This article is more than 5 years old. Information may no longer be current.
What circumstances would lead you to choose a sutureless technique for posterior segment IOL placement?
Click Here to Manage Email Alerts
Click here to see the Cover Story for this Point/Counter.
Variety of techniques needed
I believe that attempting to tailor the approach to each complicated IOL scenario leads to the best surgical outcomes, and so surgeon facility with a number of different techniques is critical.
I typically use sutureless scleral fixation (SSF) as my preferred technique in two situations. First, if there is a three-piece IOL that has fallen out of position, I will reposition that IOL with the SSF approach. This is simple and elegant, requires few maneuvers and avoids the potential corneal issues associated with IOL exchange, and a second corneal incision and IOL are not required.
In eyes that need an IOL exchange (one-piece lens) or are aphakic, I also typically choose to use the SSF approach because I prefer to have the IOL in the sulcus rather than in the anterior chamber. There is really no good evidence that a modern anterior chamber IOL is not a perfectly reasonable choice in most of these situations.
As our approach to SSF has evolved into a transconjunctival technique in many cases, the procedure has become more reliable and is associated with less surgical trauma. Of note, I do not perform SSF in eyes that have had significant trauma and/or have significant iridodonesis. When significant iris mobility is present, there is a good chance that iris chafing and uveitis-glaucoma-hyphema type syndromes will develop. In these eyes, I will typically suture fixate a CZ70BD lens (Alcon) with a Gore-Tex suture.
Jonathan L. Prenner, MD, is an associate clinical professor of ophthalmology at Rutgers Robert Wood Johnson Medical School. Disclosure: Prenner reports no relevant financial disclosures.
Two main methods for fixation
Advances in vitreoretinal surgical instrumentation to assist with the management of IOL-related complications has allowed an increasing role for vitreoretinal surgeons in IOL fixation. There are two principal methods for scleral fixation: sutureless IOL fixation and scleral-sutured IOL fixation.
With sutured scleral-fixated IOLs, drawbacks may be more pseudophakodonesis, which could influence the visual quality; the need for larger incisions for IOL insertion; and long-term suture breakdown, which may result in the need for future refixation. However, I have found that IOLs allowing for four-point fixation (such as the Akreos AO60), with the strength and longevity of a Gore-Tex suture, can negate significant pseudophakodonesis or suture longevity issues, plus the IOL can be inserted with a small-incision technique.
For a dislocated IOL that is not damaged, and the IOL has haptics amenable to scleral fixation without sutures, sutureless IOL scleral fixation is the preferable and most minimally invasive procedure compared with IOL exchange with sutured fixation. Small-gauge vitreoretinal instrumentation for scleral fixation of IOLs in this manner using trocar cannulas and/or tunnels may be considered. With good lens centration and fixation, this method offers postoperative axial stability of the IOL while avoiding suture-related problems. Nevertheless, with intrascleral fixation of haptics, there are concerns about exposure/erosion of the haptic through the sclera over time and the risk of eventual lens decentration.
In cases in which IOL exchange or secondary IOL placement is necessary, a scleral-fixated IOL suspended with a suture is my preferred procedure. I favor the Akreos AO60 or the enVista MX60 lens (both Bausch + Lomb) and fixation with a Gore-Tex suture. This relatively minimally invasive procedure allows insertion of the IOL through a comparatively small incision slightly larger than a standard cataract surgery wound and sutured fixation using 25-gauge sclerotomy sites suitable for pars plana vitrectomy surgery. The Gore-Tex suture also likely improves suture longevity and IOL stabilization.
I encourage surgeons to be well-versed in various IOL fixation techniques. As these techniques evolve and more long-term outcomes data become available, it will help guide us in choosing the most appropriate patient intervention.
Joseph N. Martel, MD, is an assistant professor of ophthalmology at the University of Pittsburgh School of Medicine. Disclosure: Martel reports no relevant financial disclosures.