This article is more than 5 years old. Information may no longer be current.
Glued IOL technique provides secure fixation in absence of capsule support
Stable IOL placement was seen in the first published North American case series of the surgical technique.
Click Here to Manage Email Alerts
Using fibrin glue to help seal the wound in the early postoperative period of implanting a posterior IOL in an eye that lacks capsule support achieved universal secure IOL fixation, according to the first North American case series of the intrascleral haptic fixation technique.
“However, the glue itself is not the critical component of the surgery, but rather the key is capturing the haptics into the sclera,” lead investigator Yuri McKee, MD, a corneal and refractive surgeon in private practice in Mesa, Ariz., told Ocular Surgery News. “The glue seals down the flaps, so the eye does not leak.”
Yuri McKee
The study, which appeared in the Journal of Cataract and Refractive Surgery, was conducted at Price Vision Group in Indianapolis, where McKee previously served as a corneal and refractive surgeon. All 50 cases included in the study were performed between October 2012 and October 2013; McKee implanted 34 of the IOLs.
Before joining Price Vision Group, McKee practiced in Atlanta, where he preferred the iris suture fixation technique. In 2011, he was approached by a retina colleague to implant a secondary IOL in a patient with little iris remnant and previous extracapsular cataract extraction.
At the time, McKee was familiar with the glued IOL technique developed by Amar Agarwal, MS, FRCS, FRCOphth.
“My initial reception to a glued IOL was rather cool, a sentiment shared by a number of my colleagues,” McKee said. “But this patient really did not have any other option. Although my first glued IOL surgery was extremely difficult and I did not feel I was very elegant, by some amazing stroke of luck, the patient had a great outcome. She had a significant improvement over her preoperative aphakic refraction.”
In 2012, McKee connected with Agarwal at the American Academy of Ophthalmology meeting and disclosed that he was having difficulty with the technique. As a result, Agarwal dispatched his son, Ashvin Agarwal, MD, to Price Vision Group to offer advice on the surgery.
“Having tutelage from an experienced surgeon in this technique greatly shortens the learning curve,” McKee said.
Glued IOL candidates
Candidates for the glued IOL technique do not have adequate capsular support for a lens in the posterior chamber. The first step is a pars plana vitrectomy to remove all vitreous traction, which also establishes a pars plana infusion. Two limbus-based partial-thickness scleral flaps and tunnels are then created exactly 180° away from each other in the horizontal meridian. Under each flap, a sclerotomy is made though the ciliary sulcus. Next, the haptics of the IOL are passed through the sclerotomies.
“We then tuck the haptics into tunnels that are continuous with the scleral flaps,” McKee said. “Hence, the haptic becomes enclaved in the sclera.”
Glue is then applied to seal the flaps, which also seals the sclerotomy.
“You now have a permanent fixation of the haptic within the sclera with no sutures,” McKee said.
The problem with sutures is that they degrade over time.
“In fact, in this study, two cases were actually lenses that had been previously sutured in which the suture broke after many years and the lens fell back into the vitreous,” McKee said.
Besides being a sutureless procedure, McKee said that by removing all the vitreous, eyes are quiet and heal rapidly, as fast as regular cataract surgery. Agarwal has also demonstrated that the lens is stable.
“There is no pseudophakodonesis, which he has shown with high-speed photography,” McKee said.
Moreover, McKee believes that these lenses are unlikely to fall in the future because there is no suture to break.
IOL type
One-piece acrylic IOLs are not used with the glued IOL technique because the haptics are only appropriate for placement in an intact capsular bag, McKee said.
“You need thin, flexible haptics that can fit into the scleral tunnel, which are found on three-piece foldable lenses or on one-piece PMMA lenses,” he said.
McKee recommended two lenses: the study lens, STAAR CQ2015A, which has polyimide haptics, and the Aaren Scientific EC-3 Precision Aspheric Lens, which has polyvinylidene haptics.
“The key to both of these lenses is that the haptic material is made of very resilient and flexible material, so as you manipulate the lens with the two Asico 23-gauge Tan forceps inside the eye, the haptic will not break or kink,” he said.
In the study, patients were examined several times up to 1 year.
“We had very stable IOL placement,” McKee said. One patient, in particular, was an aggressive eye rubber who after 3 months broke the optic-haptic junction, but the haptic itself remained embedded in the scleral tunnel.
Creation of the scleral tunnel continuous with the 2-sided scleral flap with the custom diamond blade.
Creation of the sclerotomy under the scleral flap 1.5 mm posterior to the limbus. The IOL haptic will exit the sclerotomy and be tucked into the scleral tunnel.
Source: McKee Y
Self-limiting postoperative hypotony occurred in 30% of eyes in early cases, which was reduced to 10% in latter cases.
“Some of the hypotony was due to leakage from the sclerotomy when we passed the haptic into the scleral tunnel and then glued on top of it,” McKee said. “Placing an air bubble into the posterior chamber will tamponade any fluid leakage until the glue cures, a matter of 1 to 2 minutes.”
There was no vision loss or loss of any eye.
“We were able to meet or exceed aphakic refraction, so all patients maintained or gained best corrected vision,” McKee said. In addition, all patients discontinued their postop drops within 4 to 6 weeks after surgery.
Since the study, McKee and colleagues have used the glued IOL technique in more than 100 cases.
“Our results continue to improve as our surgical experience continues to accumulate,” he said. “Glued IOL is now my standard of care when there is insufficient capsule support for a lens. In fact, I no longer consider placing an anterior chamber IOL for any reason.” – by Bob Kronemyer
Reference:
McKee Y, et al. J Cataract Refract Surg. 2014;doi:10.1016/j.jcrs.2014.04.027.For more information:
Yuri McKee, MD, can be reached at Swagel Wootton Hiatt Eye Center, 220 S. 63 St., Mesa, AZ 85206; email: mckeemd@swhec.com.Disclosure: McKee is an unpaid consultant to Mastel Precision Surgical Instruments, the manufacturer of the customized diamond blade he uses in the glued IOL procedure. In lieu of consulting fees, a charitable donation is made for each diamond blade sold.