Scleral fixation a viable option for one piece toric IOLs in select cases

Two case reports demonstrated potential for the novel technique in avoiding IOL explantation.

Good lens centration with scleral fixation can be achieved when poor capsular support decenters a one-piece IOL initially placed within the capsular bag.

The lenses in two cases remained stable at 30-months’ follow-up, J. Bradley Randleman, MD, editor-in-chief of the Journal of Refractive Surgery, and colleagues reported in the journal.

There are particular potential benefits for patients with one-piece toric IOLs who otherwise would have no option for IOL fixation and would require an invasive IOL exchange, thus losing the benefit of the toric IOL, Randleman said.

“IOL repositioning is an adventure every time a case presents, because there is an unknown aspect of the surgery,” Randleman said. However, the study authors did not advocate planned scleral fixation of a one-piece toric IOL.

Case selection and technique

In the two cases, a one-piece toric IOL (SN6AT series, Alcon Laboratories) was initially placed within the capsular bag but became decentered due to poor capsular support.

J. Bradley Randleman, MD 

J. Bradley Randleman

“Instead of creating a traditional tunnel incision toward the cornea, the reverse scleral pocket, first described by Richard Hoffman, MD, is made as a partial-thickness scleral incision, starting at the limbus and then heading away from the cornea,” Randleman said. A 10-0 non-dissolvable suture captures and secures the lens haptics in a lasso fashion, and sutures are buried within the scleral pockets.

Randleman said patients should be selected carefully for scleral fixation.

“Although this technique has great promise for IOL fixation, there may be other alternatives, including iris fixation or glue techniques for three-piece IOLs,” he said.

Randleman credits Samuel Masket, MD, co-author and surgeon in one of the two cases, as a pioneer of modern lens surgical technique and inspiration for this technique in particular.

In the first case, a 68-year-old woman whose manifest refraction was –10.0 +4.0 × 85 before cataract surgery achieved improvement to –0.75 +1.50 × 120 at 4 months after IOL repositioning. The second case involved an 81-year-old woman whose corrected distance visual acuity was limited by age-related macular degeneration. By 6 weeks postoperatively, her manifest refraction was –1.25 +0.75 × 170.

Unusual steps

One of the unique surgical maneuvers involved in scleral fixation is wound construction.

A second unusual step is passing the needle from the opposite side of the cornea both under and over the IOL haptic, feeding that needle into an open bore needle, Randleman said.

“This is not a difficult step, but it is quite different than most other things we do in our intraocular cases,” he said.

Randleman recommended watching available video clips online at Healio.com/ophthalmology and on the International Society of Refractive Surgery website, www.isrs.org.

“I have always found video to be the most effective way to learn new techniques when I cannot learn them in person,” Randleman said.

Despite its potential utility, however, controversy remains over use of the technique for one-piece IOLs.

“With any suture fixation for IOLs, there is always a long-term concern for suture breakage and IOL dislocation,” he said. “However, if this were to occur in the future, we feel the surgeon would still have the same options available to them for repair that were present when we performed this scleral fixation technique.”

Randleman also recommended that clinicians continue to seek out new surgical techniques in order to offer their patients reasonable options for repair when IOL malpositions occur. – by Bob Kronemyer

Reference:
Emanuel ME, et al. J Refract Surg. 2013;doi:10.3928/1081597X-20130117-10.
For more information:
J. Bradley Randleman, MD, can be reached at Emory Vision, 875 Johnson Ferry Road, Suite 100, Atlanta, GA 30342; 404-778-2264; email: jrandle@emory.edu.
Disclosure: Randleman has no financial interest in the study, and as editor-in-chief of the Journal of Refractive Surgery he did not participate in the editorial review of the manuscript.

Good lens centration with scleral fixation can be achieved when poor capsular support decenters a one-piece IOL initially placed within the capsular bag.

The lenses in two cases remained stable at 30-months’ follow-up, J. Bradley Randleman, MD, editor-in-chief of the Journal of Refractive Surgery, and colleagues reported in the journal.

There are particular potential benefits for patients with one-piece toric IOLs who otherwise would have no option for IOL fixation and would require an invasive IOL exchange, thus losing the benefit of the toric IOL, Randleman said.

“IOL repositioning is an adventure every time a case presents, because there is an unknown aspect of the surgery,” Randleman said. However, the study authors did not advocate planned scleral fixation of a one-piece toric IOL.

Case selection and technique

In the two cases, a one-piece toric IOL (SN6AT series, Alcon Laboratories) was initially placed within the capsular bag but became decentered due to poor capsular support.

J. Bradley Randleman, MD 

J. Bradley Randleman

“Instead of creating a traditional tunnel incision toward the cornea, the reverse scleral pocket, first described by Richard Hoffman, MD, is made as a partial-thickness scleral incision, starting at the limbus and then heading away from the cornea,” Randleman said. A 10-0 non-dissolvable suture captures and secures the lens haptics in a lasso fashion, and sutures are buried within the scleral pockets.

Randleman said patients should be selected carefully for scleral fixation.

“Although this technique has great promise for IOL fixation, there may be other alternatives, including iris fixation or glue techniques for three-piece IOLs,” he said.

Randleman credits Samuel Masket, MD, co-author and surgeon in one of the two cases, as a pioneer of modern lens surgical technique and inspiration for this technique in particular.

In the first case, a 68-year-old woman whose manifest refraction was –10.0 +4.0 × 85 before cataract surgery achieved improvement to –0.75 +1.50 × 120 at 4 months after IOL repositioning. The second case involved an 81-year-old woman whose corrected distance visual acuity was limited by age-related macular degeneration. By 6 weeks postoperatively, her manifest refraction was –1.25 +0.75 × 170.

Unusual steps

One of the unique surgical maneuvers involved in scleral fixation is wound construction.

A second unusual step is passing the needle from the opposite side of the cornea both under and over the IOL haptic, feeding that needle into an open bore needle, Randleman said.

“This is not a difficult step, but it is quite different than most other things we do in our intraocular cases,” he said.

Randleman recommended watching available video clips online at Healio.com/ophthalmology and on the International Society of Refractive Surgery website, www.isrs.org.

“I have always found video to be the most effective way to learn new techniques when I cannot learn them in person,” Randleman said.

Despite its potential utility, however, controversy remains over use of the technique for one-piece IOLs.

“With any suture fixation for IOLs, there is always a long-term concern for suture breakage and IOL dislocation,” he said. “However, if this were to occur in the future, we feel the surgeon would still have the same options available to them for repair that were present when we performed this scleral fixation technique.”

Randleman also recommended that clinicians continue to seek out new surgical techniques in order to offer their patients reasonable options for repair when IOL malpositions occur. – by Bob Kronemyer

Reference:
Emanuel ME, et al. J Refract Surg. 2013;doi:10.3928/1081597X-20130117-10.
For more information:
J. Bradley Randleman, MD, can be reached at Emory Vision, 875 Johnson Ferry Road, Suite 100, Atlanta, GA 30342; 404-778-2264; email: jrandle@emory.edu.
Disclosure: Randleman has no financial interest in the study, and as editor-in-chief of the Journal of Refractive Surgery he did not participate in the editorial review of the manuscript.