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Surgeon details scleral tunnel and glue technique for secondary posterior chamber IOL fixation

Scleral tunnel fixation helps prevent long-term suture degradation problems with secondary IOLs.

Issue: August 10, 2014

ByRoger F. Steinert, MD

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Aphakia correction has been explored with multiple techniques including epi-keratophakia and intracorneal inlays, but secondary IOL placement has become the gold standard. Secondary IOL placement either in aphakia or during an IOL exchange with no capsular support leaves the surgeon primarily with three surgical choices: use of an angle-supported anterior chamber IOL, an iris-fixated IOL, or a scleral-fixated posterior chamber IOL with or without an anterior vitrectomy and synechiolysis.

Scleral fixation of a posterior chamber IOL typically involves the use of sutures to fixate the haptics to the sclera while the haptics are usually housed within the ciliary sulcus. This technique provides IOL stability even in the absence of any capsular support, but time-related suture degradation can compromise the IOL stability within the eye and result in IOL subluxation or dislocation, requiring further surgical intervention to correct the problem.

An alternative technique is the partial externalization of the IOL haptics and securing the haptics within a tight-fitting scleral tunnel, thus eliminating the need for sutures for haptic fixation to the sclera. Such a technique usually requires a surgical assistant to help with holding the externalized haptic while the surgeon does surgical manipulation within the eye. Elimination of needing an assistant and completion of the entire procedure by the surgeon help simplify the technique. Further, the use of tissue adhesive facilitates sealing of the scleral flap and the conjunctiva without the need for sutures. Long-term follow-up and haptic stability within the scleral tunnel require continued evaluation.

In this column, Steinert describes his surgical technique of a scleral tunnel-fixated posterior chamber IOL combined with tissue adhesives to close the surgical wound. Steinert’s technique should be of great help to the anterior segment surgeon because it eliminates the need for a surgical assistant and further describes his preferred posterior chamber IOL for this technique. Steinert describes the surgical technique in a stepwise fashion that should help all anterior segment surgeons who may be interested in this new and useful technique.

Thomas “TJ” John, MD
OSN Surgical Maneuvers Editor

Roger F. Steinert

Initially published by Gábor Scharioth, the option of fixating a posterior chamber IOL with a scleral tunnel and glue has been most widely publicized and innovatively modified by Amar Agarwal. The reason for pursuing an alternative method of securing posterior chamber IOLs is because of late suture breakage of posterior chamber IOLs, whether iris fixated or scleral fixated.

There were several key breakthroughs to my acceptance of this technique. I had the privilege of seeing Agarwal perform live surgery, and I also heard other surgeons adopting this technique and not reporting late complications. The final key to accepting this technique was the realization that it is the scleral tunnel, not the glue, that is responsible for long-term stability. This is not a particularly easy technique to become comfortable with or to learn. It is also far from the hardest. The results have the potential of better long-term stability, and therefore, it is worth the effort to master this technique.

I have two preferred IOLs for scleral tunnel-glue fixation. (I have no proprietary interest with either of these.) Initially, I was using the AQ2010V (STAAR Surgical). The advantage of this lens is that the haptic diameter is 13.5 mm, which is logical for scleral fixation, and it also has a 6.3-mm optic. The major advantage of this lens is that the haptics are made of polyimide. This is a tough, flexible material that facilitates the ability to pass the haptics through the scleral wall without permanent deformation. Most posterior chamber IOLs have PMMA haptics that can kink or break in attempting to deliver them through the wall of the eye. A disadvantage of the silicone optic, however, is that when it is injected, it rapidly expels itself from the injector. It is important for the surgeon to grasp the lead haptic before this happens in order to avoid the lens passing through the pupil and disappearing into the posterior chamber.

More recently, I moved to the EC-3 PAL (Aaren Scientific) as my IOL of choice for this technique. (Aaren was recently acquired by Carl Zeiss Meditec, and the IOL will soon be marketed as a Zeiss product.) The lens has an acrylic optic that unfolds much more slowly than the silicone optic. The optic is 6 mm, and the haptic diameter is 13 mm, but I have not found that this slightly smaller size has a perceptible disadvantage. The major advantage of the EC-3 PAL, in addition to the slower release from the injector of the acrylic optic, is the polyvinylidene fluoride haptics. These haptics are extremely elastic and have excellent memory and, therefore, will not break or permanently deform. Moreover, they are a deep blue color that is easily seen through the scleral tunnel. This facilitates the surgeon’s ability to determine how much of the haptic has been inserted into the scleral tunnel.

Key steps to surgery

Carefully mark 180° and then dissect centered on those marks. If you do not get your two haptic fixations exactly 180° apart, you will have a decentered IOL (Figures 1 and 2).

Next, use gentian violet on the end of the needle when you create the tunnel (Figure 3a). I use a 23-gauge needle when I make the tunnel (Figure 3b). The ink mark helps you find the tunnel when you go back to place the haptic.

Figure 1. Corneoscleral markings at 180° to facilitate IOL haptic placement within the sclera.

Figure 2.Preparation for IOL haptic placement.

Images: Steinert RF

Figure 3a. Application of gentian violet to the needle tip before creation of the scleral tunnel.

Figure 3b. A 23-gauge needle is used for creation of the scleral tunnel.

Figure 4. An anterior chamber maintainer is used to prevent globe collapse.

Figure 5. Entry into the ciliary sulcus region using an MVR blade.

Figure 6. Use of coaxial action microforceps to secure the first IOL haptic as the lens is inserted.

Figure 7. Use of retention “sliders” from the Mackool hooks to externally stabilize the first haptic while the second haptic is manipulated.

Figure 8a. Agarwal’s “handshake” maneuver using two instruments to secure the second haptic. The first forceps go through a side-port incision and grasp the second trailing haptic.

Figure 8b. The grasped second haptic is then handed over to the second coaxial action forceps that have passed through the ciliary sulcus incision on the opposite side.

Figure 8c. The second haptic is externalized.

Figure 9. Haptic insertion into the scleral tunnel.

Figure 10. Haptic insertion into the scleral tunnel is then repeated on the opposite side.

Figure 11. Completion of the procedure using tissue glue to close the scleral flap and the overlying conjunctiva.

Next, insert an anterior chamber maintainer, if you have not done so already; it is important to use an anterior chamber maintainer in order to avoid collapse of the globe (Figure 4). Make a puncture through a ciliary sulcus region with a 21-gauge blade, such as an MVR blade, on each side to deliver the haptics (Figure 5). Then use coaxial action microforceps to secure the first haptic as the lens is inserted and deliver it out through one of your two openings in the ciliary sulcus region (Figure 6). This haptic will need to be secured while you manipulate the second; I prefer one of the retention “sliders” from the Mackool hooks (Figure 7).

Next, deliver the second haptic with two instruments. The first forceps go through a side-port incision and grasp the second trailing haptic (Figure 8a), and then that haptic is handed off to the second coaxial action forceps that passed through the ciliary sulcus incision on the opposite side (Figures 8b and 8c). Agarwal refers to this as the “handshake” maneuver.

Next, insert each haptic into the tunnel (Figures 9 and 10).

At this point, you finally apply the tissue glue, consisting of thrombin and fibrinogen (Tisseel, Baxter), rapidly gluing the flap and then the conjunctiva in place. This provides a watertight seal and a clean closure. Do not use excess fibrin glue; the technique is to squeegee out any excess glue rapidly so that the tissue planes are in close apposition (Figure 11). Take care not to over-pressurize the eye, which can “blow out” the watertight seal created by the tissue glue.

In summary, scleral tunnel fixation solves long-term suture degradation problems with secondary IOLs. The haptic itself is much more durable than any suture material. The tissue glue seals the sclerotomy and provides short-term stability, but it is the scleral compression of the haptic that creates permanent stability. The likelihood of long-term stable fixation makes the scleral tunnel fixation technique worth the effort.