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Sutureless scleral fixation technique can be used to implant IOLs in eyes lacking capsular support
A novel technique works with a three-piece IOL and without sutures, scleral flaps or fibrin glue.
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Sutureless scleral fixation may be a viable approach to IOL implantation or IOL rescue when eyes lack sufficient capsular support, according to 1-year follow-up of a novel surgical technique.
To avoid complications of more traditional methods of IOL implantation in these eyes with insufficient capsular support, Jonathan L. Prenner, MD, and colleagues at NJ Retina developed a technique of ciliary sulcus-based scleral fixation of a posterior chamber IOL without the use of sutures, scleral flaps or fibrin glue. The procedure had been deemed successful in short-term observations over the past 3 years, but no study had determined its efficacy over a longer period of time.
“The question was whether or not implanting the haptics into the sclera over time was going to lead to a complication like bleeding, erosion or infection,” Prenner told Ocular Surgery News. “It turned out that the lenses were very stable. We did not see any significant complications over a time period of 1 year.”
Long-term follow-up
A retrospective chart review, published in Retina, of 24 consecutive cases included 18 eyes with lens dislocation and six eyes that underwent surgery for other reasons. All underwent posterior chamber IOL implantation using a three-piece IOL and the sutureless scleral fixation technique.
Within 1 month after surgery, vitreous hemorrhage developed in two eyes, IOP was elevated in one eye, and hypotony developed in one eye. All of these conditions resolved within 1 month.
After 1 year postoperatively, three eyes had spontaneous IOL dislocation that required IOL exchange, with two of the dislocations occurring within 3 months after surgery and one dislocation occurring nearly 1 year after surgery. In the latter case, the patient had experienced significant trauma to the eye before sutureless scleral fixation, and dislocation of a haptic resulted in IOL malposition. No further complications occurred after IOL exchange in all three cases.
“That’s the biggest concern, that the lens, despite putting it into the right place, moves over time,” Prenner said. “The good news is that, if it’s going to slip out of position, it likely will do so early on, and so once you make it past the 3-month time point, the lenses are pretty much in there for good.”
Additionally, iris capture of the IOL developed in one patient, necessitating lens repositioning; in another patient, cystoid macular edema developed and was managed with triamcinolone acetonide injection 15 weeks after surgery.
Mean visual acuity was 1.30 ± 0.86 preoperatively and improved to 0.69 ± 0.62 at 3 months postoperatively and 0.52 ± 0.58 at 1 year.
Maneuvering haptics
In the short term, the three-piece IOL can be implanted or rescued in a sulcus-based position that is minimally invasive without the need for suture fixation, the study authors said.
“By implanting the haptics in the sclera without sutures, we have a more durable result, as there is nothing really to erode or break,” Prenner said.
Prenner said he considers the sutureless scleral fixation technique to be a simple solution because it does not require glue or scleral cutdowns, with the most difficult aspect pertaining to the manipulation of the haptics.
“We’re not really used to handling free haptics,” he said. “It just takes a little bit of time to become facile with how much you can stress haptics and maneuver them without causing damage.”
In the future, Prenner said additional microsurgical instrumentation could make the procedure even more simple and will increase its reliability over time.
“It’s a great technique,” he added. “Any time you do something new, you have to hold your breath and know you’re going to be in the sharp part of the learning curve, but it goes pretty quickly. It’s been a nice approach to have in the tool belt for vitreoretinal surgeons doing these kinds of cases.” – by Kristie L. Kahl
- Reference:
- Wilgucki JD, et al. Retina. 2015;doi:10.1097/IAE.0000000000000431.
- For more information:
- Jonathan L. Prenner, MD, can be reached at NJ Retina, 10 Plum Street, Suite 600, New Brunswick, NJ 08901; email: jonathanprenner@gmail.com.
Disclosure: Prenner reports no relevant financial disclosures.
Perspective
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Priya Narang, MS
This is a well-conducted study that highlights the advantages of a scleral fixation of IOL, the greatest advantage of which comes from intrascleral tucking of haptics. I recommend making a sclerotomy at 1 to 1.5 mm from the limbus rather than 2 mm as was done in this study. The point of concern is the amount of haptics externalized, as it tends to be inadequate in large eyes. The incidence of haptic slippage from the scleral tunnels can be minimized by this and also by measuring the white-white diameter (WTW) in eyes before the beginning of the procedure. I would recommend taking WTW diameter into consideration for all cases undergoing a sutureless scleral fixation. Creating a scleral pocket with a 23-gauge trocar can lead to a big and wide tunnel, which can eventually lead to haptic slippage, as the haptic does not fit snugly into the scleral pockets. A 26-gauge tunnel seems to work very well in my experience and can minimize the chances of haptic slippage and an eventual IOL dislocation in the postoperative period.
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