Numerous innovative techniques have been developed for addressing dislocated IOLs in eyes without sufficient capsular support. Maggi and colleagues were one of the first to introduce the concept of sutureless scleral fixation of an IOL. Recently, the implementation of vitreoretinal surgical instrumentation to assist with IOL fixation has gained popularity.
Indeed, the advantages of smaller-gauge vitreoretinal instrumentation have fostered the development of numerous surgical techniques and novel applications in cases involving a dislocated IOL in eyes without sufficient capsular support. These techniques involve cannula-based sutureless intrascleral fixation or sutured scleral fixation. In some cases in which the dislocated IOL is not damaged, IOL rescue with repositioning and scleral fixation may be more desirable than IOL exchange. In other cases, IOL explantation and scleral fixation of a new IOL may be desirable. I describe a simple and minimally invasive approach using 27-gauge vitreoretinal instrumentation for cases in which IOL exchange with scleral fixation is desirable.
A complete 27-gauge vitrectomy is performed, freeing all the vitreous adhesions from the IOL and allowing the IOL to be freely mobile within the vitreous cavity. The IOL is then elevated into the anterior chamber. This may be accomplished by engaging the IOL optic with a soft-tip extrusion cannula in combination with 27-gauge forceps or with other techniques. The dislocated IOL is then externalized through a superior corneoscleral tunnel from the anterior chamber.
Two scleral “pockets” of about 3 mm in length are created 180° apart about 3 mm posterior to the corneoscleral limbus and then tunneled anteriorly. Two sclerotomies are made through the pocket roof 2 mm apart and 2 mm from the limbus using a 27-gauge trocar. Twenty-seven-gauge forceps (such as Maxgrip, Alcon) are used to loop needless 9-0 Prolene suture through the 27-gauge sclerotomies, externalized through the main corneoscleral tunnel and passed through the eyelet of the IOL (such as the CZ70BD IOL, Alcon). The suture is then internalized back through the corneoscleral tunnel and externalized through the adjacent sclerotomy in the scleral pocket. The same process is repeated for the second haptic. The lens is placed in the ciliary sulcus via the superior corneoscleral tunnel and centered, and the sutures are tied and buried within the scleral pocket.
Small-gauge vitreoretinal instrumentation for scleral fixation of IOLs using trocar cannulas, tunnels, sutures or combination approaches is an effective surgical option for the treatment of aphakia or IOL dislocation. These techniques often yield significant visual improvement with minimal postoperative complications. As these techniques evolve and more long-term outcomes data become available, it will help guide us in choosing the most appropriate intervention for our patients.
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- Maggi R, et al. J Cataract Refract Surg. 1997;doi:10.1016/S0886-3350(97)80104-6.
- Prasad S. Retina. 2013;doi:10.1097/IAE.0b013e31827b6499.
- Prenner JL, et al. Retina. 2012;doi:10.1097/IAE.0b013e3182479b61.
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- Joseph Martel, MD, is an assistant professor of ophthalmology at UPMC and the University of Pittsburgh. He can be reached at Eye & Ear Institute, 203 Lothrop St., Suite 757, Pittsburgh, PA 15213; email: firstname.lastname@example.org.
Disclosure: Martel reports no relevant financial disclosures.