Inadequate capsular support at the time of cataract surgery may be remedied by implantation of iris-fixated, anterior chamber, or transsclerally fixated IOLs.1-12 Scleral-fixated IOLs require a precise surgical technique and prolonged surgical time. They may also cause suture-induced inflammation, and suture degradation may lead to delayed IOL subluxation or dislocation. The surgeon must also adjust the suture length and tension of a scleral-fixated IOL to ensure good centration. We have found that the use of fibrin glue is a welcome addition to the process of implanting scleral-fixated IOLs.
We use Tisseel (Baxter, Deerfield, Illinois) or ReliSeal (Reliance Life Sciences, India), which are both available in sealed packs containing freeze-dried human fibrinogen and thrombin, aprotinin solution, and sterile water. Fibrin glue provides airtight closure and takes approximately 3 to 20 seconds to adhere to the scleral bed. It helps with adhesion as well as hemostasis.
The use of fibrin glue is currently an off-label treatment in ophthalmology; however, it has been used for the repair of lacerated canaliculi,13 to seal full thickness macular holes,14,15 cataract incisions,16-19 and corneal perforations. It has also been used for traumatic lens capsule perforations,20 temporary closure of scleral flaps after trabeculectomy in eyes with hypotony,21 conjunctival fistula closure,22 conjunctival autografts,21 and amniotic membrane transplantation.23,24
SURGICAL TECHNIQUE
The infusion cannula or anterior chamber maintainer is inserted, and localized peritomy is completed. Then, two partial thickness limbal-based scleral flaps (3 mm x 3 mm) are made, 180° diagonally apart and approximately 1.5 mm from the limbus (Figure 1). Next, all vitreous traction is removed via pars plana or anterior vitrectomy, and two straight sclerotomies are formed 1.5 mm from the limbus and under the existing scleral flaps. Preparation of a scleral tunnel incision, about 2 mm from the limbus, is made. The IOL is introduced with the left hand. The tip of the leading haptic is grasped with a pair of micro rhexis forceps (MicroSurgical Technology, Redmond, Washington) and pulled through the inferior sclerotomy following the curve of the haptic (Figure 2). It is then externalized under the inferior scleral flap. Similarly, the trailing haptic is externalized through the superior sclerotomy under the scleral flap (Figure 3).
The IOL haptic tuck is an important maneuver. The IOL haptic should be lying beyond the scleral flap. At this point, a scleral pocket is created in the area where it is extending out, and the haptic is tucked inside the scleral pocket, made with a 22-gauge needle (Figure 4). The IOL must be checked that it is firmly in place, and then the reconstituted fibrin glue is injected through a cannula under the superior and inferior scleral flaps. Local pressure is given for approximately 3 to 20 seconds to form fibrin polypeptides, and then the same fibrin glue is used to close the conjunctiva.
DISCUSSION
Use of fibrin glue to assist in sutureless posterior chamber IOL implantation may be useful when a scleral-fixated IOLs is indicated, such as with subluxated or dislocated IOLs, zonulopathy, or secondary IOL implantation. If a posterior chamber IOL becomes dislocated, we can use fibrin glue to reposit the same IOL, thereby reducing further manipulation. Externalizing the greater part of the haptic along its curvature stabilizes the axial positioning of the IOL, preventing tilt.25
Visually significant complications due to late subluxation26 are preventable with the use of fibrin glue. Additionally, this technique prevents the suture-related complications of erosion, knot exposure, and dislocation of the IOL after a suture disintegration or break.27-29 The risk of scleral melting30-32 and haptic exposure is present only in high-risk patients, such as those with rheumatoid arthritis.
When any type of tissue derivative is used, there is the potential of transmitting viral infections.33 Therefore, informed consent is mandatory. There is no danger of intraocular infection gaining entry through the tunnel because the fibrin glue seals the flaps, leaving no possible entry route for microbes. In our experience, we have seen no glue-induced intraocular inflammation. We have performed this procedure in more than 50 eyes, all of which postoperatively had clear media, and scleral indentation showed no change in the axial positioning of the IOL. After 6 months, none of the IOLs were decentered, and we did not observe any complications.
Fibrin glue-assisted sutureless posterior chamber IOL implantation is appropriate for eyes in which posterior capsule support is deficient or absent. We suggest long-term follow-up to judge the long-term functional and anatomical outcome of the procedure.
Amar Agarwal, FRCS, FRCOphth, is Director of Dr. Agarwal Eye Hospital and Eye Research Centre, Chennai, India. He states that he holds no financial interest in the products or companies mentioned. Professor Agarwal may be reached at tel: +91 44 2811 6233; e-mail: dragarwal@vsnl.com.
Athiya Agarwal, MD, DO, practices at Dr. Agarwal Eye Hospital and Eye Research Centre, Chennai, India. She states that she has no financial interest in the products or companies mentioned. Dr. Agarwal may be reached at tel: +91 44 2811 6233; email: dragarwal@vsnl.com.
Soosan Jacob, MS, FRCS, DNB, MNAMS, practices at Dr. Agarwal Eye Hospital and Eye Research Centre, Chennai, India. She states that she has no financial interest in the products or companies mentioned. Dr. Jacob may be reached at tel: +91 44 2811 6233; email: dragarwal@vsnl.com.
Dhivya Ashok Kumar, MD, practices at Dr. Agarwal Eye Hospital and Eye Research Centre, Chennai, India. She states that she has no financial interest in the products or companies mentioned. Dr. Agarwal may be reached at tel: +91 44 2811 6233; email: dragarwal@vsnl.com.
