Sutureless intrascleral posterior chamber IOL fixation offers stability, centration

As innovations in IOL design and optics continue to improve visual and refractive outcomes in cataract surgery, ongoing advances in surgical technique enable specialists to further maximize outcomes and manage challenging cases.

Posterior chamber IOLs are sutured in back of the iris or the capsular bag. However, suturing may not be feasible in cases with insufficient capsule, trauma, aniridia, pseudoexfoliation, lens subluxation or loss of zonular integrity.

In recent years, evolving techniques have enabled surgeons to perform intrascleral haptic fixation, with or without sutures. Experts say the technique and its variants improve the long-term stability of posterior chamber IOLs.

Sutureless intrascleral haptic fixation of a three-piece posterior chamber IOL in the ciliary sulcus in eyes with no capsule support was first reported by Scharioth and colleagues in the Journal of Cataract and Refractive Surgery in 2007.

The original sutureless technique involved tucking the IOL haptics into scleral tunnels parallel to the limbus, with no suturing or gluing.

Amar Agarwal, MS, FRCS, FRCOphth, and Soosan Jacob, MS, FRCS, pioneered the handshake technique, which allows surgeons to safely transfer the lens haptic from hand to hand in closed-globe surgery. Image: Agarawal A

Also in 2007, Amar Agarwal, MS, FRCS, FRCOphth, OSN APAO Edition Board Member, and Soosan Jacob, MS, FRCS, introduced a key innovation to sutureless intrascleral posterior chamber IOL implantation: the use of fibrin glue to secure the scleral flaps under which the lens haptics are tucked.

Drs. Agarwal and Jacob also pioneered the handshake technique, in which the surgeon transfers the lens haptics from one hand to the other to safely manipulate them in a closed-globe surgical setting.

“The Scharioth-Agarwal technique has made sulcus fixation of [posterior chamber] IOLs a straightforward and safe technique,” Rupert Menapace, MD, OSN Europe Edition Board Member, said. “The technique is especially valuable for young patients, as it excludes suture degradation or cheese-wiring over the decades.”

Dr. Agarwal said there is a high degree of stability afforded by gluing as opposed to suturing.

“One main reason for good results in the glued IOL is that there is no pseudophakodonesis in such cases, unlike a sutured IOL, which moves like a hammock,” Dr. Agarwal said. “On high-speed videography … one can see that the glued [posterior chamber] IOL does not move.”

Jorge L. Alió, MD, PhD, OSN Europe Edition Board Member, was somewhat less optimistic about sutureless intrascleral posterior chamber IOL fixation.

Jorge L. Alió

“Intrascleral posterior chamber IOL fixation might have a role in pseudophakic secondary implantations in the absence of capsular support,” Dr. Alió said. “However, still studies have failed to demonstrate how stable it is in the long term and whether tilt or decentration happened with this technique.”

In addition, the technique is invasive, requires a pars plana vitrectomy and 19- or 20-gauge forceps to grasp the haptics, and leaves the lens trapped in the sclera.

“The term ‘glued IOL’ is, in my opinion, wrong, as fibrin glue does not have the tensile strength to keep fixed an IOL haptic but can only attach somehow the scleral flap for about less than 24 hours,” Dr. Alió said.

Dr. Menapace said that the choice of technique hinges on surgeon experience and skill.

“It is important to know that there is no evidence in support of the true superiority of scleral, iris or even chamber angle fixation of [posterior chamber] or [anterior chamber] IOLs,” Dr. Menapace said. “In a given situation, the surgeon’s decision on the preferred option should be based on specific circumstances but also, and most importantly, on his personal expertise. Using an approach the surgeon is not familiar with will inherently yield suboptimal results.”

John A. Hovanesian, MD, FACS, OSN U.S. Edition Cornea/External Disease Board Member, described sutureless intrascleral IOL fixation as safer and easier than suturing a lens into the scleral flap.

“There are several advantages to this technique,” Dr. Hovanesian said. “First, it doesn’t involve sutures, so the risk of having sutures that come loose or are inadvertently cut goes away. Another advantage there is that scleral fixation with sutures is a somewhat clumsy procedure where there are long strands of thread that are in the operative field. It’s a challenging and frustrating procedure for surgeons to perform in many cases, whereas this technique is quite elegant.”

Dr. Agarwal noted that the technique has been performed in children with good results.

Indications and lens types

Indications for sutureless posterior chamber IOL fixation have expanded exponentially, Dr. Menapace said.

“The necessity of alternative IOL fixation in eyes with lacking capsular support is still current,” Dr. Menapace said. “The indication scenario, however, has changed. Early on, planned aphakia or complicated surgeries obviating primary lens implantation were predominant indications. More recently, delayed secondary subluxation of the lens-bag complex in conjunction with pseudoexfoliation syndrome has increasingly gained importance.”

Rupert Menapace

Any three-piece IOL is suitable for intrascleral fixation, Ike K. Ahmed, MD, FRCSC, OSN U.S. Edition Glaucoma Board Member, said. He said he prefers foldable three-piece acrylic or silicone lenses and advises against using one-piece foldable acrylic lenses or hydrophobic lenses.

Rigid one-piece PMMA lenses are not amenable to sutureless fixation, Dr. Ahmed said.

“I have tried this with a rigid PMMA lens, and I don’t advise it,” he said. “I think it’s difficult to implant a PMMA lens, and it’s certainly a risk that I’ve seen haptics break with the one-piece PMMA lenses. A three-piece PMMA lens might be amenable, but a one-piece PMMA would be a no-go, so I generally avoid it in that situation. I would take the PMMA lens out of the eye and then exchange it for a three-piece acrylic lens and fixate it intrasclerally.”

Dr. Alió said that the ideal lens is a three-piece implant with PMMA haptics or non-hydrogel haptics.

“My favorite is the Alcon MS60, as it is a 6-mm lens with very firm haptics and a very solid structure. I do not use multifocal IOLs for these purposes as we cannot guarantee the stability of the lens in either position,” Dr. Alió said.

The glued IOL technique cannot be done with a single-piece foldable IOL because the haptics are not firm to tuck and glue, Dr. Agarwal said.

Basic technique

The basic glued fixation technique, as described by Dr. Agarwal in his Complications Consult columns in Ocular Surgery News, involves creating two 2.5 mm × 2.5 mm lamellar scleral flaps placed 180· apart. Sclerotomies are made under the flaps, 1 mm to 1.5 mm from the limbus. A pars plana vitrectomy is performed with a 23-gauge vitrector introduced through the sclerotomy or an anterior vitrector directed through a corneal paracentesis.

A corneoscleral incision is created to introduce the IOL and the leading haptic of the IOL. After the IOL is injected into the eye, the leading haptic and trailing haptic are brought to the exterior through the sclerotomies using 23-gauge MicroSurgical Technology (MST) forceps. The haptics are fixed into scleral pockets created at the edge of the flap with a 26-gauge needle. The scleral flaps are held down with fibrin glue.

Dr. Agarwal described the benefits of gluing the haptics, conjunctiva and corneal incision.

“The glue seals the haptics to the sclera,” he said. “The glue further helps in preventing any exposure of the vitreous to the outside as all are sealed with the glue. This prevents any chance of endophthalmitis. A third advantage of the glue is that the glue seals the sclerotomy created with the scleral flap so that there is no trabeculectomy sort of opening left. Finally, the same glue is used to seal the conjunctiva and the clear corneal incisions.”

Dr. Ahmed said it is important to use the proper instrumentation when performing glued IOL fixation.

“Micro-instruments like micro-forceps really make these techniques much more manageable,” Dr. Ahmed said.

Despite the name of the technique, glue alone does not maintain long-term IOL stability, Dr. Hovanesian said.

“To describe this procedure as a glued IOL doesn’t fully characterize the stability of the lens fixation,” he said. “It implies that the glue and nothing else is holding the lens in place. [Fibrin glue] only retains adhesion for a week or so. What’s really securing the lens in this procedure is a scleral pocket that the tip of the IOL haptic is tucked into. The glue holds down the partial thickness scleral flap that covers the entrance to this tunnel externally.”

As described by Drs. Agarwal and Jacob in OSN, the handshake technique involves the surgeon, using two MST forceps, holding the haptic with one set of forceps and directing another set of forceps through the opposite sclerectomy or side port. Holding the haptic at its tip before externalizing it prevents it from snagging on the sclerotomy.

Some variations can be used. For transscleral suturing, Dr. Menapace advised an ab externo approach. He cited a cadaver study in which Duffey and colleagues found the ab externo approach highly accurate and predictable.

“Many surgeons prefer an ab interno approach, guiding the needle behind the iris into where they feel the sulcus should be located. The sulcus, however, exhibits a great variability in location and shape,” he said. “Often enough a true sulcus is lacking at all.”

Potential drawbacks

Sutureless intrascleral haptic fixation has potential drawbacks, such as poor preoperative planning and insufficient scleral tissue, Dr. Ahmed said.

“Some of the pitfalls with these techniques are inadequate planning, particularly when it comes to the incisions and where you make the incisions and where you make your scleral grooves. So, it’s always important to plan where the haptic will be fixated and make your incisions accordingly, No. 1,” Dr. Ahmed said. “No. 2, the sclera needs to be of reasonable thickness and reasonable health.”

Surgeons should also be wary of blebs and be sure to perform a vitrectomy as part of the intrascleral fixation procedure, Dr. Ahmed said.

“If there’s a pre-existing trabeculectomy bleb, I would avoid it because that could potentially cause bleb failure by manipulating the conjunctiva,” he said. “Vitrectomy is important. If the vitrectomy has not been adequately performed, there’s a high risk of vitreous incarceration with the technique.”

Measurement of the white-to-white diameter of the cornea is also critical. If the white-to-white measurement is 12 mm and a foldable IOL is 13 mm, there would not be enough externalized haptic to tuck and glue. A vertical glued IOL is a suitable substitute, because the vertical white-to-white distance is shorter than the horizontal white-to-white distance. Scleral flaps would be created at the 12 o’clock and 6 o’clock positions in such a case, Dr. Agarwal said.

In addition, glued posterior chamber IOLs may solve the problem of IOL subluxation in cases of pseudoexfoliation, Dr. Agarwal said.

“Today’s literature shows lots of patients who were operated years back for cataract and had pseudoexfoliation today have those IOLs subluxated, even some with endocapsular rings,” he said. “With glued IOLs this will not happen. Pseudoexfoliation is a progressive condition. With time the lenses will subluxate more. What we do is remove the cataract totally and put in the glued IOL. So, the basic problem of pseudoexfoliation is never present, and for life the IOL will remain sturdy and fixed.”

Alternatives to sutureless intrascleral fixation include iris suture fixation of the IOL, which enables positioning of the lens in the frontal plane because it is attached to the iris, an iris clip IOL such as the Artisan (Ophtec) and anterior chamber IOLs, Dr. Alió said.

“The advantage of anterior iris fixation is the visual control of the fixation areas both intra- and postoperatively,” Dr. Menapace said.

However, anterior fixation poses potential risks, he said.

“These techniques also have their downsides. Anterior fixation may stress the endothelium, though evidence is so far lacking. With posterior fixation, the amount of tissue enclavated is difficult to control and disenclavation for repositioning traumatic,” Dr. Menapace said.

Limitations of sutureless fixation include thin sclera and miotic pupil, which typically coincides with pseudoexfoliation syndrome and delayed dislocation of the lens-capsule complex, he said.

A look at the literature

In their pioneering 2007 study, Scharioth and colleagues reported that no complications occurred during 3-month follow-up of the first five cases of sutureless fixation.

In a subsequent 2010 study, also published in the Journal of Cataract and Refractive Surgery, Scharioth and colleagues reported outcomes in 63 patients followed for a mean 6.8 months. Results showed that two posterior chamber IOLs were decentered and 61 IOLs were stable and well-centered. No cases of recurrent dislocation, endophthalmitis, retinal detachment or glaucoma were identified.

Results also showed a statistically significant improvement in corrected distance visual acuity (P = .005).

In a study published in the Journal of Cataract and Refractive Surgery by McAllister and Hirst, sutured scleral IOL fixation yielded positive visual outcomes but resulted in various complications.

The study included 82 eyes of 72 patients who underwent surgery between 1993 and 2008. Mean patient age at the time of surgery was 62 years. Mean follow-up was 83.3 months.

Results showed a statistically significant mean improvement in Snellen corrected distance visual acuity of 1.6 lines (P = .001). Corrected distance visual acuity was improved or unchanged in 59 eyes and diminished in 23 eyes.

The most common postoperative complication was ocular hypertension, identified in 25 eyes; 11 of those 25 eyes had a history of glaucoma. In addition, suture breakage occurred in five eyes. In total, 44 eyes had at least one complication; 36.4% of complications were reported in the first week after surgery, and 63.6% of complications were reported after 1 week.

Subsequent surgery was required in 13 eyes (15.8%), the authors reported.

The authors identified suture rupture as a potential risk for patients younger than 40 years. – by Matt Hasson

References:

Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008;34(9):1433-1438.

Duffey RJ, Holland EJ, Agapitos PJ, Lindstrom RL. Anatomic study of transsclerally sutured intraocular lens implantation. Am J Ophthalmol. 1989;108(3):300-309.

Jacob S, Kumar DA, Agarwal A. Glued IOL procedure evolves with use of handshake technique. Ocular Surgery News. Feb. 10, 2011;29(3):32.

Kumar DA, Agarwal A, Jacob S, et al. Sutureless scleral-fixated posterior chamber intraocular lens. J Cataract Refract Surg. 2011;37(11):2089-2090.

Kumar DA, Agarwal A, Prakash G, Jacob S, Saravanan Y, Agarwal A. Glued posterior chamber IOL in eyes with deficient capsular support: a retrospective analysis of 1-year postoperative outcomes. Eye (Lond). 2010;24(7):1143-1148.

McAllister AS, Hirst LW. Visual outcomes and complications of scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg. 2011;37(7):1263-1269.

Scharioth GB, Pavlidis MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg. 2007;33(1):1851-1854.

Scharioth GB, Prasad S, Georgalas I, Tataru C, Pavlidis MM. Intermediate results of sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg. 2010;36(2):254-259.

For more information:

Amar Agarwal, MS, FRCS, FRCOphth, can be reached at Dr. Agarwal’s Eye Hospital, 19 Cathedral Road, Chennai 600 086, India; fax: +91-44-28115871; email: dragarwal@vsnl.com.

Ike K. Ahmed, MD, FRCSC, can be reached at Credit Valley EyeCare, 3200 Erin Mills Parkway, Unit 1, Mississauga, Ontario L5L 1W8, Canada; +1-905-820-6789; fax: +1-905-820-0111; email: ike.ahmed@utoronto.ca.

Jorge L. Alió, MD, PhD, can be reached at Vissum Institute, Avenida de Denia, s/n, 03016 Alicante, Spain; +34-965150025; fax: +34-965151501; email: jlalio@vissum.com.

John A. Hovanesian, MD, FACS, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653, U.S.A.; +1-949-951-2020; fax: +1-949-380-7856; email: drhovanesian@harvardeye.com.

Rupert Menapace, MD, can be reached at Medical University of Vienna, Vienna General Hospital, Department of Ophthalmology, Waehringer Guertel 18-20, A-1090 Vienna, Austria; +43-1-40400-7941; fax: +43-1-40400-6630; email: rupert.menapace@meduniwien.ac.at.

Disclosures: Dr. Agarwal is a consultant for Abbott Medical Optics, Bausch + Lomb and STAAR Surgical. Drs. Ahmed, Alió and Menapace has no relevant financial disclosures. Dr. Hovanesian is a consultant for Abbott Medical Optics and Bausch + Lomb.

 

When is it advisable to suture IOL haptics, and when should haptics be tucked or glued into a scleral tunnel?

 

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.