Scleral fixation of IOLs is one of the modalities adopted for secondary IOL fixation, and good results have been reported with this method. Every surgery has its pros and cons, including scleral-fixated IOLs. Suture-related complications have been reported, and to avoid erosion of the knots through the conjunctiva, scleral flaps to cover the knots or rotation of the sutures into scleral tissue without flaps have been recommended. Steady traction on transscleral sutures secures the IOL insertion into the ciliary sulcus. Due to the atrophy of scleral flaps over time, the suture end often gets exposed, causing granuloma formation and increased risk of infection.
A major problem after transscleral implantation is suture erosion, which normally happens in the late post-surgery period; 10-0 or 9-0 polypropylene sutures have been reported to degrade after a prolonged period in the eye. There was speculation that a knotless polypropylene suture lying flush under the conjunctiva may be less prone to degradation and erosion through the sclera, and for the same reason, ab externo 2-0 point knotless fixation of scleral-fixated IOLs was reported as a technique. Nevertheless, a surgeon should always be wary of suture degradation and erosion, and patients should have a programmed follow-up. To overcome the issue of suture degradation, the use of Gore-Tex suture has also been reported and is believed to offer long-term stability for IOL fixation.
Suture degradation leads to malposition of the IOL, which in turn leads to decreased vision with unwanted optical images. The video demonstrates a case that underwent scleral fixation of an IOL around 10 years back and presented with suture knot exposure with a tilted and subluxated IOL. The IOL was explanted, and IOL fixation was then secured with glued IOL fixation.