Surgical techniques for scleral fixation of an intraocular lens (IOL) in eyes with inadequate capsular support have expanded remarkably during the past few years. A common approach is the sutureless flanged intrascleral IOL fixation technique described by Yamane et al.1 This involves externalizing IOL haptics through scleral tunnels created with 30-gauge needles and securing them to the sclera using small flanges created with cautery. The elegant use of haptic flanges avoids the need for creating scleral tunnels2 or using surgical glue3 and greatly simplifies the surgery.
We have adapted the Yamane technique to be familiar for vitreoretinal surgeons.4 Our technique involves feeding the IOL haptics into receiving needles with a procedure confined to the posterior segment. With this, we avoid manipulations of the lens within the anterior segment (See video below). Our approach allows for refixation of displaced three-piece IOLs to the scleral without creating a large corneal incision and performing a lens exchange. In situations with a dislocated single-piece IOL, it is initially removed through a corneal incision, and a new three-piece IOL is inserted in the eye.
Richard H. Johnston
Our patient was a 78-year-old male who presented with a dislocated IOL a few days after cataract surgery. His preoperative visual acuity was 20/50, as measured by Snellen. We proceeded with a 23-gauge pars plana vitrectomy (PPV) by inserting trocars cannulas in the infratemporal, supratemporal and supranasal quadrants at 3.5 mm behind the limbus. A chandelier light source was inserted inferiorly. A PPV was performed, the capsular complex and vitreous adhesions were removed from the IOL, and the lens was allowed to descend within the posterior segment. A 30-gauge needle with a wide inner cannula (TSK Laboratories, Tochigi-Ken, Japan) was inserted through the sclera on the surgeon's right side at a 20° angle and 2 mm behind the limbus. Using a bimanual approach, the IOL was positioned using aspiration from the vitrectomy handpiece, and the first haptic was grasped with the Grieshaber MaxGrip forceps (Alcon, Forth Worth, TX) and fed into the lumen of the 30-gauge needle. A second 30-gauge needle was inserted through the sclera on the surgeon's left side approximately 180° from the first needle, and the second haptic was secured in a similar manner. Both needles were externalized simultaneously to bring out both haptics. The haptic ends were cauterized to create small flanges that were inserted into the sclera. A 360° scleral depressed exam was performed, and no peripheral retinal findings of concern were observed. The trocars and the chandelier light were removed, and the sclerotomies are closed using sutures. Several months after surgery, the patient achieved a final visual acuity of 20/25 without any complications.
It is important to note that other groups have presented similar variations of the Yamane technique. Bonnell et al. recently published their technique where the second haptic was docked to the needle within the posterior segment.5 The main purpose of this modification was to allow the surgeon to place the second haptic more reliably and avoid uncontrolled needle use in the anterior chamber. This technique requires removal of the dislocated intraocular lens and insertion of a new lens in all cases.
- Yamane S, Sato S, Maruyama-Inoue M, Kadonosono K. Flanged Intrascleral Intraocular Lens Fixation with Double-Needle Technique. Ophthalmology. 2017;124(8):1136–1142. doi:10.1016/j.ophtha.2017.03.036 [CrossRef] PMID:28457613
- Gabor SG, Pavlidis MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg. 2007;33(11):1851–1854. doi:10.1016/j.jcrs.2007.07.013 [CrossRef] PMID:17964387
- 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(9):1433–1438. doi:10.1016/j.jcrs.2008.04.040 [CrossRef] PMID:18721701
- Johnston RH. Transconjunctival Intrasceral IOL Fixation with a Modified Double-needle Technique Using a Posterior Segment Approach. Florence, Italy: European VitreoRetinal Society; 2017.
- Bonnell AC, Mantopoulos D, Wheatley HM, Prenner JL. Surgical Technique for Sutureless Intrascleral Fixation of a 3-Piece Intraocular Lens Using a 30-Gauge Needle. Retina. 2019;39(suppl 1):S13–S15. doi:10.1097/IAE.0000000000001889 [CrossRef] PMID:29160789