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Sutureless intrascleral posterior IOL fixation method may be safer than other fixation techniques
The Y-fixation technique achieves anatomical and optical stability.
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The hallmark of a new surgical technique for posterior chamber IOL implantation is two incisions forming a “Y,” created 2 mm from the limbus exactly 180° apart diagonally. In addition, the sutureless technique is accomplished by intrascleral IOL fixation rather than transscleral fixation.
According to Toshihiko Ohta, MD, PhD, who devised the Y-fixation technique, the procedure is more simple and safer than other intrascleral IOL fixation techniques. For instance, the Y-shaped incision omits the need to create large lamellar scleral flaps or to use fibrin glue.
“This simplifies haptic externalization and greatly improves wound closure,” Ohta told Ocular Surgery News. The risk of infection from exposure of the haptic on the sclera is also eliminated.
“Using fibrin glue has a theoretical possibility of causing viral infections; therefore, it is mandatory to obtain informed consent from a patient before the operation,” Ohta, a professor at Juntendo University Shizuoka Hospital in Shizuoka, Japan, said. Ohta devised the technique in 2009 because he wanted to employ a method without using fibrin glue.
Performing the technique
Ohta said that the most challenging step in developing his technique was finding the appropriate positions to make the corneal incisions.
“Smooth surgery became possible by making an incision at the 2 o’clock and 8 o’clock positions, respectively, and then inserting an IOL at 10 o’clock,” he said. In addition, the infusion cannula should be positioned at 4 o’clock to prevent interference when creating the incisions.
The two major steps of the technique are creating the sclerotomy and extracting the IOL haptic. The sclerotomy is done parallel to the iris at the Y-shaped incision with a 24-gauge angled microvitreoretinal knife.
Y-fixation technique.
Postoperative status of the anterior chamber shows that the haptics are fixed stably without any IOL decentration or tilt.
Images: Ohta T
The fixed IOL haptic can be seen through the sclera.
“The knife enables us to create a scleral tunnel easily,” Ohta said. “There is a risk of dropping the IOL in the eye during IOL externalization. To prevent this failure, all procedures should be performed at the iris level.”
Ohta said insertion of the trailing haptic into the anterior chamber may prove problematic. There is also a risk of clockwise rotation of the IOL and of the leading haptic slipping back into the eye. To avoid such problems, the IOL can be pushed to the back of the iris and moved to the 2 o’clock position by using a push-and-pull hook that is inserted through the side port at the 1 o’clock position.
“Surgery can be performed more safely and securely by using the instruments (Y-marker and forceps) specially designed for this technique,” Ohta said. Postoperative repositioning of the IOL is easier with intrascleral fixation than with suture fixation.
Retrospective study
In the Journal of Cataract and Refractive Surgery, Ohta described his technique and shared the results of 44 eyes of 40 patients.
“We achieved both anatomical and optical stability,” he said. “These results were better than I expected.”
In the retrospective study, there were no intraoperative complications, and all IOLs were stable and centered at the conclusion of surgery.
“There was significantly less IOL decentration and tilt than with suture fixation,” Ohta said. Astigmatism was also reduced.
At the American Academy of Ophthalmology meeting in November 2013, Ohta introduced a new technique called “T-fixation,” for which he received a “Best of Show” award in the video category.
“A T-shaped incision is made instead of a Y, which eliminates the need to create a lamellar scleral flap or correct the IOL power,” Ohta said. “The risk of vitreous hemorrhage is also eliminated.” – by Bob Kronemyer