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Y-fixation technique used for intrascleral haptic fixation of posterior chamber IOL
The developer of the technique said that it achieves anatomical and optical stability.
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My special guest in this column is Toshihiko Ohta from Japan, who has devised a simplified and safe method of sutureless intrascleral posterior chamber IOL fixation. It is called the Y-fixation technique, and it is used in eyes with deficient capsules.
Amar Agarwal, MS, FRCS, FRCOphth
OSN Complications Consult Editor
Under peribulbar anesthesia, a 5-mm conjunctival peritomy is done at the 2 o’clock and 8 o’clock positions (Figures 1 to 6). A reference marker and a Y marker (Duckworth & Kent) are used for marking. Two Y-shaped incisions are made 2 mm from the limbus exactly 180° apart diagonally. An infusion cannula or anterior chamber maintainer is inserted. To prevent interference with the creation of the Y-shaped incision, the infusion cannula should be positioned at 5 o’clock. Anterior vitrectomy is performed, if necessary. A 23-gauge MVR knife is used to perform a sclerotomy parallel to the iris at the Y-shaped incision, and a scleral tunnel is made parallel to the limbus at the end of the Y-shaped incision.
Next, a 2.4-mm to 3-mm keratome is used to make a corneal incision at 10 o’clock for injector-assisted IOL implantation. A standard three-piece IOL is implanted with an injector, and the trailing haptic is left outside the corneal incision. The leading haptic is grasped at its tip with 25-gauge IOL haptic-gripping forceps (Eye Technology), pulled through the sclerotomy and externalized on the left side. After the trailing haptic is inserted into the anterior chamber with forceps, a U-shaped hook (Duckworth & Kent) is used to guide it to the center of the pupil (U-shaped hook technique). The tip of the haptic is grasped with the 25-gauge forceps, pulled through the second sclerotomy and externalized on the right side. The tip of the IOL haptic is subsequently inserted into the limbus-parallel scleral tunnel with forceps, after which the IOL is positioned and centered. A single 8-0 nylon suture is used to fix the haptic to the scleral bed in order to prevent it from shifting immediately after surgery, and the incision is closed with 8-0 Vicryl. After the incision is closed completely and the haptic embedded into the sclera, the anterior chamber maintainer or infusion cannula is removed. Finally, the conjunctiva is closed with 8-0 Vicryl.
Figure 1. A Y-shaped incision is made 2 mm from the limbus.
Figure 2. A 23-gauge MVR knife performs sclerotomy parallel to the iris.
Images: Ohta T
Figure 3. The 23-gauge MVR knife creates a scleral tunnel.
Figure 4. A U-shaped hook is used to guide the IOL haptic to the center of the pupil. Then the tip of the IOL haptic is grasped with 25-gauge forceps and pulled through the second sclerotomy.
Figure 5. An 8-0 nylon suture is placed in the scleral bed to prevent shifting of the IOL immediately after surgery.
Figure 6. The sclera is sutured with 8-0 Vicryl, the incision is completely closed, and the haptic is embedded into the sclera.
Discussion
Gabor et al described a technique for intrascleral fixation of both haptics in the ciliary sulcus by means of a parallel scleral tunnel, with a 24-gauge needle being used to create a straight sclerotomy. However, extracting the haptic is difficult, the procedure can only be done with a three-piece IOL, and closure is problematic. Agarwal et al used a 22-gauge needle to create a straight sclerotomy and bioadhesive to attach the haptics and to glue the scleral flaps and overlying conjunctiva. However, their technique has problems regarding closure and postoperative hypotony, the use of fibrin glue and the creation of a lamellar scleral flap.
The Y-fixation technique is a new intrascleral IOL fixation method that does not involve complicated manipulation and achieves safer sutureless fixation. With the Y-fixation technique, a Y-shaped incision is made in the sclera and a 23-gauge MVR knife is used to create the sclerotomy instead of a needle. The Y-shaped incision eliminates the need to raise a lamellar scleral flap, while performing sclerotomy with the 23-gauge MVR knife simplifies extraction of the haptic and greatly improves wound closure.
Conclusion
Various modifications have come out regarding the intrascleral haptic fixation of a posterior chamber IOL and glued IOL techniques. Each technique has its own pros and cons. It is up to the surgeon to choose which technique is the best. I think the Y-fixation technique is simpler and safer than the other intrascleral IOL fixation techniques. The technique is a new-generation secondary IOL implantation method that achieves both anatomical and optical stability. Further development of the technique can be expected in the future.
- References:
- Agarwal A, et al. J Cataract Refract Surg. 2008;34(9):1433-1438.
- Gabor SG, et al. J Cataract Refract Surg. 2007;33(11):1851-1854.
- For more information:
- Amar Agarwal, MS, FRCS, FRCOphth, is director of Dr. Agarwal’s Eye Hospital and Eye Research Centre. Agarwal is the author of several books published by SLACK Incorporated, publisher of Ocular Surgery News, including Phaco Nightmares: Conquering Cataract Catastrophes, Bimanual Phaco: Mastering the Phakonit/MICS Technique, Dry Eye: A Practical Guide to Ocular Surface Disorders and Stem Cell Surgery and Presbyopia: A Surgical Textbook. He can be reached at 19 Cathedral Road, Chennai 600 086, India; fax: 91-44-28115871; email: dragarwal@vsnl.com; website: www.dragarwal.com.
- Toshihiko Ohta, MD, PhD, can be reached at Department of Ophthalmology, Juntendo University Shizuoka Hospital, 11-22 Nagaoka, Izunokuni city, Shizuoka 410-2295, Japan; 81-55-948-3111; fax: 81-55-948-5088; email: ohta803@mist.ocn.ne.jp.
Disclosures: Agarwal and Ohta have no relevant financial disclosures.