Publication Exclusive: Gore-Tex suture can be used in small-incision scleral fixation of hydrophilic acrylic IOL

Secondary IOL placement is often associated with an IOL exchange due to previous IOL subluxation or dislocation and, less commonly, aphakic correction. The location of IOL placement is within the anterior chamber or posterior chamber. Techniques include anterior chamber angle haptic placement, iris fixation, ciliary sulcus placement with or without scleral suture fixation based on capsular support status, or IOL haptic externalization with haptic tucking in the scleral pocket or, rarely, within an intact capsular bag.

While anterior chamber placement is straightforward, posterior chamber placement involves a choice of sutures and wound size, depending on whether a foldable or non-foldable IOL is chosen. Additionally, both the path of the IOL and the final resting position of the IOL should be free of vitreous for an optimal result and a smooth surgical completion of the procedure.

While a large incision wound with a non-foldable IOL works well and is time tested, the move toward providing optimal vision for our patients involves a smaller incision with less iatrogenic induction of corneal astigmatism combined with a foldable IOL. There is a trend toward moving from Prolene sutures to Gore-Tex sutures for scleral-fixated IOLs, due to potential suture longevity and IOL stability over time.

In this column, Dr. Ayres describes a useful technique of small-incision secondary scleral fixation of a foldable IOL using Gore-Tex sutures in a stepwise fashion, which may be an attractive alternative to techniques currently in use. However, continued monitoring of patients over time is essential to evaluate the safety and efficacy of this procedure.

Thomas John, MD, OSN Surgical Maneuvers Editor

Over the past several years, several techniques for suture fixation of posterior chamber lenses have been described. Initially, the majority of surgeons were using 9-0 or 10-0 polypropylene suture and single-piece PMMA lenses. The problems with these techniques included the need for larger incisions and the concern over late suture hydrolysis or breakage leading to IOL dislocation. These concerns were partially alleviated by using intrascleral haptic fixation of three-piece IOLs. Haptic fixation addresses the problem of larger incisions, but the technical challenge and hydrolysis of the haptic can still lead to dislocation and tilt.

I would like to describe a technique for small-incision scleral fixation of the Bausch + Lomb AO60 hydrophilic acrylic implant using 7-0 Gore-Tex suture (CV-8). I am not sure who first described this technique, but it was first described to me by John Berdahl, MD. I have slightly modified his technique in this article.

The technique

The first step of this technique is to mark the limbus at two locations 180° across from each other. I tend to sit temporal and mark at 6 o’clock and 12 o’clock because I think I get less bleeding. Peritomies are created at these two locations, and cautery is used to prevent bleeding. I mark the sclera 2 mm posterior to the limbus at 6 o’clock and 12 o’clock and create sclerotomies using 23-gauge valved trocars 4 mm apart centered over the scleral mark. In the more proximal sclerotomy, I tend to leave the trocar in the sclera, and I use the lancet for the more distal sclerotomy.

Once the sclerotomies are created, I make a 4-mm shelved temporal incision into the anterior chamber and place a nasal paracentesis for placement of an anterior chamber maintainer. If the patient has not had a vitrectomy, this is the best time for a pars plana vitrectomy or anterior vitrectomy. I strongly suggest using Triesence (triamcinolone acetonide injectable suspension, Alcon) or Kenalog (triamcinolone acetonide, Bristol- Myers Squibb) to help stain the vitreous. It is critical that there is no vitreous in the anterior chamber and anterior one-third of the eye for this technique to be safe. At this stage, if performing an IOL exchange, the malfunctioning IOL is removed.

Click here to read the publication exclusive, Surgical Maneuvers, published in Ocular Surgery News U.S. Edition, May 25, 2015.