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Simple suture technique resolves pupillary capture after transscleral fixation of IOL
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Placing one suture into the posterior chamber may facilitate treatment of persistent pupillary capture after transscleral fixation of an IOL and avoid lens explantation or exchange, according to a surgeon.
Using one double-armed paracentral suture localized anterior to the IOL and posterior to the iris assists in gliding the iris over the sutures and the IOL optic, and limits the movement of the posterior-tilting IOL, Ignasi Jürgens, MD, PhD, said.
“Up to now, when you get a pupillary capture of the optic of the intraocular lens, and this capture doesn’t resolve during the first postoperative weeks, you need to explant or extract the lens and resuture it again,” Jürgens told Ocular Surgery News. “By just placing this suture, you avoid explanting, resuturing or exchanging the lens.”
Technique
The technique, as reported in the Journal of Cataract and Refractive Surgery, was performed on both eyes of one patient in whom relapsing pupillary capture occurred 1 day and 2 months after pars plana vitrectomy and transscleral sulcus fixation of an IOL for treating spontaneous dislocation of the IOL into the vitreous cavity in both eyes. The technique was performed at 4 months and 8 months after the first episode of intermittent pupillary capture. There have been no signs of recapture during a 1-year follow-up after placing the suture.
“We usually wait about 1 month after preventive measures have failed,” Jürgens said. “It depends on the type of pupillary capture, whether it is intermittent or constant. If it is a constant capture, you may do this earlier. But I usually recommend 1 month, trying first to see if there is any response to treatment with miotic drops.”
The technique involves inserting the needle of a 10-0 polypropylene suture through the temporal sclera into the posterior chamber behind the iris plane but in front of the IOL optic. The suture is externalized by feeding the needle into the lumen of a 27-gauge needle.
A second 27-gauge needle is then inserted through the bed of the new nasal scleral flap using the same procedure to externalize the other needle on the other end of the 10-0 polypropylene suture; the flap covers the suture knot.
Figure 1. Insertion of the first needle of the double-armed 10-0 polypropylene suture. The 10-0 polypropylene suture is exteriorized by feeding the needle into the lumen of a 27-gauge hypodermic needle.
Figure 2.The suture passes behind the iris but in front of the optic of the IOL.
Images: Jürgens I
Figure 3. Suture position after passing the second needle through the bed of the scleral flap. This flap will cover the knot of the suture.
Figure 4. Both ends of the 10-0 polypropylene suture are tightened together and toward the scleral flap.
Figure 5. The knot is placed under the scleral nasal flap, which is repositioned before closing the conjunctival peritomy.
Figure 6. Correct IOL position after surgery. There is no recurrence of the pupillary capture because the iris glides over the sutures and the scleral-fixated sutured posterior chamber IOL does not tilt.
The sutures are brought out of the eye and tied under the nasal scleral flap, and the nasal flap is repositioned over the knot and covered by the conjunctiva (Figures 1-6).
IOL iris capture is usually a temporary complication, possibly causing blurred vision or pain. It may also cause pupillary block with secondary glaucoma and iritis and restrict pupil dilation, which can be treated using miotic agents or laser iridotomy, according to the report.
Complications of this new technique are rare. The iris and ciliary body may bleed if the needles are not correctly oriented during surgery, which is a similar complication that may also occur in the primary implantation of transscleral sulcus fixation of an IOL. The risk of this complication is reduced by using feeder needles. Another potential long-term complication is that the knot may erode the conjunctiva if it is not placed exactly under the scleral flap, according to Jürgens.
Benefits
The procedure is considered a “less traumatic” surgery compared with resuturing or explanting the IOL, and provides IOL stability while decreasing the chance of tilting, decentration, and pseudophakodonesis, according to the study.
Jürgens considers the simple technique to be similar to those that surgeons use for transscleral sulcus fixation of an IOL, placing sutures through the ciliary sulcus.
“Ideally, you don’t have this pupillary capture,” he said. “So, the thing is to prevent this complication during the primary surgery when you implant the IOL. This technique is so simple and easy that I don’t think we need a lot of development of the technique itself.”– by Kristie L. Kahl