In eyes with insufficient or no capsular support, IOL implantation and fixation techniques are still controversial. Many reports in the literature confirm that anterior chamber or iris-fixated IOLs can be implanted, or, alternatively, a posterior chamber IOL can be fixated in the ciliary sulcus using transscleral suturing or gluing.1-22 We recently developed a sutureless technique for sulcus fixation of a posterior chamber IOL using permanent incarceration of the haptics in a scleral tunnel parallel to the limbus. This method combines the control of a closed-eye system with the postoperative axial stability of the posterior chamber IOL.22
After peritomy, the eye is stabilized either by 25-gauge pars plana infusion or with an anterior chamber maintainer. We try to prevent any diathermy of episcleral vessels to reduce the risk for scleral atrophy. Two straight sclerotomies ab externo are prepared with a sharp, 24-gauge cannula (Neopoint Luer No. 17; Servoprax GmbH, Wesel, Germany) located 1.5 to 2 mm postlimbal and exactly 180° from each other (Figure 1).
The cannulas are then used to create a limbus-parallel tunnel at approximately 50% scleral thickness, starting from the ciliary sulcus sclerotomies and ending with externalization of the cannula after 2 or 3 mm. A standard three-piece IOL with a haptic design fitting to the diameter of the ciliary sulcus is implanted with an injector, and the trailing haptic is fixated in the corneal incision. The leading haptic is then grasped at its tip with end-gripping 25-gauge forceps, pulled through the sclerotomy, and left externalized (Figure 2). With the same forceps, the haptic is then introduced into the intrascleral tunnel (Figure 3). The same maneuvers are performed with the tailing haptic. The ends of the haptics are left in the tunnels to prevent foreign body sensation and erosion of the conjuctiva and to reduce the risk for inflammation. The sclerotomies are checked for leakage. If necessary, they are sutured. For a full video of this procedure, please visit www.eyetube.net/videos/default.asp?lilese.
We have used this technique in more then 50 eyes over the past 3 years. Our standard IOLs are the Sensar AR40e (Abbott Medical Optics Inc., Santa Ana, California) and the AcrySof (Alcon Laboratories, Inc., Fort Worth, Texas); however, we have also used multifocal IOLs, such as the ReZoom (Abbott Medical Optics Inc.; Figure 4).
Our technique is appropriate for fixation of standard three-piece posterior chamber IOLs. However, it should not be used to fixate newer one-piece acrylic or silicone IOLs. Management of secondary implantation or refixation of dislocated posterior chamber IOLs with scleral tunnel fixation of the haptic is less technically demanding because it stabilizes the IOL in the posterior chamber without the use of difficult suturing procedures. This technique also enables the surgeon to easily recenter the IOL. Posterior chamber IOL torsion and decentration can be minimized by accurate placement of the haptics in the scleral tunnel, above the ciliary sulcus. To avoid torsion, the haptic design of the implanted three-piece IOL should be the same as the diameter of the ciliary sulcus.
Incarcerating a longer part of the haptic stabilizes the axial position of the IOL, which should decrease the incidence of tilt.24 Intraoperative IOL centration is possible due to adjustments made to the final intrascleral position of the haptics (Figure 5).
The potential complications of using sutures for transscleral fixation of posterior chamber IOLs include suture erosion, suture knot exposure, and recurrent dislocation caused by a broken suture.25,26 All are avoidable with the sutureless technique. Some techniques for scleral fixation of secondary IOLs, located within a scleral pocket, require two suture passes through the sclera for each haptic. This creates twice as much potential for adverse bleeding events and twice as many endophthalmitis ports as our nonsuturing technique.
Intrascleral fixation is an established technique in retinal surgery (ie, silicone scleral buckling procedures) as well as refractive surgery. Because of the overall diameter of the IOLs, we do not exert higher forces on the sclera. Scleral tunnels are well known in cataract surgery procedures, and scleromalacia should not be expected unless the patient has preexisting inflammation, such as scleritis, episcleritis, rheumatoid arthritis, or herpes zoster ophthalmicus.27-29 Because the tips of the haptics are buried, conjunctival erosion should not occur. The risk for chronic inflammation or recurrent bleeding is potentially lower than with sulcus-fixated IOL because there is no contact with the ciliary body. Very rigid haptics (ie, those made of PMMA) may lead to slow dislocation from eye rubbing or contusion. We therefore recommend using IOLs with more flexible haptics, such as Prolene or Teflon (DuPont, Wilmington, Delaware).
A modified technique can be performed for any procedure that requires transscleral IOL fixation. This includes implantation of secondary IOLs, repairing dislocated IOLs,19,30-32 and use of adjunctive surgical devices, such as the Ahmed Capsular Tension Segment and Cionni Capsular Tension Ring (both manufactured by Morcher GmbH, Antony, France). This technique simplifies scleral fixation of dislocated posterior chamber IOLs and allows successful repositioning of dislocated and subluxated posterior chamber IOLs. It also minimizes intraoperative maneuvers and could thus reduce the risk for intraoperative trauma. Furthermore, this technique can be performed with standard three-piece posterior chamber IOLs without the need for special haptic architecture or preparation. Additionally, there is no need to store or order special IOLs for rare indications.
Diego de Ortueta, MD, FEBO, is a Senior Consultant at the Aurelios Augenzentrum, Recklinghausen, Germany. Dr. de Ortueta states that he has no financial interest in the products or companies mentioned. He may be reached at firstname.lastname@example.org.
Gabor B. Scharioth, MD, is a Senior Consultant at the Aurelios Augenzentrum, Recklinghausen, Germany. Dr. Scharioth states that he has no financial interest in the products or companies mentioned. He may be reached at email@example.com.
Anand R, Bowman RW. Simplified technique for suturing dislocated posterior chamber intraocular lens to the ciliary sulcus [letter]. Arch Ophthalmol. 1990;108:1205-1206.
Azar DT, Wiley WF. Double-knot transscleral suture fixation technique for displaced intraocular lenses. Am J Ophthalmol. 1999;128:644-646.
Bloom SM, Wyszynski RE, Brucker AJ. Scleral fixation suture for dislocated posterior chamber intraocular lens. Ophthalmic Surg. 1990;21:851-854.
Chan CK. An improved technique for management of dislocated posterior chamber implants. Ophthalmology. 1992;99:51-57.
Chang S. Perfluorocarbon liquids in vitreoretinal surgery. Int Ophthalmol Clin. 1992;32(2):153-163.
Chang S, Coll GE. Surgical techniques for repositioning a dislocated intraocular lens, repair of iridodialysis, and secondary intraocular lens implantation using innovative 25-gauge forceps. Am J Ophthalmol. 1995;119:165-174.
Fanous MM, Friedman SM. Ciliary sulcus fixation of a dislocated posterior chamber intraocular lens using liquid perfluorophenanthrene. Ophthalmic Surg. 1992;23:551-552.
Friedberg MA, Pilkerton AR. A new technique for repositioning and fixating a dislocated intraocular lens. Arch Ophthalmol. 1992;110:413-415.
Kokame GT, Yamamoto I, Mandel H. Scleral fixation of dislocated posterior chamber intraocular lenses; temporary haptic externalization through a clear corneal incision. J Cataract Refract Surg. 2004;30:1049-1056.
Little BC, Rosen PH, Orr G, Aylward GW. Trans-scleral fixation of dislocated posterior chamber intraocular lenses using a 9/0 microsurgical polypropylene snare. Eye. 1993;7:740-743.
Maguire AM, Blumenkranz MS, Ward TG, Winkelman JZ. Scleral loop fixation for posteriorly dislocated intraocular lenses; operative technique and long-term results. Arch Ophthalmol. 1991;109:1754-1758.
Nabors G, Varley MP, Charles S. Ciliary sulcus suturing of a posterior chamber intraocular lens. Ophthalmic Surg. 1990;21:263-265.
Schneiderman TE, Johnson MW, Smiddy WE, et al. Surgical management of posteriorly dislocated silicone plate haptic intraocular lenses. Am J Ophthalmol. 1997;123:629-635.
Shin DH, Hu BV, Hong YJ, Gibbs KA. Posterior chamber lens implantation in the absence of posterior capsular support [letter and reply by WJ Stark, GL Goodman, JD Gottsch]. Ophthalmic Surg. 1988;19:606-607.
Smiddy WE. Dislocated posterior chamber intraocular lens; a new technique of management. Arch Ophthalmol. 1989;107:1678-1680.
Smiddy WE, Flynn HW Jr. Needle-assisted scleral fixation suture technique for relocating posteriorly dislocated IOLs [letter]. Arch Ophthalmol. 1993;111:161-162.
Smiddy WE, Ibanez GV, Alfonso E, Flynn HW Jr. Surgical management of dislocated intraocular lenses. J Cataract Refract Surg. 1995;21:64-69.
Thach AB, Dugel PU, Sipperley JO, et al. Outcome of sulcus fixation of dislocated posterior chamber intraocular lenses using temporary externalization of the haptics. Ophthalmology. 2000;107:480-484; discussion by WF Mieler, 2000;107:485.
Koh HJ, Kim CY, Lim SJ, Kwon OW. Scleral fixation technique using 2 corneal tunnels for a dislocated intraocular lens. J Cataract Refract Surg. 2000;26:1439-1441.
Lewis JS. Ab externo sulcus fixation. Ophthalmic Surg. 1991;22:692-695.
Mohr A, Hengerer F, Eckardt C. Retropupillare Fixation der Irisklauenlinse bei Aphakie; Einjahresergebnisse einer neuen Implantationstechnik. [Retropupillary fixation of the iris claw lens in aphakia; 1 year outcome of a new implantation technique.] Ophthalmologe. 2002;99:580-583.
Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surgery. 2008;34:1433-1438.
Gabor SG, Pavlidis MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg. 2007;33:1851-1854.
Teichmann KD, Teichmann IAM. The torque and tilt gamble. J Cataract Refract Surg. 1997;23:413-418.
Por YM, Lavin MJ. Techniques of intraocular lens suspension in the absence of capsular/zonular support. Surv Ophthalmol. 2005;50:429-462.
Wagoner MD, Cox TA, Ariyasu RG, et al. Intraocular lens implantation in the absence of capsular support; a report by the American Academy of Ophthalmology. (Ophthalmic Technology Assessment.) Ophthalmology. 2003;110:840-859.
Ahmed TY, Carrim ZI, Diaper CJM, Wykes WN. Spontaneous intraocular lens extrusion in a patient with scleromalacia secondary to herpes zoster ophthalmicus. J Cataract Refract Surg. 2007;33:925-926.
Mamalis N, Johnson MD, Haines JM, et al. Corneal-scleral melt in association with cataract surgery and intraocular lenses: a report of four cases. J Cataract Refract Surg. 1990;16:108-115.
Watson PG, Hayreh SS. Scleritis and episcleritis. Br J Ophthalmol.1976;60:163-191.
Moreno-Montanes J, Heras H, Fernandez-Hortelano A. Surgical treatment of a dislocated intraocular lens-capsular bag-capsular tension ring complex. J Cataract Refract Surg. 2005;31:270–273.
Gross JG, Kokame GT, Weinberg DV. In-the-bag intraocular lens dislocation; the Dislocated In-the-Bag Intraocular Lens Study. Am J Ophthalmol. 2004;137:630–635.
Jehan FS, Mamalis N, Crandall AS. Spontaneous late dislocation of intraocular lens within the capsular bag in pseudoexfoliation patients. Ophthalmology. 2001;108:1727–1731.