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Glued IOL technique addresses issues of previous surgical approaches
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The presence of the posterior capsule to support a lens implant has for decades been considered an important factor in the success of IOL surgery. However, during surgery, not all patients have this structure present, and other approaches may be required to maintain IOL stability after implantation.
The first approach, which is still used widely today, is to implant an angle-supported anterior chamber lens, along the lines of Dr. Charles Kelman’s design from the late 1970s. Although the lens is simple to implant, accurate sizing is critical to avoid late complications such as corneal decompensation and uveitis-glaucoma-hyphema syndrome. Another technique in use for many years is to fixate the haptics of a posterior chamber IOL to the sclera using sutures externalized through the scleral wall. These sutures are usually under a partial-thickness scleral flap. This technique is best done with specially designed PMMA IOLs with eyelets for the suture. The problem here is that the lens is rigid and requires a 7-mm incision, which may induce astigmatism. The sutures can break or erode through to the exterior. The surgery itself is time consuming and fiddly, and lens tilt is a risk.
To try to overcome these issues, some have advocated the use of different flap creation such as the Hoffman pocket. Stronger suture materials such as Gore-Tex are much less likely to break, but IOL tilt and surgical time are still issues. Suturing the IOL to the iris is also recommended by some as a simpler alternative to scleral suturing.
In 2006, another method of fixing the IOL was suggested using pockets created in the scleral wall to lodge the ends of the IOL haptics as an alternative to a suture. In 2010, Gabor Scharioth, MD, PhD, reported his results of 60 eyes using this technique with a variety of three-piece IOLs.
This issue of OSN Europe Edition has a review of a variation of the Scharioth technique by placing the haptics under a partial-thickness scleral flap secured in place with fibrin glue. Amar Agarwal, MS, FRCS, FRCOphth, the innovator of the use of fibrin glue for the scleral flaps, and his colleagues describe the various additional uses that can be added to the glued flap technique. These include use with Descemet’s stripping corneal surgery and also a no-assistant technique. Instruments have now been designed to assist in carrying out these operations, and the best ways to use them are described in some detail in the article. The so-called “handshake” technique makes the handling of the IOL inside the eye much more controllable. The advantages of securing the haptics in this way are said to be better IOL stability and thus less pseudophakodonesis, as well as no risk of late suture breakage. Eric Donnenfeld, MD, who uses this technique, comments further that he likes it because of the stability issue and he thinks that it is easier to perform. Francis Price, MD, comments in the article as to how the glue lasts only a few days but is just here to help close the scleral flaps. He said that the haptics of these IOLs degrade because they are polypropylene. This is incorrect as they are extruded PMMA. He describes how in his use of this technique, the ends of the haptics are annealed to create a bulbous end that is better trapped within the scleral tunnel.
Another use of support using a scleral tunnel is to place a capsular hook within it to assist in the stabilization of a capsular bag with insufficient zonular support. This has been described by Soosan Jacob, MS, FRCS, DNB, and her technique is described here.
All of these techniques are ingenious and address many of the issues with previous surgical approaches. We will have to wait and see how well they last with no extrusion of the haptics or hooks through the sclera either coming externally or internally, or dislocation of the IOLs.
- For more information:
- Richard B. Packard, MD, FRCS, FRCOphth, is the OSN Europe Edition Chairperson of the Editorial Board. He can be reached at Arnott Eye Associates, 22a Harley St., London W1G 9BP, England; email: eyequack@vossnet.co.uk.
Disclosure: Packard reports no relevant financial disclosures.