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Modification to sutureless scleral fixation for placing secondary IOL proposed
Intravenous catheter creates and holds open the scleral tunnels for threading the haptics through the sclera.
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A proposed modification to sutureless scleral fixation during placement of a secondary IOL entails using a 24-gauge intravenous catheter to create and hold open the scleral tunnels for threading the haptics through the sclera. Once the haptics are secure, the catheters are then removed.
“When performing prior cases of sutureless scleral fixation of an IOL, we found that a challenging step of the procedure was tucking the haptics into the scleral tunnels,” Joseph D. Benevento, MD, an assistant professor of ophthalmology at Icahn School of Medicine at Mount Sinai, told Ocular Surgery News. “This step was particularly difficult if the haptics were bent during externalization or if tissue edema or hemorrhage obscured the openings of the tunnels.”
Technique
In the modified technique published in Ophthalmic Surgery, Lasers and Imaging Retina, an infusion cannula is placed in the inferotemporal quadrant, establishing a standard three-port vitrectomy setup. Two partial-thickness scleral flaps oriented 180° from each other are created at the limbus. A pars plana vitrectomy is done to remove vitreous or lens particles if needed. At each scleral flap, a 24-gauge intravenous catheter is used to create a scleral tunnel, and after trimming, the flexible catheter is left in place. Two straight sclerotomies are created in the scleral flap beds. When the IOL is introduced, the trailing haptic is left in the corneal wound and the leading haptic is externalized with two 25-gauge forceps and introduced into the catheter. The trailing haptic is then also externalized and introduced into the other catheter. After the IOL is centered, both catheters are removed, leaving the haptic in the scleral tunnel. Wound closure is with fibrin glue and sutures, if needed.
Benefits of technique
Benevento and colleagues had attempted to pass the haptics into the bore of a needle or a 25-gauge vitrectomy port, but were frustrated by some of the necessary manipulations.
One of the benefits of the modification compared with standard suturelessscleral fixation is that the intravenous catheter can be placed through the sclera before the corneal wound is created and before the haptics are externalized.
“This order of events minimizes the manipulation necessary when the eye and intraocular lens are less stable,” Benevento said. “The flexible catheter also does not distort the shape of the globe, thus allowing good visualization during other steps of the procedure.”
Additionally, the technique “maintains a smooth, wide and visible tunnel that easily accepts the haptic, even if the haptic is bent,” Benevento said. “The scleral tunnels cannot be lost or closed during other surgical maneuvers.”
As for the learning curve, “This maneuver is no more difficult than the other steps in the procedure, and we believe it makes the surgery overall easier,” Benevento said.
Benevento and colleagues have performed approximately 10 cases with the modification.
“Although we have yet to review these surgeries systematically, all patients have a stable, well-centered IOL, with postoperative visual acuities that are only limited by pre-existing pathology,” Benevento said.
The researchers plan to perform and report a detailed analysis of their outcomes.
For his most recent cases, Benevento has started the needle pass for the catheter from the edge of the scleral flap.
“This requires less accuracy in externalizing the catheter because the pass begins at the end of the tunnel at which the position is more critical,” he said. – by Bob Kronemyer
- Reference:
- Benevento, J, et al. Ophthalmic Surg Lasers Imaging Retina. 2015;doi:10.3928/23258160-20150422-12.
- For more information:
- Joseph D. Benevento, MD, can be reached at New York Eye and Ear Infirmary of Mount Sinai, 310 E. 14th St., New York, NY 10003; email: jbenevento@nyee.edu.
Disclosure: Benevento reports no relevant financial disclosures.