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Sutureless intrascleral posterior chamber IOL fixation has advantages, disadvantages
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Implantation of an IOL when capsular support is insufficient or lacking is always challenging, even for experienced cataract surgeons.
A scleral-fixated IOL, despite being technically challenging, has long been regarded as a good primary or secondary technique for IOL implantation in cases without enough capsular support. It offers good centration, reasonable stability and durability for IOL implantation. However, its technical difficulties make its application limited to experienced anterior segment surgeons and can be associated with a high rate of surgical complications. In a report by McAllister and colleagues, 44 out of 82 eyes (53.7%) encountered at least one complication and 13 eyes (15.8%) required subsequent surgery.
Besides a higher surgical complication rate, the need to use sutures for scleral fixation of an IOL also leads to a number of suture-related problems. A suture with knots that are not properly rotated and exposed will cause significant ocular surface irritation, granuloma formation or even introduction of pathogens into the intraocular space through the suture track, hence causing endophthalmitis. The durability of the suture is also of great concern if the IOL is needed for the long term. In our experience, the 10-0 Prolene suture, which is commonly used for a scleral-fixated IOL, will have a higher chance of melting or breaking after about 10 years. This may pose a significant concern in children or young adults with an expected long lifespan.
Sutureless technique
In recent years, a sutureless technique for intrascleral fixation of an IOL has been described. Scharioth and Agarwal reported their sutureless techniques in 2007 and 2008, respectively. Since then, a number of variants have been described. The principle is to use a three-piece posterior chamber IOL, with its haptics pulled out through the sulcus and overlying the sclera, and then tucked intrasclerally with or without the help of glue. With the help of microsurgical instruments, such as 23-gauge vitreoretinal end-grasping forceps, for pulling out the haptics, this technique has been less technically demanding than its sutured counterpart in the past. More importantly, the whole process can be performed within a relatively closed environment because a foldable IOL is used instead of the traditional rigid PMMA IOL. This significantly reduces the chance of intraoperative complications, such as expulsive hemorrhage. In Scharioth’s series of 63 patients, there are only two cases of IOL decentration but no serious complications of endophthalmitis, retinal detachment or glaucoma.
Potential drawbacks
Despite its numerous advantages, the sutureless techniques may still have a number of unresolved issues.
First, there is no specifically designed IOL for this purpose. All IOLs used for sutureless intrascleral fixation are existing posterior chamber IOLs. The dimension of posterior chamber IOLs is usually not more than 13 mm. This may not be long enough for horizontal fixation of IOLs in many patients because of a long horizontal white-to-white distance. This limits the technique to be applicable mostly in the vertical meridian. In cases in which the vertical meridian is not suitable for constructing surgical wounds, it may be difficult to employ this technique.
Second, tucking a posterior chamber IOL intrasclerally invariably causes some stretching of the haptics and haptic-optic junctions. It remains unclear how durable the IOL can be to withstand this kind of stretching before it becomes damaged or deformed. Because the technique is relatively new, longer-term and large-scale studies will help reveal a clearer picture of its safety and efficacy.
References:
Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008;34(9):1433-1438.
Jacob S, Kumar DA, Agarwal A. Glued IOL procedure evolves with use of handshake technique. Ocular Surgery News. Feb. 10, 2011;29(3):32.
McAllister AS, Hirst LW. Visual outcomes and complications of scleral-fixated posterior chamber intraocular lenses. J Cataract Refract Surg. 2011;37(7):1263-1269.
Scharioth GB, Pavlidis MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg. 2007;33(11):1851-1854.
For more information:
Dennis S.C. Lam, MD, FRCOphth, can be reached at Dennis Lam and Partners Eye Center, Suite 1515, Central Building, 1-3 Pedder Street, Central, Hong Kong; email: dennislam8@cuhk.edu.hk.
Disclosures: Drs. Fan and Lam have no relevant financial disclosures.