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Glued IOL procedures performed using the no-assistant technique
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An estimated 20.5 million Americans older than 40 years have a cataract in one of their eyes, and 6.1 million have pseudophakia or aphakia. Aphakia is suboptimal, since image degradation is an integral factor. Hence, secondary IOL implantation is usually a required, stand-alone surgical procedure to make the eye pseudophakic and restore vision in the presence of a functional posterior segment and a clear cornea without any associated anatomic alterations.
To correct aphakia, secondary IOL implantation is usually preferred over corneal procedures such as epikeratophakia. Although there are various surgical techniques that are helpful for secondary IOL implantation, the choice of the surgical procedure may often be dictated by, among other factors, the presence or absence of the posterior lens capsule.
The status of the posterior lens capsule can vary from being totally intact to partially deficient to totally absent. In the presence of a totally intact capsule, the technique is similar to primary cataract surgery, where the IOL is simply implanted into the posterior capsular bag. When the posterior capsule is compromised, the implantation technique may vary from ciliary sulcus implantation to single- or dual-haptic transscleral fixation of the IOL, depending on the amount of remaining posterior lens capsule and the associated zonular support.
In the absence of any contraindications, an intact iris with a normal anterior chamber angle anatomy may invite a secondary IOL that is angle- or iris-supported, depending on the surgeon’s preference and comfort level.
In an aphakic eye without sufficient posterior lens capsule, posterior chamber IOL implantation demands that the surgical technique provide full stabilization of the IOL to provide long-term useful and functional vision to the recipient. While sutures can be used for this procedure, the techniques can be surgically demanding and cumbersome. Additionally, the sutures may erode through the tissue, or the suture material can degrade over time leading to potential IOL destabilization, requiring further surgical intervention at a later date.
Hence, there seems to be a trend toward sutureless, scleral pocket fixation of externalized haptics with fibrin glue sealing of the surgically created scleral flaps. Although this evolving technique is continuing to gain the interest of anterior segment surgeons, it often requires a third hand by way of an assistant helping the primary surgeon to hold the haptic during the procedure. Elimination of the third hand can restore surgeon independence in performing this procedure.
In this surgical maneuvers column, Priya Narang, MD, describes her technique of glued IOL without the need for an assistant in the operating room.
Thomas “TJ” John, MD
OSN Surgical Maneuvers Editor
The no-assistant technique is a simplified and modified method of haptic externalization during the glued IOL surgery described by Amar Agarwal, MS, FRCS, FRCOphth, and colleagues. Agarwal’s technique requires an assistant to hold the leading haptic during the process of externalization of the IOL haptics.
The no-assistant technique is an effort to decrease dependence on the assistant surgeon and make the procedure more dependent on the operating surgeon. It can be used to effectively maintain the externalization of the leading haptic during the entire surgery.
The technique works on the principle of “vector forces.” The mid-pupillary plane is a major contributor to the success of this technique. In the Agarwal method of glued IOLs, the handshake technique for the trailing haptic is performed below the mid-pupillary plane and the vector forces act in a way that the leading haptic tends to slip back into the eye if not grasped properly by an assistant (Figure 1).
The direction of vector forces changes completely once the trailing haptic reaches or crosses the mid-pupillary plane. This causes further extrusion of the leading haptic from the sclerotomy site and abolishes the need for an assistant to hold the leading haptic (Figure 2), which reduces the risk for any potential assistant-related complications during the surgery.
Figure 1. The handshake technique for the trailing haptic is shown, performed below the mid-pupillary plane. An assistant holds leading haptic, as it tends to slip into the eye.
Figure 2. As the trailing haptic crosses the mid-pupillary plane, the vector forces cause more extrusion of the leading haptic from the sclerotomy site.
Images: Narang P
Surgical technique
Two partial-thickness scleral flaps, 2.5 mm by 2.5 mm, are fashioned 180° apart. Infusion is then introduced into the eye either by a trocar-cannula or an anterior chamber maintainer (Figure 3a).
The sclerotomy is made with a 20-gauge needle about 1.5 mm from the limbus, beneath the scleral flaps (Figure 3b). A 23-gauge vitrectomy probe is introduced from the sclerotomy site, and a thorough vitrectomy is performed (Figure 4a). Triamcinolone can be used to stain the vitreous for easy visualization. A corneal tunnel is fashioned with a 2.8-mm keratome, and a side-port incision is framed midway between the left sclerotomy site and the corneal tunnel (Figure 4b).
A three-piece, monofocal, foldable IOL with modified C-loop haptic configuration is loaded, and the tip of the haptic is slightly brought out from the cartridge. A 23-gauge glued IOL forceps is introduced from the left sclerotomy site, the loaded cartridge is introduced into the eye and the tip of the IOL haptic is grasped (Figure 5a). The IOL is then slowly injected into the eye.
Once the entire IOL has unfolded, the tip of the leading haptic is pulled and externalized (Figure 5b). The surgeon flexes the trailing haptic with the glued IOL forceps in the right hand and introduces it into the eye so as to cross the mid-pupillary plane toward the 6 o’ clock position. The surgeon then leaves the leading haptic and reintroduces the glued IOL forceps with the left hand from the side-port incision into the eye (Figure 6a). The haptic is then transferred from the right glued IOL forceps to the left hand, also known as the handshake technique. The surgeon withdraws the right glued IOL forceps from the eye and reintroduces it from the right sclerotomy site (Figure 6b). The trailing haptic is now transferred from the left hand to the right hand.
Figure 3. Two partial scleral thickness flaps are created (A) and infusion introduced into the eye. Sclerotomy is made (B) with 20-gauge needle beneath the flap, approximately 1.5 mm from limbus.
Figure 4. Vitrectomy done with 23-gauge probe introduced from the sclerotomy site (A). A 2.8-mm corneal tunnel and a side-port incision are framed (B).
Figure 5. The tip of the haptic is grasped (A) and the IOL is slowly unfolded. The leading haptic is pulled (B) and externalized.
Figure 6. The trailing haptic (A) is flexed into the eye toward 6 o’clock position, crossing the midpupillary plane (Note: The leading haptic lies free at the left sclerotomy site). The haptic is transferred to the left and glued IOL forceps is introduced from the side-port incision. The glued IOL forceps (B) is reintroduced from right sclerotomy incision. The haptic is transferred from left hand to right hand and is pulled and externalized.
The surgeon holds the haptic tip and externalizes it by pulling the haptic (Figure 7a). A scleral pocket is created using a 26-gauge needle parallel to the sclerotomy site along the edge of the flap (Figure 7b). The haptics are tucked and a vitrectomy is performed to cut any vitreous strands at the sclerotomy site (Figure 8a). Infusion is stopped, the scleral bed is dried and glue is applied to seal the flaps (Figure 8b). Fibrin glue can also be used to seal all the conjunctival peritomy sites and corneal incisions.
Inappropriate handling of the leading haptic can lead to complications such as haptic disfigurement, kinking or breaking of the haptic that often requires an IOL exchange; haptic slippage into the eye; or a dropped IOL. Various methods to prevent the leading haptic from slipping back into the eye have been described. The sponge tire of an iris hook, as described by George Beiko, MD, and Roger F. Steinert, MD, can be used to plug onto the haptic so that an assistant is not required to hold it.
The technique described in this article has been used in more than 100 cases to date and was reproducible in all cases with no intraoperative complications. This technique is an attempt to make the process of haptic externalization, considered the most technically demanding part of the surgery, easier and more feasible.
Figure 7. Both haptics are externalized. A scleral pocket is created with a 26-gauge needle.
Figure 8. Haptics are tucked in the scleral pocket (A). Fibrin glue (B) is applied beneath the flaps to seal.