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Simple technique creates scleral flaps in sulcus/scleral IOLs
Changing the direction and shape of the flaps simplifies procedures and shortens operating time.
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It is not a rare occurrence that we come across an aphakic eye in need of secondary IOL implantation, or another situation where a simple cataract operation is complicated by an extensive capsular rupture rendering the bag unsuitable for even a ciliary sulcus-supported IOL. The decision here lies with the surgeon whether to use an anterior chamber IOL or to suture a posterior chamber IOL into the sulcus through the sclera. Either course of action has merits and drawbacks. For several years, we have taken the route of suturing IOLs in the sulcus and during this period have devised some modifications to our technique.
When a secondary IOL implantation is required, we simply start with an imaginary line going from 2 o’clock to 8 o’clock, through the center of the pupil (figure 1). We select this axis to avoid the horizontal anterior ciliary arteries. Alternatively, a corneal marker can be used for more accuracy. The conjunctiva over the desired site is retracted and diathermy applied (figure 2).
Technique
Here is where we have simplified and modified the technique. Traditionally surgeons have used limbal based scleral flaps (figure 3). One problem with these was the awkward angle for the 8 o’clock flap. It was never easy to keep the thickness of the flap consistent, sometimes even resulting in buttonholes. Another disadvantage was that it was time consuming. We simply changed the direction of the flaps so that the base is always inferior (figure 4). This was less time consuming but it was still difficult to form the two corners of the rectangular flap at 8 o’clock, as quite frequently the area was slanting away from us because of the structure of the eye.
Our final modification in simplifying these flaps was to make them triangular with the apex pointing more or less superiorly ( figure 5). The area of this triangle is centered on the spot where we planned to bring out the suture, usually 1 to 1.5 mm from the limbus.
The remainder of the procedure is again the surgeon’s own choice. Traditionally we were taught to perform railroading of the needles to bring out the suture, but now, after making the incision superiorly and passing our usual 10-0 polypropylene suture through the holes in the IOL haptics, we can pass the curved needle directly from the incision toward the desired site (figure 6). We have found this technique simple and quick.
Another simplified step is not to cut the suture when tying the knot, but to take another bite through the sclera and to grasp the double suture at a stretch and tie around it (figure 7).
The advantage of this procedure is realized at the time of a complicated capsular rupture. We can implant a primary IOL behind the iris under the same local anesthesia without spending too much time by simply closing the superior wound and making the flaps, which are very easy to make.
 Marking the site for the flaps. | |
 Retracting the conjunctiva and cauterizing the sclera. |  Traditional limbal based rectangular flaps. |
 First modification to inferior based flaps |  Final modification to inferior based triangular flaps. |
 Direct insertion of the needle through the incision to the flap site. |  Tying the knot without cutting the suture. |
For Your Information:
- Khurram A. Mirza, FRCS, is a registrar in ophthalmology at University College Hospital, Galway, Ireland. He can be reached at 118 Rosard, Cappagh Road, Barna, Galway, Ireland; (353) 91-582399; fax: (353) 86-58113324; e-mail; khurram@indigo.ie.
- Frank Kinsella, FRCS, is a consultant ophthalmologist at University College Hospital, Galway, Ireland; (353) 91-524222; fax: (353) 91-526588.