Intrascleral posterior chamber IOL fixation good alternative, will not likely change treatment paradigm

Issue: April 2012

ByH. Burkhard Dick, MD

H. Burkhard Dick

I think intrascleral posterior chamber IOL fixation is an important topic to discuss. We are talking about eyes that have already lost their lens or did not receive a lens. These are challenging eyes. In the past, we saw a lot of these eyes, but it is not that often that we see these cases that have no lens now. These are usually traumatic cataracts, where the eye had to be closed first and lost the lens, and then we recognize that there is still some functionality.

The discussion starts with whether to treat these patients with contact lenses or to undergo intraocular surgery, reconstruction surgery, with IOL implantation. There are both pros and cons for intrascleral posterior chamber IOL fixation.

Cons

I am not sure if it offers long-term stability because, from what I understand, we do not have long-term follow-up with these eyes. Scharioth mentioned about 7 months, which is not that long because we are talking about an IOL fixation that is expected to last decades. In addition, I have not yet seen a paper on decentration and long-term stability.

The number of surgeons using this technology is limited. The reason is quite simple: It is a complex surgery. A pars plana vitrectomy approach is needed, which means that excessive vitrectomy is necessary in these eyes because once the haptic comes into contact with the vitreous strands, this might result in with a disaster, such as retinal detachment or persistent cystoid macular edema.

You have to introduce the forceps, which means you need specific instruments for this rare surgery, and it is an invasive surgery.

We also have to take into account additional costs — for instance, the fibrin glue. You cannot, at least in Europe, use separate fibrin glue for several patients, for instance. That means you will use one single fibrin glue, which is most often a dual component system and you just change the needles.

This needs to be done under general anesthesia instead of local anesthesia, as not every patient is suitable to go under general anesthesia — for instance, older patients sometimes have comorbidities.

So this technique means that preoperatively, the surgeon has to see if the sclera is sufficient enough to implant the haptics. This can lead to many issues related to patients who are not good candidates for other reasons, including other medication use, such as anticoagulants. Some eyes are not suitable because, for example, they have scleromalacia or insufficient sclera tissue, especially the high myopes, which have very thin sclera.

And it is only possible for use with the three-piece IOL, limiting lens options.

Pros

A major pro of the technique is, of course, we do not have sutures. So there will be no suture issues in terms of the long-lasting rigidity of the sutures. I fully agree that it is definitely not glued, as mentioned in the cover story. It may look like it is glued, and it sounds attractive that the IOL is glued, but it is not. You are gluing only the sclera and hoping that there will be some kind of restructuring.

I do think that the approach is a good alternative. It is a good technique in the hands of experienced surgeons. It has great potential for strengthening and enriching our surgical armamentarium, but I am sure it will not replace other methods of IOL fixation because many experienced surgeons already have experience with other technologies and feel comfortable with them, and there is no need for these rare cases, which are often emergency cases, to change the entire strategy. The surgeons who are using this technology and have evaluated it to a higher level are satisfied, which is most important, but it will not be a game changer.

For more information:

H. Burkhard Dick, MD, is an OSN Europe Edition Associate Editor. He can be reached at Universitäts-Augenklinik, Bochum, In der Schornau 23-25, 44892 Bochum, Germany; +49-234-299-3100; fax: +49-234-299-3109; email: burkhard.dick@kk-bochum.de.

Disclosure: Dr. Dick has no relevant financial disclosures.