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No-assistant glued IOL surgery may lead to fewer complications
The Agarwal method for glue-assisted intrascleral IOL fixation is modified to externalize the haptics without an assistant present.
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The glue-assisted intrascleral haptic fixation surgical method created by Amar Agarwal, MS, FRCS, FRCOphth, is assistant-dependent, which can potentially lead to complications due to inappropriate assistance during the surgery, according to a surgeon at the Indian Intraocular Implant and Refractive Surgery Meeting in Chennai, India, who presented a modified version of the surgery that eliminates the need for an assistant.
“When we eliminate the use of a third hand in this surgery, we prevent ourselves from many untoward incidences,” Priya Narang, MS, told Ocular Surgery News at the meeting.
An assistant is needed to hold the leading haptic for the surgeon until the trailing haptic has been externalized and both haptics are removed from the sclerotomy sites.
Complications in the surgery can occur because of haptic disfigurement, such as haptic kink; haptic breakage; slippage of leading the haptic into the eye and eventually a dropped IOL.
Haptic breakage can occur when undue pressure is exerted while holding the haptic. IOLs may need to be exchanged if the residual haptic break has an inadequate length for the surgery. Kinking of the haptic can make tucking in the scleral pockets difficult for the surgeon, according to Narang.
“One more technical problem that a surgeon can face in this surgery is the flipping or the ‘off and on’ saluting of the IOL optic during the process of externalization,” Narang said. “This occurs due to a twist of the leading haptic by an assistant while grasping when the trailing haptic is being externalized.”
Narang developed the no-assistant technique when she realized her assistant would struggle visualizing and holding the haptic during externalization, which led to slippage of the IOL back into the eye. Although surgical expertise is required for the assistant, the visualization of the haptic is enhanced with an observatory tube attached to the operating microscope, the absence of which causes a challenge for the assistant, especially if they are presbyopic.
“In this technique, as the surgeon flexes the trailing haptic beyond the mid-pupillary plane, the chances of slippage of leading haptic into the eye are almost nullified,” Narang said.
The technique works on the principle of vector forces. When the mid-pupillary plane is crossed, the direction of the vector forces will change.
“The forces, which try to pull the leading haptic in to the eye, act in a reverse fashion to cause more extrusion of the leading haptic from the sclerotomy site when the trailing haptic crosses the mid-pupillary plane,” Narang said.
By decreasing the dependence on the assistant, the technique can be more precise and predictable with maintenance of the externalization of the haptic under the control of only the surgeon. A surgeon can then plan a glued IOL surgery even if the assistant is on leave.
Another approach practiced is the use of sponge tires of iris hooks or capsule retractors to prevent the leading haptic from slipping; however, this method has extra costs associated with it and takes more time, according to Narang.
Narang’s procedure has been performed and completed in 15 cases with no intraoperative complications observed.
A disadvantage to the technique is based on the learning curve of the basic glued IOL surgery, Narang said.
How well the technique is perceived will determine the subsequent studies that will be performed in the future, Narang said. – by Cheryl DiPietro
References:
Narang P. J Cataract Refract Surg. 2013;doi:10.1016/j.jcrs.2012.11.001.
Narang P. J Cataract Refract Surg. 2013;doi:10.1016/j.jcrs.2013.05.017.
For more information:
Priya Narang, MS, can be reached at the Narang Eye Care & Laser Centre, Aeon complex, Vijay Cross Roads, Navrangpura, Ahmedabad 380009, Gujarat, India; email: narangpriya19@gmail.com.
Disclosure: Narang has no relevant financial disclosures.