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Glued IOL a valuable technique for anterior segment surgeons
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As cataract and refractive surgeons, we would ideally want the IOL to be well centered and positioned in the capsular bag. However, due to certain preoperative constraints or intraoperative issues, it might not always be possible to achieve this. If the capsular bag integrity is lost, then the choice of IOL depends on the extent of capsular support available, anterior chamber dimension, endothelial status, iris status, age of patient and, above all, the experience and expertise of the surgeons with a particular technique. The options available are an anterior chamber IOL, an iris clip/iris-fixated IOL and a scleral-fixated IOL, either sutured or glued. In case of zonular laxity, the extent of laxity determines the use of an endocapsular ring/segments with or without scleral fixation.
Sutured scleral-fixated IOLs have been widely used over the last few decades with good surgical outcomes. However, the technique is technically challenging and time consuming. The associated complications, including IOL decentration, tilt and long-term suture degradation (unless 9-0 Prolene suture is used), contribute to suboptimal visual recovery.
The concept of sutureless intrascleral haptic fixation was described by Scharioth in 2007. Agarwal modified the technique to include a scleral flap and used a Scharioth tunnel to secure the IOL. The scleral flap on top of the haptic was sealed with fibrin glue. The technique was termed glued IOL.
The technique is simpler and faster to perform than sutured scleral fixation, but the most important advantage is the stability and centration it offers. Tilt, decentration and pseudophakodonesis are much less with a glued IOL than with a sutured IOL. Any three-piece IOL can be used for the procedure, but a larger IOL, about 13 mm, is preferred to allow a sufficient haptic fixation, especially in high myopes who have large eyes.
The other prerequisites of sutured scleral IOLs are also applicable: a good vitrectomy especially in the area of the sclerotomies, accurate placement of the sclerotomies 180° apart and adequate dimension of the scleral flaps. Anterior segment surgeons might need to be trained to place sclerotomies and perform a good vitrectomy either with a pars plana approach or through the corneal paracentesis.
Various techniques of externalizing the haptic for fixation of a glued IOL have been described, the most common being the handshake technique as described by Agarwal. Narang has described the no-assistant technique to externalize the haptic through the sclerotomies.
The other advantage of the glued IOL is the possibility of gluing a dislocated three-piece IOL in situ without having to remove or exchange the IOL. However, in case of a single-piece dislocated IOL, we might still have to suture the bag or exchange the IOL with a glued IOL.
During intraoperative large posterior capsular rents with retained nuclear fragments, a glued IOL has been used as a scaffold to prevent the pieces from falling into the vitreous cavity.
Combining DSAEK or DMEK with a glued IOL in patients with corneal decompensation and aphakia is an interesting option because the IOL segregates the anterior chamber from the posterior chamber, allowing a better and longer air tamponade, which is required for these surgeries.
Although results with a glued IOL are good, it is not without its share of complications. If placed improperly, the scleral flap or tunnel will need to be redone. Inadvertent damage to the iris or ciliary body can cause bleeding during the sclerotomies or in the process of externalizing the haptic of the IOL. An incomplete anterior vitrectomy can cause a tug or pull on the retina while the IOL is manipulated, resulting in retinal complications. Postoperatively, there can be exposure of the haptic, which might need to be addressed.
As anterior segment surgeons, we should be well versed with the various techniques to fixate or place an IOL when the capsular bag complex is unstable or deficient. The advantages and disadvantages of the various options available and the surgeon’s comfort finally decide which IOL fixation technique to use.
Glued IOL is an excellent concept, and the results so far indicate that it is a technique that is going to stay, and, as anterior segment surgeons, we need to master.
References:
Gabor SG, et al. J Cataract Refract Surg. 2007;doi10.1016/j.jcrs.2007.07.013.
Ganekal S, et al. J Refract Surg. 2012;doi:10.3928/1081597X-20120221-01.
Kumar DA, et al. Curr Opin Ophthalmol. 2013;doi:10.1097/ICU.0b013e32835a939f.
Kumar DA, et al. J Cataract Refract Surg. 2013;doi:10.1016/j.jcrs.2013.03.004.
For more information:
Dennis S.C. Lam, MD, FRCOphth, can be reached at State Key Laboratory in Ophthalmology, Sun Yat-Yen University, 54 South Xianlie Road, Guangzhou 510060, People’s Republic of China; email: dennislam.gm@gmail.com.
Disclosure: Srinivasan and Lam report no relevant financial disclosures.