Glued intraocular lens (IOL) implantation is a novel technique for scleral IOL implantation in eyes with absent or insufficient capsular support. A quick-acting surgical fibrin sealant derived from human blood plasma, which has both hemostatic and adhesive properties, is used to seal ocular tissues such as scleral flaps or conjunctiva. The sutureless intrascleral fixation of the standard three-piece posterior chamber IOL in the ciliary sulcus of eyes without capsule support was first described in 2007 by Gabor and Pavlidis1 and later modified by Agarwal et al. as glued transscleral IOL implantation.2 This technique has gained popularity with anterior segment and vitreoretinal surgeons. In the current study, a modified glued IOL technique is described for implantation of a posterior chamber IOL in a case without capsular support.
The surgical technique is shown in detail in Video 1 (available in the online version of this article). After conjunctival peritomy, two partial scleral thickness flaps (approximately 2.5 × 2.5 mm) are made 180° opposite of each other. A three-piece posterior chamber IOL was used for implantation. A looped 9-0 polypropylene suture with an attached curved needle (PC-9 suture; Alcon Laboratories, Inc., Fort Worth, TX) was tied to each haptic tip of the IOL (Figure 1A). A sclerotomy wound was created beneath the scleral flaps with a 23-gauge microvitreoretinal blade, approximately 1 to 1.5 mm from the limbus. To release any vitreous adhesions or strands, an anterior vitrectomy was performed. A corneal incision was then prepared using a 2.8-mm blade to introduce the foldable three-piece foldable IOL. One needle was inserted into the posterior chamber and passed transsclerally through the sclerotomy site (Figure 1B). Similar manipulation was made with the other needle at the opposite sclerotomy site. The IOL was grasped at the optic with forceps and placed as one haptic in the posterior and anterior chambers (Figure 1C). The suture needle that fastened the leading haptic was passed to the sclerotomy site, then pulled to externalize the haptic through the sclerotomy site (Figure 1D). Next, the other haptic was placed into the posterior chamber and similar manipulations were performed to externalize the other haptic through the other sclerotomy site. Corneal incision was sutured with a 10-0-nylon suture.
(A) Each haptic tip of the intraocular lens is tied. (B) PC-9 suture needle (Alcon Laboratories, Inc., Fort Worth, TX) is passed transsclerally through the sclerotomy site. (C) A three-piece foldable intraocular lens is inserted manually into the anterior chamber. (D) The haptic is externalized through the sclerotomy site by pulling out the PC-9 suture.
A scleral tunnel was created with a 23-gauge microvitreoretinal blade to place the externalized haptic at the edge of the scleral flap (Figure 2A). The needle of a PC-9 suture was passed through the scleral tunnel. During this step, a cannula was used to guide the needle (Figure 2B). Afterward, the PC-9 suture was pulled and the haptic was placed into the scleral tunnel (Figure 2C). A similar manipulation was made with the other needle at the opposite site. The PC-9 suture was then cut at the end of the scleral tunnel. Vitrectomy was performed at the sclerotomy site to release any vitreous strands or adhesions. The scleral flaps and conjunctival peritomy sites were sealed with glue (Figure 2D). Postoperatively, topical moxifloxacin and prednisolone acetate 1.0% eye drops were prescribed four times daily for 4 weeks.
(A) Scleral pockets are made with a 23-gauge microvitreoretinal blade. (B) PC-9 suture needle (Alcon Laboratories, Inc., Fort Worth, TX) is passed through the scleral tunnel with the aid of a cannula. (C) Haptic is placed into the scleral tunnel by pulling of the suture. Haptics were tucked into the scleral pocket by applying two forces in the same direction. (D) Fibrin glue is applied on the scleral bed.
Conventional sutured scleral fixation of an IOL implantation has several suture-related disadvantages, including suture erosion, suture knot exposure, dislocation of IOL after suture disintegration, and broken suture.3–6 The sutureless glue-assisted posterior chamber IOL implantation technique prevents suture-related complications. The scleral tunnel fixation of the IOL haptic stabilizes the IOL in the posterior chamber without difficult suturing procedures.7 Placing the IOL haptic into the scleral tunnel and beneath the flap prevents further movement of the haptic and results in decreased pseudophacodonesis.2,8 Also, tucking of the ends of the haptic into the scleral tunnel prevents foreign body sensation and erosion of the above conjunctiva, and reduces inflammation risk.7
The externalization of the IOL haptics is the key step in glued IOL implantation. In standard glued IOL fixation, forceps are passed through the sclerotomy and the tip of the leading haptic is grasped and externalized with forceps.2 An assistant holds the haptic and the second haptic is grasped with forceps and flexed into the anterior chamber. A second set of forceps is introduced through the side port and the haptic is transferred from the first forceps to the second using the handshake technique.9 This standard externalization technique has some drawbacks. First, it requires an assistant to clutch the leading haptic. Second, it requires two sets of forceps to grasp the IOL haptic. Third, improper grasping of the IOL haptics can lead to damage, such as broken haptic or haptic deformation, which can result in an IOL exchange.10,11 Moreover, if vitreous bands are present in the posterior chamber, the forceps can pull these vitreous bands.
With the suture-assisted sutureless technique, the haptics are externalized with a PC-9 suture instead of forceps. Because the IOL haptic is fastened with PC-9 suture before the IOL insertion, haptic damage is much less likely. This technique offers easier intraocular manipulations for haptic externalization, so it can be performed by any surgeon who has previously performed a conventional sutured scleral fixation. This technique does not require an assistant or use of forceps. Also, different techniques for haptic externalization have been described. The haptics of the IOL were externalized with a 25-gauge needle by Rodríguez-Agirretxe et al.12 and with a 27-gauge needle by Yamane et al.13 Recently, Takayama et al.14 reported a transconjunctival sutureless intrascleral IOL fixation technique that uses intrascleral tunnels guided with catheter and 30-gauge needles.
Another important step of the glued IOL technique is placement of the IOL haptic into the scleral tunnel and beneath the flap. This secure tuck of the IOL haptic within the scleral tunnel provides great stability to the IOL and prevents pseudophacodonesis. In the standard glued IOL implantation, the IOL haptic is placed into the scleral tunnel using only IOL forceps at the point of haptic externalization. In this technique, the IOL haptic is placed into the scleral tunnel using a cannula to guide the suture needle, thus allowing better placement of the haptic. Also, haptics are tucked within the scleral tunnel by applying two forces in the same direction (Figure 2C).
The slippage of suture from haptic can occur during haptic externalization. One of the most important points in this technique is the fastening of the suture close to the end of the haptic. Moreover, because the sclerotomy is performed with a 23-gauge microvitreoretinal blade, no resistance is experienced during externalization of haptic. This technique does add time to the procedure due to the need to tie knots to the haptic.
The suture-assisted sutureless technique is an alternative procedure to the conventional glued transscleral IOL implantation. Easier manipulations and the ability to perform the procedure without an assistant are major advantages of this technique.
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- Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue–assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008;34:1433–1438. doi:10.1016/j.jcrs.2008.04.040 [CrossRef]
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