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When is it advisable to suture IOL haptics, and when should haptics be tucked or glued into a scleral tunnel?
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Suturing minimizes trauma, preserves cosmesis
 Mark Packer |
The haptics should always be sutured. Richard Hoffman, MD, has developed a stunning technique that allows suture fixation without conjunctival dissection. One initiates the procedure with two opposite peripheral corneal incisions as if one were performing limbal relaxing incisions (in fact, the incisions can often be aligned on the steep axis to correct astigmatism as a useful byproduct). The posterior lip of the incision is then grasped with fine, toothed forceps, and intrascleral dissection is performed (I like to use a micro crescent knife). Once two generous pockets are constructed, the sutures are passed either ab interno through the ciliary sulcus, scleral pocket and conjunctiva, or ab externo in the reverse order and mated with a needle in the posterior chamber. I like to mark the posterior limit of the pockets on the conjunctiva with a marking pen so I know where to pass the sutures. The sutures are then drawn out of the pocket via the corneal incisions with a small hook and tied down so that the knots are buried in the pockets.
This procedure is equally appropriate for secondary IOL implantation in an eye without adequate capsular support or for suture fixation of a subluxated IOL or dislocated IOL-capsular bag complex (as we see in late pseudoexfoliation cases). The elimination of both conjunctival dissection and construction of scleral flaps minimizes trauma to the eye. Except for occasional subconjunctival hemorrhage, these eyes can look as clear and quiet as a standard phaco on postop day 1.
Mark Packer, MD, is a cataract surgeon practicing at Drs. Fine, Hoffman, Packer & Sims, in Eugene, Ore. Disclosure: Dr. Packer has no relevant financial disclosures.
Sutureless fixation safe, easy and predictable
 Som Prasad |
Gábor Scharioth, MD, first described the sutureless intrascleral haptic fixation technique. Then, Amar Agarwal popularized the glued IOL, which is especially useful if one is using larger sclerostomies and instruments such as 20 gauge. He then modified his technique to include tucking a short part of the haptic into a scleral tunnel to stabilize the IOL and to prevent any tilt and decentration. Special forceps are now available from DORC to facilitate the maneuver to tuck the haptic into the scleral tunnel.
Except for scleromalacia, there are no particular contraindications to this technique, which allows the use of standard three-piece IOLs. This means that special IOLs do not have to be ordered, improving logistics. Because the haptics are not dependent on scleral sutures for fixation, there is no risk of late suture breakage, which is a major concern with scleral suture fixation of IOLs. There is minimal uveal contact, therefore minimizing long-term concerns. Reported outcomes are excellent with minimal complications. These techniques are increasingly being adopted by many surgeons and are easy to learn and reproducible for an accomplished anterior segment surgeon.
Som Prasad, MS, FRCSEd, FRCOphth, FACS, is consultant ophthalmologist, Spire Murrayfield Hospital, Wirral University Teaching Hospital NHS Foundation Trust, Wirral, U.K. Disclosure: Dr. Prasad has no relevant financial disclosures.