Jacob paper clip capsule stabilizer can help manage subluxated cataracts

The device is aimed at fixating the capsular bag in a sutureless manner to the scleral wall.

Issue: December 10, 2018

ByAmar Agarwal, MS, FRCS, FRCOphth

BySoosan Jacob, MS, FRCS, DNB

Subluxated cataracts are managed depending on the degree of zonular dialysis. For a subluxation of up to one quadrant, a capsular tension ring may be used. However, for larger subluxations, some form of scleral fixation is necessary to avoid a decentered or subluxated bag in the postoperative period.

The currently available devices for scleral fixation are all sutured and include the Ahmed segment, the Cionni single and double hook rings, and the Assia segment. All of these devices are sutured onto the scleral wall using either 9-0 Prolene suture or Gore-Tex suture. There are many disadvantages of having to suture these devices to the scleral wall. Manipulations are required to pass long and thin needles across the anterior chamber, which can involve complicated maneuvering. This makes surgery more difficult and also takes longer. In addition, the tension with which the suture knot is tied down determines the degree of centration of the IOL. If the knot is tied too loose or too tight, the IOL remains decentered, necessitating cutting the suture and performing the entire complicated maneuvering of sutured scleral fixation again.

One of the authors (SJ) has described the glued endocapsular ring and the glued capsular hook technique for sutureless capsular bag stabilization. In addition, the Jacob capsule stabilizer (Morcher), designed by SJ, makes this a simple procedure to perform. It is a new device that is aimed at fixating the capsular bag in a sutureless manner to the scleral wall.

Design of the device

**Figure 1.** Jacob paper clip capsule stabilizer. The fixation element is 2.5 mm wide with two flanges on either side and a central extension, forming a paper clip component. The haptic is 13 mm long with indentations.

The paper clip capsule stabilizer is made of blue PMMA and is a single-piece device that has a fixation element and a haptic. The fixation element has two flanges on either side and a central extension, which together form the paper clip component. This paper clip component fixes on to the rhexis rim and thus engages the rhexis. The haptic passes transsclerally through a sclerotomy that has been made under a scleral flap and is then tucked into an intrascleral Scharioth tunnel. The haptic is 13 mm long and has indentations that help obtain a firm grip within the Scharioth tunnel. The fixation element is 2.5 mm wide and can be easily passed into the anterior chamber through the phaco incision (Figure 1).

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Surgical procedure

If the degree of subluxation is more than one quadrant, a Jacob capsule stabilizer is used. A scleral flap is created centered on the area of dialysis. Phaco incisions are created. Intravitreal preservative-free triamcinolone acetonide is injected to identify any prolapsed vitreous, and if present, a vitrectomy is done. A rhexis is made so as to leave an adequate rim of capsule on the side of dialysis. The retroiridal space is expanded by injecting viscoelastic into the eye, and a sclerotomy is made in either an ab interno or ab externo fashion using a 23-gauge needle. Under cover of viscoelastic, the paper clip capsule stabilizer is inserted into the anterior chamber by introducing the haptic first. Alternatively, an anterior chamber maintainer with balanced salt solution irrigation may be used to maintain the well-formed chamber.

**Figure 2.** A coat-hanger configured intrascleral Scharioth tunnel and tuck are shown.

After again expanding the retroiridal space with viscoelastic, 23-gauge microforceps are inserted into the anterior chamber through the sclerotomy behind the iris and in front of the anterior capsule, and the haptic of the Jacob capsule stabilizer is grasped and externalized through the sclerotomy. The paper clip element of the capsule stabilizer is grasped and engaged onto the rhexis rim. Pulling the haptic then centers the bag into place. The haptic is trimmed and tucked into an intrascleral Scharioth tunnel. The tunnel may be made with a gentle slant toward the limbus in a coat-hanger configuration so as to give additional stability. This is easily achieved by initiating the tunnel from the outer corner of the scleral bed (Figure 2).

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The degree of centration of the tuck determines the degree of centration of the capsular bag. Greater pull is obtained by increasing the degree of tuck. Additional translimbal capsular hooks may be placed to give extra intraoperative support. The Jacob capsule stabilizer as well as conventional translimbal capsular hooks, if applied, provide the intraoperative support required for various steps of the cataract surgery. A gentle hydrodissection is done, and phacoemulsification of the nucleus and cortex aspiration are then performed as conventionally described for subluxated cataracts. A capsular tension ring may be inserted at any stage that is comfortable to the surgeon before either nucleus removal or cortex aspiration. This provides additional forniceal expansion during all steps of cataract surgery. The IOL is implanted into the bag, all additional translimbal capsular hooks that were placed are removed, and final tuck of the haptic of the capsule stabilizer is once again adjusted if required. The scleral flap and the conjunctiva are closed with fibrin glue at the end of surgery (Figures 3 to 5).

**Figure 3.** A subluxated cataract of more than 180° is seen (a). A partial-thickness scleral flap is created centered on the area of dialysis (b). A rhexis is created, leaving an adequate rim on the side of dialysis (c). An ab interno sclerotomy is made using a 23-gauge needle. An ab externo sclerotomy may also be made (d). The Jacob capsule stabilizer is introduced into the anterior chamber, and the tip of the haptic is grasped by end-gripping forceps (e). The fixation element of the capsule stabilizer is grasped and engaged onto the rhexis rim (f).

The Jacob capsule stabilizer may also be used to fixate the capsular bag in case of intraoperative zonular dialysis or to fixate early or delayed subluxated in-the-bag IOLs.

**Figure 4.** A 26-gauge needle is used to create an intrascleral Scharioth tunnel (a). The haptic of the Jacob capsule stabilizer is trimmed to the desired size (b). The haptic is tucked into the intrascleral Scharioth tunnel (c). Phacoemulsification of the nucleus is performed with additional translimbal capsular hooks inserted, if needed, for added intraoperative support (d). A capsular tension ring is inserted into the capsular bag for forniceal expansion (e). Cortex aspiration performed (f).

This device allows for easier, faster and safer surgery. There is less maneuvering needed than with sutured segments and there are no suture-related postoperative complications. Intraoperative centration and adjustment of the position of the IOL may be done by simply adjusting the degree of tuck of the haptic. For larger degrees of subluxation, two capsule stabilizers may be used.

**Figure 5.** The IOL is inserted into the bag (a). Position of IOL is checked, and additional translimbal capsular hooks are removed (b). The haptic of the Jacob capsule stabilizer is adjusted to the final desired position, and the scleral flap is closed with fibrin glue (c). Conjunctiva is also closed with fibrin glue (d).

Subluxated in-the-bag IOLs may also be refixated easily and simply using the Jacob capsule stabilizer. This is done in a similar manner as for the subluxated cataract by making a scleral flap centered on the zone of dialysis followed by a sclerotomy through which the haptic of the Jacob capsule stabilizer is externalized. The fixation element is then used to engage the rhexis rim, and the IOL is pulled into position. In larger subluxations, more than one capsule stabilizer may be used. The degree of tuck of the haptic determines the centration of the IOL.

References:
Assia EI, et al. J Cataract Refract Surg. 2009;doi:10.1016/j.jcrs.2009.02.046.
Cionni RJ, et al. J Cataract Refract Surg. 1998;doi:10.1016/S0886-3350(98)80218-6.
Davis D, et al. Ophthalmology. 2009;doi:10.1016/j.ophtha.2008.11.018.
Fernández-Buenaga R, et al. Eye (Lond). 2013;doi:10.1038/eye.2013.95.
Glued capsular hook Soosan Jacob. www.youtube.com/watch?v=M8AHOMVCz4k. Published Aug. 18, 2015. Accessed Aug. 1, 2018.
Glued capsular hook for subluxated cataract Soosan Jacob with audio 5 min. www.youtube.com/watch?v=sz4DiMnHDCk. Published March 23, 2016. Accessed Aug. 1, 2018.
Glued capsular hook in subluxated IOL Soosan Jacob 3 2 min with audio. www.youtube.com/watch?v=DOu45gIwHOE. Published Oct. 11, 2014. Accessed Aug. 1, 2018.
Hasanee K, et al. Ophthalmol Clin North Am. 2006;19(4):507-519.
Hara T, et al. Ophthalmic Surg. 1991;doi:10.3928/1542-8877-19910601-16.
Hayashi K, et al. Ophthalmology. 2007;doi:10.1016/j.ophtha.2006.09.017.
Jacob S, et al. J Cataract Refract Surg. 2003;doi:10.1016/S0886-3350(02)01534-1.
Jacob S, et al. J Cataract Refract Surg. 2012;doi:10.1016/j.jcrs.2011.12.001.
Jacob S, et al. J Cataract Refract Surg. 2014;doi:10.1016/j.jcrs.2014.10.009.
Jacob S, et al. Med Hypothesis Discov Innov Ophthalmol. 2013;2(1):3-7.
Jakobsson G, et al. J Cataract Refract Surg. 2010;doi:10.1016/j.jcrs.2010.04.042.
Jehan FS, et al. Ophthalmology. 2001;doi:10.1016/S0161-6420(01)00710-2.
New glued capsular hook Soosan Jacob with audio 5 4 min final. www.youtube.com/watch?v=O3KLj5I2ijY. Published March 20, 2016. Accessed on Aug. 1, 2018.

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; email: dragarwal@vsnl.com; website: www.dragarwal.com.

Disclosures: Jacob reports she has a patent pending for the glued capsular hook. Agarwal reports no relevant financial disclosures.