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PUBLICATION EXCLUSIVE: Surgeons share experiences, pearls for meeting challenges of sutureless scleral IOL fixation
In the absence of a lens capsule that can support an IOL, sutureless scleral fixation of the lens is an attractive option, without the risk of suture deterioration over time. But the fixation must be secure for the mostly three-piece posterior chamber lenses with extremely flexible haptics.
Amar Agarwal, MS, FRCS, FRCOphth, OSN APAO Edition Board Member, likens sutured IOLs to a broken camera lens that has been sutured to the lens body. “You will not be able to take good quality pictures because the lens will move with the lens body,” he said. “Similarly, by suturing an IOL to the eye, the lens will move with the eye, resulting in pseudophakodonesis.”
To remedy this problem, Agarwal has popularized a surgical technique over the years that uses intrascleral haptic fixation of an IOL with fibrin glue to seal created scleral flaps. “A glued IOL inserts the lens into an intrascleral (Scharioth) pocket and then glues everything down,” he said. “This way, the IOL is fixed into the eye and moves as one unit. The quality of vision is extremely good.”
Agarwal said the mechanics of a glued IOL can be demonstrated by viewing slow-motion video of the eye. “You will see that the lens is rock steady and that there is no movement,” he said.
Image: Hovanesian JA
Detection of pseudophakodonesis is another important aspect of a slow-motion recording. “A high frames-per-second recording of a glued IOL does not demonstrate pseudophakodonesis,” Agarwal said. “This can be attributed to the intrascleral tucking of the haptics that prevents any movement of the IOL.”
The main surgical skill required when performing glued IOL surgery is to externalize the haptics through a sclerotomy. To achieve this, Agarwal developed the handshake technique, in which two glued IOL forceps are used inside the eye.
“One forceps holds one haptic and transfers it with a handshake to the other glued IOL forceps,” Agarwal said. “This is continued until the tip of the haptic is caught by one of the glued IOL forceps, at which point the haptic can be externalized without breaking the haptic.”
Agarwal said the handshake technique has “made life very easy for the glued IOL surgeon, as one can perform the surgery faster and easier.”
However, “it is crucial to grab the haptic with the glued IOL forceps from the tip and not from anywhere else down the entire length of the haptic,” Agarwal said.
Good track record
Sutureless IOL surgery, in general, “has an established track record in terms of safety, longevity and stability inside the eye that is now fairly well proven, both abroad and in the United States,” OSN Cataract Surgery Section Editor John A. Hovanesian, MD, FACS, said. “To some extent, we can define the lens position with these sutureless lenses as well.”
On the other hand, technique is important for any type of IOL fixation without capsular support. Still, in his hands, the sutureless glued IOL technique popularized by Agarwal “is much easier than handling sutures,” Hovanesian said. “But that is obviously highly surgeon dependent.”
For sutureless techniques, the centration of the entry points is important, according to Hovanesian.
“You want to have the two entry points — the two sclerotomies — exactly diametrically opposite across the pupil for proper centration,” he said. “Being careful when marking for those incisions is key because if the line that bisects the two entry points for the haptics is off from the center of the pupil, the IOL may also be significantly decentered. This usually does not yield a very good functional visual result.”
- Click here to read the full publication exclusive, Cover Story, published in Ocular Surgery News U.S. Edition, January 25, 2017.