Innovative technique variations offer options in difficult cases
Amar Agarwal, MS, FRCS, FRCOphth, is an amazingly innovative surgeon and a prolific writer and educator. He has popularized the so-called “glued posterior chamber IOL technique.” In this technique, the haptics a of a posterior chamber IOL are placed in scleral tunnels under a scleral flap. The flap is glued in place with temporary fibrin glue under conjunctiva as well. It is really an intrascleral fixation of the posterior chamber IOL, and the glue is not critical. One could close the scleral flaps with sutures as an alternative because fibrin glue is expensive and not universally available. High-quality microforceps, such as those manufactured by MicroSurgical Technology, are a requirement.
My fellows and I played a role in studying and popularizing scleral suture fixated posterior chamber IOLs in the late 1970s and early 1980s. The epidemic of pseudophakic bullous keratopathy caused by closed loop anterior chamber lenses required a solution for IOL exchange. Exchange for another anterior chamber IOL, especially in the face of significant peripheral anterior synechia and often secondary glaucoma, was less than ideal. A posterior chamber IOL could be sutured to the iris, but many irides were abnormal with large iridectomies and pupil distortion.
Special IOLs, including the Alcon CZ70BD and Storz P366UV, were designed with haptic eyelets by my fellows and I to simplify transscleral suturing. We started by placing the transscleral sutures under scleral flaps using 9-0 and 10-0 polypropylene sutures, but some lenses subluxated secondary to suture breakage at 15 or more years after placement. This led to the use of Gore-Tex sutures, which to date appear to be permanent. Richard Hoffman developed an elegant technique eliminating the conjunctival flaps using a cornea-based scleral flap. I have also abandoned polypropylene sutures after experiencing many cases of late suture breakage or degradation. I have found that a polyester suture, Mersilene available from Ethicon, works well, and to date, I have experienced no cases of suture failure using this material.
Each approach to scleral fixation of posterior chamber IOLs requires significant technical skill and experience. Most comprehensive ophthalmologists refer these cases to consultative surgeons with high-volume practices that manage complex IOL problems. While I find the glued IOL technique to have many attractive features, I personally have not adopted it. I continue to use scleral or iris fixation techniques with a nondegradable suture such as Gore-Tex or polyester. A modern four-point fixation anterior chamber IOL remains a reasonable option in many cases, but a posterior chamber IOL is better when performing Descemet’s stripping endothelial keratoplasty or Descemet’s membrane endothelial keratoplasty.
In the literature, there is no convincing data supporting one form of scleral posterior chamber IOL fixation or even iris fixation of an IOL over another. One should use a suture unlikely to biodegrade or the glued IOL technique, especially in younger patients. The literature supports modern anterior chamber IOLs as a reasonable option when an endothelial keratoplasty is not planned. Vitrectomy (often pars plana) skills, iris reconstruction or even artificial iris implantation, synechiolysis and glaucoma management are often critical to success. Cystoid macular edema is not uncommon, and retinal tears or detachment can occur. Many very sick eyes can be salvaged by surgeons skilled in these advanced reconstructive techniques. We are fortunate indeed to have many innovative surgeons such as Dr. Agarwal continue to advance the art and science in our field and openly share their learnings and experience.