; fax: 708-429-2226; e-mail: tjcornea@gmail.com.
- Oren N. Fass, MD, can be reached at orenfass@gmail.com.
- Disclosures: Drs. Fass and John have no financial interests in the products or companies mentioned in this article.
